Week 7 Hypertension and Dyslipidemia Flashcards by Andrea Maiorini

ACE-I Angiotensin Converting Enzyme Inhibitors Drugs/Treat/MOA

PRIL drugs
HTN; first line
1st line for HTN and CKD and HTN and DM w/ albuminuria (renal protection)
MOA: prevent conversion of A1 to A2 via inhibition of ACE-1 enzyme
Hydrolyzes bradykinin

Some: HRT Failure/ Myocardial Infarction/ Nephropahty
***Helps prevent cardiac remodeling

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ACE-1 ADE

PRIL drugs
Increase bradykinin: Dry non productive cough in 10% of patients (switch to ARB)
Angioedema (d/t ^ bradykinin)
Black BOX: do not use in pregnancy; can cause injury to fetal kidneys
First dose hypotension/HyperKalemia/increase serum Creatinine >30% ^ concerned for acute kidney injury (AKI)
**Captopril: neutropenia

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ACE-I Drug Drug

PRIL- Druges
Caution with other drugs that increase potassium: Potassium sparing diuretics, SGLT2 inhibitors, Sulfamethoxazole-trimethoprim (increased risk in sudden death; abx used to treat UTI)

Do not prescribe ACE-1/ DRI/ ARB/ ARNIs
ACE-1 and ARNI: wash out period 36 hrs; risk hyperkalemia and angioedema

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ACE-1 Prescribing Considerations

PRIL-Drugs
EnalaPRILat is the only IV formulation

No not start ACE-1 if K+ is >5.5

D/C ACE-I if SCr increases 30% from baseline

Should use with CKD patients but still watch SCr

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All RAAS Drugs (ACE-1/ ARB/
ADE and Drug Drug Interactions

BLACK BOX: Fetal kidney injury

First Dose Hypotension
Hyperkalemia
Increase Serum Creatinine (SCr) AKI > 30%
AVOID ACE-I/ ARB/ DRI/ ARNI
Potassium increasing drugs: Potassium-sparing diuretics/ SGLT2 inhibitors/ Sulfamethoxazole-trimethoprim
Triple Whammy: RAAS/ NSAID/ACE-I or ARB
Dehydration: AKI
Lithium: neurological and N/V Hypotension

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Angiotensin II Receptor Blockers (ARB) Drugs/ Treat/ MOA

SARTAN Drugs
HTN 1st line therapy
Approved 1st line with HTN and CKD and HTN and DM w/ albuminuria

MOA: Angiotensin 1 receptor antagonist throughout the body which in turn blocks angiotensin II from binding– so it blockers II

Some: Heart Failure; Myocardial Infarction; Nephropathy
***Helps prevent cardiac remodeling

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ARB ADE

SARTAN- Drugs

ADE: Dry cough but only in 3%
Angioedema but lower risk than ACE-I

Switching from ACE-I to ARB for dry cough or to prevent angioedema worth trying especially when preventing cardiac remodeling

Less risk of cough and hyperkalemia than ACE-I// higher risk of hypotensive episodes

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Direct Renin Inhibitors (DRI)
Only 1 drug/ Drug/ Treat/ MOA

ADE/ DRUG DRUG

Aliskiren (REN for Renin)

Treat hypertension; not 1st line drug
^Risk cardiac events (rarely used in practice)

MOA: Decreases renin activity

SAME ADE and Drug drug as RAAS

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Thiazide and Thiazide Like Diuretics
Drugs/ Treat/ MOA

Drugs:
Most used: ChlorTHALIdone and
IndapamIDE
OG: HydrchlororoTHIAZIDE
MetolAZone

Treat: hypertension (first line)
Edema

MOA: Inhibit NA and H2O reabsorption at the distal convoluted tubule so there fore keeps water be excreted
Excrete K and M (Hypokalemia)
**not a strong diuretic, preferred for HTN but not HRT failure; further down tubule so not as strong

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Thiazide ADE

Same Drug Drug as RAAS

Drugs:
Most used: ChlorTHALIdone and
IndapamIDE
OG: HydrchlororoTHIAZIDE
MetolAZone

Dermatologic: sunburn and increased risk for squamous and basal cell carcinoma

Sulfa/ Sulfonamide allergy

Sexual Dysfunction: up to 25% of males (on ChlorTHALidone)

Hyper GLUC (Hydrochlorothiazide)
G=^ glucose (watch diabetes) L=^Lipids
U=^ Uric acid (watch gout)
C=^ Calcium (helpful for osteoporosis)

Chlorthalidone: ^risk hypokalemia (8%)
Indapamide: lowest risk hypokalemia and neutral glucose and lipids

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Thiazide Prescribing Considerations

Drugs:
Most used: ChlorTHALIdone and
IndapamIDE
OG: HydrchlororoTHIAZIDE
MetolAZone

Always prescribe to take in the morning once daily to avoid nocturia

Chlorthaldone and Indapamide first choice for longer half life and greater effectiveness than hydrochlorothiazide

If CrCl<30 Thiazides will not work; except for Indapamide: approved to CrCl of 10

Use lowest dose possible; increase dose does not > effect but it does >ADE

Monitor Elytes around 2 weeks and 6-12 months after

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Potassium Sparing Diuretics
Drugs/ Treat/ Use/ MOA

Triamterene and Amiloride

Treat: Edema (very weak)
Add to Thiazide to counter hypokalemia; no ordered individually for HTN
Common: Hydrochlorothiazide/triamterene

MOA: late distal convoluted tubule and collecting duct

Same Drug Drug as RAAS and Thiazide
RISK HYPERKALEMIA: check levels and do not give with ACE-I/ARB/REN
But give with Thiazide to prevent hypokalemia

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Dihydropyridine (DHP) Calcium Channel Blockers (CCB)
Drugs/ Treat/ MOA

CCB: DIPINE Drugs

HTN First line drug
DHP treat D’ High Pressure
Also: Stable angina/ migraine/ anal fissure
**Nifedipine: pregnancy HTN and tocolytic
**Nimodipine: Subarachnoid Hemorrhage

MOA: act on calcium channels in smooth vascular muscles of arterioles

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CCB ADE

DIPINE-Drugs

Only enteral; IV known to cause death

Hypotension with reflex tachycardia (Barro receptors) This is why only use with stable angina; rebound tachy can cause MI

Dose dependent peripheral edema
***NOT fluid retention NO DIURETIC; use and ACE-I or ARB
CCB: arterial vasodilation
ACE-I/ARB: venodilation

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AldosterONE Antagonists
Drugs/ Treat/ MOA

SpironolacTONE and EplereNONE

OG: Non selective SpironolacTONE: HTN, HRT failure, ascites, acne vulgars, hirsutism; therapy transgender feminizing hormone

EplereNONE: HTN and HRT failure

MOA: Both block the action of aldosterone in the distal nephron

Spironolactone also blocks androgen

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AldosterONE Antagonists

SpironolacTONE and EplereNONE

Hyperkalemia

Spironolactone: Anti Androgen Effects: gynecomastia/ impotence/ Menstrual irregularities

Monitor with other drugs that can cause hyperkalemia

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Beta Blockers
1st Gen
2nd Gen
3rd Gen

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OLOL-Drugs
1st Gen: Beta 1/2 blockers: start with N-Z
2nd Gen: Beta 1 blockers: start with A-M
3rd Gen: Beta Blocker and vasodilatory mechanisms (carvedilol, labetalol, nebivolol)

Non Selective Beta Blockers: First Generation

ADE

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OLOL Drugs N-Z
Treat: HTN/ HRT failure/ Angina/ AFib/ Migraine/ Tremor/
Propranolol (for PROfessionals): performance anxiety
Timolol: glaucoma eye drops
Blockade of Beta 1 and Beta 2
***Sotalol also blocks potassium channels (class 3 antidysrhythmic)

BOX Warning: Ischemic HRT disease with abrupt d/c (restart ASAP post operative)

Bradyarrhythmias (bradycardia and AV Blocks)
Bronchospasm: NOT for COPD/ Asthma
CNS Effects: fatigue/ sexual disorders/ depression
Hypoglycemia masking: be careful with diabetes

Selective Beta Blocker: Second Generation

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OLOL-Drugs A-M
Treat HTN/ HRT Failure, angina, AFib, migraine
Used with HTN with present cardiac condition

MOA: selective Beta 1 receptor found on the heart

BOX Warning: Ischemic HRT disease with abrupt d/c (restart ASAP post operative)

Bradyarrhythmias (bradycardia and AV Blocks)
Bronchospasm: MUCH LESS
CNS Effects: fatigue/ sexual disorders/ depression
Hypoglycemia masking: be careful with diabetes

Metoprolol tartate (Lopressor): immediate release 2-4 times daily

Metoporol succinate (Toprol XL): long acting extended release once daily– think SUX= XL

Beta Blocker Third Generation

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Carvedilol/ Labetalol/ Nebivolol
Treat: HTN/ HRT Failure/ Angina/ Afib/ mirage
Carvedilol: CAR=Cardiac; FDA approved for HRT Failure
Labetalol: Lab=Labor; pregnancy
Nebivolol: N= iNO; release iNO reducing systemic vascular resistance

BOX Warning: Ischemic HRT disease with abrupt d/c (restart ASAP post operative)

Bradyarrhythmias (bradycardia and AV Blocks)
Bronchospasm: C/I in ASTHMA and COPD
CNS Effects: fatigue/ sexual disorders/ depression
Hypoglycemia masking: be careful with diabetes

Alpha Blockers
Drugs/ Treat/ MOA

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SIN-Drugs
Conventional: (ZOSIN)
PraZOSIN
DoxaZOSIN
TeraZOSIN

Urologic/Selective: Alpha 1A benign prostatic hyperplasia and kidney stones
(ALL OSIN)
ALfuzOSIN
SilodOSIN (Flomax)
TamsulOSIN (Rapaflo)

MOA: alpha 1 receptors (1A 1B 1D)

ADE:
First dose phenomenon: profound orthostatic hypertension; falls risk; take at bedtime (BEERS list)

Floppy Iris Syndrome: Alpha 1 undergoing cataract surgery

Sexual Dysfunction (EJ decreased)

Alpha 2 Agonists
Drugs/ Treat/ MOA/ ADE

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Clonidine/ Methyldopa (pregnancy)/ Guafacine (ADHD)
Treat: withdrawal/ substance use disorder/ vasomotor symptoms with menopause/ HTN/ ADHD

MOA: Alpha 2 presynaptic receptors within brainstem: A2 Agonist will cause a negative feedback loop to shut down sympathetic nervous system < HR < BP < Adrenyline– can cause withdrawal symptoms is stopped suddenly

ADE: Epidural use for pain only when monitored
Bradycardia/ hypotension
Sedation and dry mouth
Withdrawal symptoms (wean slowly)

Direct Vasodilators

Drugs/ Uses/ MOA

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Hydralazine, Minoxidil
Hydralazine: Emergent HTN; Emergent HTN in pregnancy; Hrt failure
Minoxidil: HTN; topical for alopecia

MOA: Directly relax smooth muscle with little effort on veins

Direct Vasodilators

ADE

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Minoxidil Box Warning: Pericardial effusion; only use in pts who have not responded to a diuretic and two other antihypertensive agents
Box Warning II: uses with a Beta Blocker to prevent tachycardia and increased myocardial workload

Hydralazine: Induce lupus like syndrome
Hypotension with reflex tachycardia
Long term use can cause Na + H2O retention: use with a diuretic

Hypertension Pregnancy Drugs

NIfedipine (1st line) Labetalol Methyldopa Hydralazine Thiazide diuretics "Hot Mamas Need Love" Hydralazine (HTN emergency) Methydopa (a2 agonist) Nifedipine (DHP-CCB 1st line) Labetolol (non selective B-Blocker) AVOID RAAS: Kidney damage to fetus

Initial HTN Drug Selection First Line Drugs

ACE-1/ ARB DHP CCB Thiazide/Thiazide-Like diuretic ***Most important thing is BP reduction not initial drug selection Start low, go slow If BP not controlled with initial dose then increase once; if still not enough then add an additional drug (better to add a drug than go up to avoid worse ADE) ***BP is more than 20/10mmHg above goal; combo therapy should be initiated first

Drug Hierarchy HTN

First Line: ACE-1/ ARB DHP CCB Thiazide/ like drug Second Line: use a combo of above Third Line: Use a combo of above plus a Thiazide diuretic Fourth Line: Aldosterone Antagonist Fifth Line: Beta Blocker: Carvedilol, Lebetaol, Nebivolol Sixth Line: Any other classes Co-morbidities with HTN FIRST LINE: MI/HF/Angina: beta blocker CKD: ACE-I/ ARB DM w/ albuminuria: ACE-I/ ARB

HTN Monitoring when Treating

B/P every 4 weeks till at goal Q 2 weeks for severely high BP Once at goal reassess every 3-6 months Labs (Elytes and SCr) reassess 1-3 post initiation/ titration Then annually

HTN Emergency Nitrates

: vascular smooth muscle relaxation Sodium Nitroprusside: BOX WARNING: Hypotension and ischemia; Must reconstitute Nitrates: BOX WARNING: Cyanide toxicity; caution with renal impairment in older adults

HMG-CoA Reductase Inhibitors Hydrophilic vs Lipophilic CYP3A4 metabolism vs other routes High Intensity Therapy choice

STATIN- Drugs Hydrophilic: rosuvastatin, pravastatin Lipophilic: all others CYPO3A4 metabolism: Atorvastatin, Lovastatin, Simvastatin High Intensity: Atorvastatin (40-80), rosuvastatin (20-40)

HMG-CoA Reductase Inhibitors Uses/ MOA

STATINS hypercholesterolemia Primary and secondary (prevent subsequent events) prevention of CV events First choice CV reduction in: diabetes and post MI MOA: Inhibit HMG-CoA Reductase, a rate limiting step of cholesterol synthesis in the liver : trying to catch and pull cholesterol from the blood stream Pleiotropic Benefit: can lower CRP Effects LDL, TG, HDL

STATIN HMG-CoA ADE

ADE: Myopathy (muscle pain) and Rhabdomyolysis (rapid muscle break down) 5-10% pts myopathy: will resolve is medication is stopped check CK (creatine kinase) Try hydrophilic statin; may not move as easily into muscle cells Diabetes Warning: 1/500 pts at risk for developing diabetes; CV benefit outweighs risk Memory impairment? BBB crossing; Not proven Hepatoxicity: Baseline LFT and then as needed

STATIN HMG-CoA Drug Drug

check CK levels when used with Daptomycin (strong ABX) W/ Fibrates may increase myopathy CYP3A4 Statins (PACMAN loves Grapefruit juice

STATIN HMG-CoA Prescribing Considerations

Rosuvastatin: pts of East Asian descent were found to have two-fold higher levels Do not use in pregnancy or breastfeeding Therapy is lifelong High Intensity drugs do not mean Higher risk for ADE Admin at bedtime (you create cholesterol primarily at night Simvastatin only 20mg with amlodipine Lipid panel baseline and then every 4-6 weeks after initiation/titration and then every 3-12 months

Who gets a STATIN

Primary Prevention: age 30-79yrs LDL >190= high intensity statin LDL= 70-190 Diabetes: moderate intensity unless ASCVD risk then high intensity No Diabetes: 10 yr ASCVD risk calculator <5% life style 5-7.5% moderate and lifestyle 7.5-20% moderate >20% high intensity

Cholesterol Absorption Inhibitors Drug/ USE/ MOA

Ezetimibe Alternative to STATIN (myopathy) Benefit if uses with STATIN MOA: inhibits absorption at the brush border of the small intestine Reduces cholesterol in liver Effect on LDL, TG, HDL

Cholesterol Absorption Inhibitor ADE and considerations

Ezetimibe Myopathy; rare hepatotoxicity; do not use in pregnancy or breastfeeding Simvastatin and Ezetimibe: combo therapy great CV reduction

PCSK-9 Inhibitors Monoclonal antibodies Drugs/ Uses/ MOA/ ADE

Evolocumab Alirocumab MABs (monoclonal antibodies) Familiar and primary hypercholesterolemia MOA: monoclonal antibody binds to and inhibits PCSK-9; results in more LDL receptors and reduced LDL ADE: Inject site reactions one of the newest drugs on the market; expensive and long term data unknown

Fibrates Drugs/ Use/ MOA

FenoFIBRATE GemFIBRozil FenoFIBRic Acid Treat hypertriglyceridemia ^TG MOA: PPAR- alpha agonist, resulting in lower TG levels ADE: myopathy (esp when combined with other drugs) Hepatoxicity Gall stones; CONTRAINDICATED in GALL BLADDER DISEASE) Drug Drug: GemFIBRolzil can cause bleeding risk in pts on warfarin

Bile Acid Sequestrants Drug/ Uses/ MOA/ ADE

CHOLESevelam CHOLEStyramine COLEStipol Use: dyslipidemia adjunct; diarrhea with bile acid malabsorption; diabetes adjunct (cholesevelam); hyperthyroidism (cholestyramine specific) MOA: resin binds to bile acid preventing their absorption and promoting excretion GI: constipation, cramping, bloating Malabsorption of fat soluble vitamins (ADEK) Malabsorption of other drugs (separate by 2-4 hour window) Gallstones Colesvelam preferred d/t lowest ADE CONTRAINDICATED: DO NOT GIVE if TG>300 (can increase) and with gallbladder disease

Week 7 Hypertension and Dyslipidemia Flashcards

(40 cards)