Module 7: (b) Initial HTN Meds Flashcards
(44 cards)
1
Q
ACE Inhibitors (“pril”) -Common Drugs
A
- Lisinopril (Very commonly used)
2. Captopril (Short-acting) (Not used commonly in primary care)
2
Q
ACE Inhibitors (“pril”) -Adverse Effects
A
- Cough (up to 20% of patients)
- HYPERKALEMIA **
- Teratogenic AVOID in pregnancy
- ANGIOEDEMA (Avoid w/ hx of Angioedema
3
Q
ACE Inhibitors (“pril”) -African American Considerations?
A
- AA’s may not have substantial BP lowering w/ ACEi
- AA are 5x greater risk of Angioedema
—Educate Pt to seek ER care if they experience s/s of Angioedema - Research has shown that ACEi and CCB combo had powerful benefits in AA patients
4
Q
ACE Inhibitors (“pril”) -When to Use?
A
- Proteinuric CKD
- HFrEF
- Post-MI
5
Q
ACE Inhibitors (“pril”) -Monitoring?
A
- ACEi can cause INCREASE in serum creatinine
- may be benign or significant - Recheck renal function within 4 weeks. Sometimes Much sooner
Individuals at High risk include:
- Bilateral renal artery stenosis
- Hypertensive nephrosclerosis
- Polycistic kidney dz, HF, and CKD
6
Q
ACE Inhibitors (“pril”) -Baseline Labs to Monitor?
A
- Baseline and periodic BP
- Serum Creatinine
- Electrolytes ESP POTASSIUM for Hyperkalemia
If Patient is on diuretic, start ACE at a lower dose (50%)
7
Q
ACE Inhibitors (“pril”) -When to Discontinue
A
- DC if serum Creatinine increases more than 30% above baseline
- REFER to nephrology
8
Q
ACE Inhibitors (“pril”) -Education?
A
- Start a BP log outpatient
2. Monitor development of dry cough
9
Q
Angiotensin II Receptor Blockers “sartan”
-Common Meds?
A
- Losartan (Most common in Primary care)
10
Q
Angiotensin II Receptor Blockers “sartan”
-Info
A
- No bradykinin-mediated cough like ACEi
- DO NOT combine ARB w/ ACEi
- Considered an alternative to ACEi
11
Q
Angiotensin II Receptor Blockers “sartan”
-Potential Adverse Reactions?
A
- Hyperkalemia (similar to ACEi)
- Teratogenic —avoid in pregnancy
- Can cause changes in renal function including AKI
- Hypotension (More than ACEi)
12
Q
Angiotensin II Receptor Blockers “sartan”
-Benefits
A
- No cough — better than ACEi for Asthma and COPD patients
- Lower incidence of Angioedema
- Enhanced uric acid secretion in gout (Particularly losartan)
13
Q
Angiotensin II Receptor Blockers “sartan”
-Monitoring
A
- BP, Serum Cr, electrolytes (esp. Potassium for Hyperkalemia)
- DC w/ significant deterioration of renal function 30% above baseline and Consult Nephrology
- If patient is on a diuretic, elderly, or volume depleted reduce dose by 50% *
14
Q
CCB
-Two major classes?
A
- Di-hydropyridines (Used more often for HTN)* (Better option for asthma or COPD)*
- Non-dihydropyridines
- CCB’s are effective for BLACK ethnicities, older adults
- Used in angina
15
Q
CCB Di-hydropyridines “pines”
-Exemplars
A
- Amlodipine (Norvasc)(Most commonly prescribed)
Nifedipine (Procardia) - Long-acting agents preferred
- Short acting agents have concern for reflex Tachycardia
16
Q
CCB Di-hydropyridines
-MOA
A
- Di-hydropyridine CCB do NOT affect conduction through the AV node
17
Q
CCB Non-dihydropyridines
-Exemplars & MOA
A
- Diltiazem (Cardizem)
- Verapamil (Calan)
- Affect conduction through the AV node AND have negative chronotropic effects
- Used for rate control in atrial fib
18
Q
CCB Di-hydropyridines
-Adverse Effects
A
- Peripheral Edema (Up to 20-30%)
2. CCB/ACE combo can decrease peripheral edema by 50% vs CCB high-dose alone
19
Q
CCB Non-dihydropyridines
-Adverse Effects
A
- Constipation (Up to 25%)
- Bradycardia and AV block
AVOID in:
-HFrEF, SSS, 2nd and 3rd degree AV block
Monitor BP, HR, LFT’s and ECG
20
Q
Beta Blocker + Non-dihydropyridine CCB
-Interaction?
A
- Potential negative additive CV effects
- HYPOTENSION
- Bradycardia
- AV Block & conduction defects
21
Q
Verapamil
-Meds that interact and should avoid?
A
- Verapamil interacts with
- Lovastatin/Simvastatin (INcrease risk of rhabdo)
- Lithium
- Phenytoin
- Amiodarone
- Codeine
Amlodipine interacts w/ simvastatin
22
Q
Thiazide Diuretics
-Exemplars
A
- Hydrochlorothiazide (HCTZ)
- Chlorthalidone (Thiazide-like diuretic) (Longer acting and more potent than thiazide. Increase risk of Hypokalemia)
- indapamide (Thiazide-like diuretic (Longer acting and more potent than thiazide. Increase risk of Hypokalemia)
- Additional benefit in osteoporosis
- Avoid in gout
23
Q
Thiazide Diuretics
-Chlorthalidone?
A
- Has been shown to be superior to HCTZ
- Reduces CV events
- Considered longer-acting and more potent
24
Q
Thiazide Diuretics
-Adverse effects
A
- Hypokalemia (More common with chlorthalidone than HCTZ
- Hyponatremia
- Hypotension
- Hyperlipidemia
- Hyperglycemia
- Hypercalcemia; HypoMagnesemia
Monitor:
- Serum Cr
- electrolytes (esp K and Na); BP
25
Potassium-Sparing Diuretics
| -Exemplars of MRA’s
1. Spironolactone
2. Eplerenone
3. Used for Heart Failure and RESISTANT HTN**
4. Potential AE:
- Hyperkalemia
5. Monitor:
- Cr
- Electrolytes (Esp Potassium)
26
Loop Diuretics
| -Exemplars and monitoring
1. Furosemide
2. Bumetanide
3. Torsemide
—Monitor potassium. Each can lower potassium
27
Beta Blockers
| -Cardioselective
1. Atenolol
2. Bisoprolol
3. Metoprolol
4. Esmolol
5. Acebutolol
28
Beta Blockers
| -Non-Cardioselective
1. Propranolol
2. Timolol
3. Nadolol
29
Beta Blockers
| -Mixed alpha/beta-blocker?
1. Carvedilol
| 2. Labetalol
30
Beta Blockers
| -Elderly
1. Not recommended for initial therapy in a sense of specific indication
2. NOT for people >60yrs old
3. >60 yrs old
- Inferior protection against CVA risk
- Small increase in mortality
31
Beta Blockers
| -Adverse Effects
1. Hypotension
2. Bradycardia**
3. Impaired glucose tolerance
4. Fatigue, depression, and sexual dysfunction
5. AVOID ABRUPT CESSATION***
- Can cause Acute MI or angina
32
Beta Blockers
| -Indications?
1. HFrEF (certain BB)
2. Chronic stable angina
3. Migraine prevention
4. Hyperthyroidism
5. Essential tremor
6. Rate control w/ Atrial Fibrillation
33
Beta Blockers
| -When to AVOID?
1. Bronchospastic Dz (Asthma, COPD)
2. Bradycardia
3. 2nd or 3rd degree AV block
4. Decompensated HF
5. Caution in Diabetes
6. BB + Non-dyhydropyridine CCB = NEGATIVE additive CV effects (hypotension)
34
Direct Renin Inhibitor
| -Exemplar and Important Info
1. Aliskiren (Tekturna)
2. DO NOT combine w/ ACEi or ARB
3. DO NOT combine w/ ARNI (used for HF)
4. AVOID Pregnancy
Similar to ACEi and ARB’s
35
Peripherally-Acting Agents
| -Alpha Blockers Exemplars
1. Doxazosin, Prazosin, Terazosin
2. Not a first-line antihypertensive
3. Careful BP monitoring
4. Can be used for PTSD and nightmares but CONSIDER Hypotension since it is a HTN medication first
36
Peripherally-Acting Agents
| -Alpha Blockers Adverse effects
1. Orthostatic Hypotension
2. FIRST DOSE at bedtime
3. Not given to older adults due to risk of Orthostatic hypotension
4. Titrate slowly over several weeks
37
Centrally-acting Agents: Alpha Agonists
| -Exemplars, AE’s and Info
1. Clonidine
2. Guanfacine
3. Can cause Drowsiness
4. Used with ADHD
5. AVOID abrupt withdrawal and TAPER to D/C
38
Centrally-acting Agents: Alpha Agonists
| -Methyldopa
1. Used during PREGNANCY
2. Can cause:
- Sedation, Orthostatic hypotension, and bradycardia
Monitor:
- BP, HR
- CBC; hemolytic anemia
- LFT’s; check more frequently first 6-12 weeks and if fever. Occurs
3. Contraindicated w/ hepatic disease
39
Mono-therapy for HTN
| -When is it Appropriate?
1. For those with BP <20/10 mmHg above goal**
40
HTN
| -Common Meds to start treatment?
1. ACEi
2. ARB
3. Long Acting Di-hydropyridine CCB (Amlodipine/Norvasc)
41
Higher Dose Antihypertensive??
| -Is it a good idea?
1. Increasing HTN med to higher doses is shown to:
- INCREASE Adverse effects w/out significant clinical value to HTN.
2. Consider titrating dose up slowly or COMBINATION therapy
42
HTN Sequential Therapy on Mono-therapy
If patient has not responded to initial mono-therapy
| -Try one drug, step it up, then try a new medication w/out combination
43
When to use Combination Therapy?
1. Combination therapy for untreated HTN >20/10 mmHg.
44
HTN Combination Therapy
| -Best Combo?
1. Long acting ACEi or ARB
PLUS
2. Long acting di-hydropyridine CCB (Amlodipine) (ACCOMPLISH TRIAL showed these results)
