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Hypertension
| Question | Answer | |
|---|---|---|
| Zestoric | Lisinopril/HCTZ | |
| Hyzaar | Losartan/HCTZ | |
| Benicar HCT | Olmesartan/HCTZ | |
| Diovan HCT | Valsartan/HCTZ | |
| Edarbyclor | Azilsartan/Chlorthalidone | |
| Lotensin HCT | Benazapril/HCTZ | |
| Atacand HCT | Candasartan/HCTZ | |
| Vaseretic | Enalapril/HCTZ | |
| Fosinopril/HCTZ | ||
| Avalide | Irebesartan/HCTZ | |
| Moexipril/HCTZ | ||
| Quinapril/HCTZ | ||
| Micardias HCT | Telmisartan/HCTZ | |
| Lotrel | Benazepril/Amlodipine | |
| Exforge | Valsartan/Amlodipine | |
| Azor | Olmesartan/Amlodipine | |
| Prestalia | Perindopril/Amlodipine | |
| Telemisartan/Amlodipine | ||
| Trandolapril/verapamil | ||
| Tenorectic | Atenolol/chlorithalidone | |
| Ziac | Bisoprolol/Hctz | |
| Metoprolol Tartrate/HCTZ | ||
| Maxzide-25 | Triamterne/HCTZ | |
| Aldactazide | Spironolactone/HCTZ | |
| Tribenzor | Olmesartan/amlodipine/HCTZ | |
| Exforge HCT | Valsartan/amlodipine/HCTZ | |
| Thiazide diuretics and thiazide like diuretics | inhibit Na re absorption in the Distal convoluted tubule (DCT), causing increased excretion of Na, CL, K and water. | |
| Thiazide Diuretics or Thiazide like Diuretics Decrease | K, Mg, Na | |
| Thiazide Diuretics or Thiazide like Diuretics Increase | Ca, UA, LDL, TG, BG | |
| Thiazide Diuretics or Thiazide like Diuretics cause | photosensitivity, Impotence, dizziness, rash | |
| Thiazide Diuretics or Thiazide like Diuretics NOTES | when crcl <30 ml/min-Thiazide have a diminished effect - except METOLAZONE (INDICATED FOR volume overload in combo with loop diuretic) | |
| Thiazide Diuretics or Thiazide like Diuretics DDI | -Decrease lithium renal clearance and Increase risk of lithium toxicity -Nsaids decrease thiazide diuretic effectiveness -Thiazides can increase Dofetilide serum conc, leading to increased risk of QT prolongation-do not use in combo | |
| Calcium channel Blockers | inhibit Ca ions from entering vascular smooth muscle and myocardial cells | |
| DHP- CCBs | more selective for vascular smooth muscle,-causes peripheral arterial vasodialation (decreased SVR and BP) and cornonary artery vasodialation. | |
| Non DHP-CCBs | are more selective for myocardium, making them less potent vadodialatiors-decrease BP by non-CCBS are due to NEGATIVE INOTROPIC (decreased forced ventricular contraction) and NEGATIVE CHRONOTROPIC (decreased HR) effects. | |
| Dihydropyridine CCBS (DHP-CCB) | -Amlodipine (Norvasc, Katerzia, Norliqva) -Nicardipine (Cardene IV)-injection -Nifedipine (Procardia XL, Aldact CC) -Felodipine -Isradipine -Nisoldipine ER (Sular) and original formulation -Clevidpine (Cleviprex) -injection | |
| Dihydropyridine CCBS (DHP-CCB) CI | Nicardipine should not be used in advanced aortic stenosis | |
| Dihydropyridine CCBS (DHP-CCB) Warnings | HYPOtension, Worsening angina, and/or MI, severe hepatic impairment, Use caution in HF -Nifedipine IR-DO NOT use in chronic hypertension or acute BP reduction or in non-preg adults (SIG hypotenstion), MI and/or Death has occured) | |
| Dihydropyridine CCBS (DHP-CCB) SE | generally well tolerated, Peripheral edema, HA, flushing, Palpitations, reflex tachycardia, fatigue, nausea, gingival hyperplasia | |
| Dihydropyridine CCBS (DHP-CCB) monitoring | Peripheral edema, BP, HR | |
| Dihydropyridine CCBS (DHP-CCB) NOTES | -Amlodipine considered safe if a DHP CCB must be used to lower BP in a pt with HF with reduced ejection fraction -Nifedipine ER-drug of choice in pregos -Procardia XL-Ghoast tab and OROS gel formulation | |
| DO NOT USE Clevidipine (Cleviprex) if | allergy to soybeans, soy products, eggs, -defective lipid metobolism, nephrosis, hyperlipidema with acute pancreatitis, severe aortic stenosis | |
| Clevidipine (Cleviprex) warnings | hypotension, reflex, tachycardia, infections (Use a strict aseptic technique due to infection risk (max time of use after vial is puncture is 12 hrs)-a lipid emulsion provides (2kcal/ml) and is milky white in color | |
| Clevidipine (Cleviprex) SE | Hypertriglyceridemia, HA, AF, NAUSEA Monitor Bp and HR | |
| Non-DHP CCBs | Verapamil (Calan Sr, Verelan, Verelan PM) Diltazem (Cardizem, Tiazac, Cardizem CD, Cardizem LA, Cartia XT, others) | Used primarily to control HR in certain arrthymias (AF) and sometimes used for hypertension and chronic stable and vasoplastic angina |
| Non-DHP CCBs CI | Hypotension (SBP <90) or cardiogenic shock, 2nd or 3rd degree AV block or sick sinus syndrome -Diltiazam: acute MI and pulm congestion -Verapamil:Severe Left ventricular dysfunction | |
| Non-DHP CCBs Warnings | HF (may worsen symptoms), bradycardia, hypotension, acute liver injury/increased LFTs, cardiac conduction abnormalities (Diltz), hypertropic cardiomyopathy (verap) | |
| Non-DHP CCBs SE | consipation (more with verap), gingival hyperplasia, edema (more with diltz), HA, Dizziness, cutanous hypersensitivy reactions (diltz) | Monitor: BP, HR, ECGs, LFTs IV:PO dose conversions are not 1:1 |
| Non-DHP CCBs DDI | use in caution with other HR lowering drugs (BB, Digoxin, clonidine, amiodarone, precedex) | |
| All CCBs DDI (except Clevidipine) | Major substrates of CYP450-3A4, check for drug interactions - use caution in strong CYP3A4 ind/inh,DO NOT USE with GFJ | |
| Diltazem and Verapamil DDI | Are substrates & inhibi of Pgp and mod inhib of Cyp3A4- can increase cont. of many drugs. Pts taking simvastatin or lovastatin should use lower doses or use pitavastain, pravastatin, rosuvastatin | |
| ACE inhibitors MOA | block the conversion of ang I to ang II resulting in decreased vasocontriction and decreased aldoserone secretion - also block the degradation of bradykinin (causes cough and angioedema) | Slow the progression down of CKD (gfr <60ml/min and or albuminuria) For HF-protect the myocardium from remodeling effects of Ang II and improve survival |
| Ace inhibitors list | -Benazepril (Lotensin) -Enalipril (Vasotec, Epaned oral sol, Enaliprat (vasotec IV) -Lisinopril (Zestril, Prinivil, Qbrelis oral sol.) -Quinapril (Accupril) -Ramipril (Altace) -Captopril -Fosinopril -Moexipril -Perinodopril -Trandolapril | |
| Ace inhibitors BW | injury and death to fetus in 2nd and 3rd trimester-d/c as soon as pregnancy is detected | |
| Ace inhibitors CI | -DO NOT use with History of angioedema -Do not use within 36 hrs of entresto -Do not use with aliskiren in pt with DM | |
| Ace inhibitors Warnings | -Angioedema -Hyperkalemia -Renal Impairment (increased risk w/bilateral renal artery stenosis (avoid use) -Hypotension/dizziness | Monitor: BP, K, renal function (increased Scr), s/sx of angioedema SE: cough, HA |
| ARB MOA | block ang II from binding to AT1 receptor on vascular smooth muscle, preventing vasoconstriction, and on the adrenal gland, preventing aldosterone secretion and subsequent NA and water retention. | Slow the progression down of CKD (gfr <60ml/min and or albuminuria) For HF-protect the myocardium from remodeling effects of Ang II and improve survival |
| ARBs List | Irbesartan (Avapro) Losartan (Cozzar) Olemsartan (Benicar) Valsartan (Diovan) Azilsartan (Edarbi) Candesartan (Atacand) Telemisartan (Micardis) | Less cough, less angioedema, NO washout period required with Entresto |
| ARBs warnings | Olmesartan: sprue-like enteropathy-severe, chronic diarrhea when substantial weight loss, can occur months to years after drug initation | Notes: Azlisartan: Keep in original container to protect from light and moisture |
| Aliskiren MOA | Tekturna- directly inhibits renin | |
| Aliskiren CI | Do not use with ace/arbs in pt with Dm | Notes: Must protect from moisture |
| Spironolactone and Elperenone MOA | Aldosterone receptor antagonists-indirectly inhibit sodium channels by blocking the aldosterone recepto r site and are the preferred add on drugs for resistant hypertension. | Used first line for heart failure. |
| Spironolactone (Aldactone) is a | NON-selective receptor antagonist (also blocks androgen), | |
| Eplerenone (Inspra) | Is a selective aldosterone receptor antagonist that does NOT exhibit endocrine SE | |
| Triamterene and amiloride | are potassium sparing diuretics that exert their effects by directly blocking Na channels in the late distal convoluted tubule and collecting duct of the nephron | Have minimal BP lowering effects but are primarily used in combo with thiazide diuretics to counteract the mild K losses seen with thiazide diuretics |
| Spironolactone | Aldactone, carospir oral sol. | 25-100 mg daily 1-2 daily divided doses |
| Triamterene | Dyrenium | 50-300 mg daily 1-2 divided doses |
| Potassium sparing Diuretics BW | Amiloride and triamterene: hyperkalemia (K> 5.5 mEq/L)- more likely in pts with Dm, renal impairment, or elderly pt | |
| Potassium sparing Diuretics Ci | Do NOT use with hyperkalemia, severe renal impairment, addisons disease (spiro) or if taking strong CYP3A4 inhib (eplerenone)-dont use with CYP3A4 inhib | |
| Potassium sparing Diuretics SE | Hyperkalemia, Increased Scr, dizziness, hyperchloremic metabolic acidosis (rare) Spironolactone: gycomastia, breast tenderness, impotence, irregular menses, amenorrhea | Monitoring: BP, K, renal function, fluid status |
| BB MOA | competitively block beta 1 and/beta -2 adrenergic receptors, their actions beta 1 (in the heart) decrease HR and myocardial contractillity, which decreases BP | Beta 2 receptor blockade causes broncoconstriction |
| BB are NOT first line | for hypertension unless the patient has stable angina, post-MI, or HF | |
| Beta blockers with intrinsic sympathomimetic activity (ISA) | Acebutolol, pindolol-partially stimulate beta receptors at rest while blocking the effects of catecolamine (nor epi)-Not recommended for pts post MI or in HF bc they do not decrease HR compared to other BB | |
| B1 Selective BB | Atenolol (Tenormin) -Esmolol (Brevibloc)-injection -Metoprolol tartrate (Lopressor)-tab and injection -Metoprolol Succinate (Toprol XL, Kapsargo sprinkle)-ER tab, cap -Acebutolol -Betaxolol -Bisoprolol | Metoprolol tartrate and succinate should be taken with or immediatly following meals |
| B1 Selective BB with Nitric oxide dependent vasodialation | Nevivolol (bystolic) | CI: Severe liver impairment (CPC b or c), SE: fatigue, HA, N/D, Increased TG, and decreased HDL |
| B1 and B2 blockers (NON-selective) | propranolol (inderal La, XL, Innopran XL, Hemageol) -Nadolol (Corgard) -Pindolol -Timolol | CI: Bronchial asthma NOTES: propranolol has a high lipid solubility and crosses BBB-migraine prophylaxis (more CNS effects) -NS BB are used to prevent variceal hemorrhage in pt with portal htn |
| NON-selective BB and A-1 blockers | Carvedilol (coreg, CR) Labetaolol-tab,injection | |
| Carvediolol (coreg, CR) | CI: severe hepatic impairment W: IOFS-pts previously with cataract surgery or on a alpha 1 blocker Se: Weight gain, edema | Notes: Take all forms with food-to decrease risk of orthostatic hypotension Coreg 3.125 mg Bid = Coreg CR 10 mg daily |
| Labetalol | SE: N NOTES: drug of choice in pregos | |
| ALL BB BBW | DO NOT DC abrubtly (esp. in CAD/IHD), gradually taper doses over 1-2 weeks to avoid acute tachy, hypertension, and or ischemia | |
| ALL BB CI | severe bradycardia-2nd/3rd AV block or sick sinus syndrome, overt cardiac failure or cardiogenic shock | Esmolol CI: Pulm hypertension, use IV non-DHP ccbs |
| ALL BB WARNINGS | Use in caution it pts with Dm-can worsen hypoglycemia and mask hypoglycemic symptoms. -Use caution with Broncospasm diseases (asthma/COPD) -Use in caution with Raynauds/PVD and pheochromocytoma -Can mask signs of hyperthyroidism (tachy) | |
| ALL BB SE | Bradycardia, hypotension,CNS effects (fatigue, dizziness, depression), impotence , cold extremeties (exacerbate raynauds) | |
| ALL monitoring for BB | HR, BP | |
| BB NOTES | -Toprol Xl-can be cut in half but should not be crushed or chewed -Kapspargo sprinkle should be swallowed whole but can be opened and sprinkled on 1tsp of soft food and eaten within 60 min | Metoprolol Tartrate IV is NOT equal to PO- IV:PO ratio is 1:2.5 |
| Carvedilol, Propranolol, Metoprolol, and nebivolol are | Major substrates of CYP2D6-monitor for drug interactions | |
| Carvedilol and propranolol are inhibitors of | Pgp and can increase serum cont. of p-gp substrates - | |
| Centrally acting Alpha 2-adrenergic agonists | Decrease BP by stimulating presynamptic alpha-2 adrenergic receptors in the brain, this decreases sympathetic outflow of NORepi-which leads to reduction in SVR (and BP) and HR. | |
| Clonidine | ER: Nexiclon XR Patch: Catapress TTS Injection: Duraclon-Epidural use only -Kapvay-ADHD | Patch: 0.1 mg/24 hr Q7 days |
| Guanfacine IR | ER: Guanfacine (Intuniv)-ADHD | |
| Methyldopa | CI: Concurrent use with MAOi and active liver disease Warnings: Risk of hemolytic anemia, hepatic necrosis SE: DILE, edema or weight gain (control with diuretics), increased prolactin levels, transient sedation, HA NOTES: can be used in pregnancy | |
| Clonidine and Guanfacine IR | Warnings: Do not DC abruptly-can cause rebound HTN, sweating, anxiety, tremors, -must taper gradually 2-4 days SE: Dry mouth, somnolence, fatigue, dizziness, constipation, decreased HR, hypotension, impotence, HA, behavioral changes | SE: Clonidine patch: skin rash, pruritius, erythema NOTES: clonidine patch-apply weekly, clean hairless area upper outer arm or chest, remove before MRI-Do not cut-takes 2-3 days to reach therapeutic effect Monitor: BP, HR, mental status |
| Direct vasodialators MoA | cause direct vasodialation of arterioles (little effect on veins), resulting in decreased SVR and BP | Hydralazine -tab, injection Minoxidil- |
| Hydralazine | CI: mitral valvular rheumatic heart disease, CAD W: DILE SE: Peripheral Edema/HA/Flushing/palpitations, reflux tachy/ N/V/peripheral neuritis, blood dyscrasisas, hypotension | Monitoring: BP, HR, ANA titer |
| Minoxidil | BW: potent vasodilator -can cause pericardial effusion due to fluid retention and angina exacerbations (due to reflux tachy)- administer with BB and loop | CI: Phenochromocytoma SE: hair growth, tachy, fluid retention (caution in recent MI or HF) |
| Hypertensive Crisis | an acute and severe BP elevation, ≥ 180/120 mmHg | 2 types: -Hypertensive emergency -Hypertensive urgency |
| Hypertensive Emergency | acute target organ damage that may be life threatening (encephalapathy, stroke, acute kidney injury, ACS), aortic dissection, acute pulm. edema | Treat with: IV meds Decrease BP by NO MORE than 25% (within first hr), then if stable decrease to ~160/100 mmHg in the next 2-6 hrs |
| Hypertensive Emergency IV meds | Clevidipine Enalaprilat Esmolol Hydralazine Labetalol Nicardipine Nitroglycerin Nitroprusside | |
| Hypertensive Urgency | Severe asymptomatic HTN, no evidence of target organ damage | Treat with: -Short acting oral meds (captopril, clonidine) or restart chronic HTN TNT, -Decreae BP gradually over 24 to 48 hrs |
Created by:
mrgarci3