4 - Hypertension

BP Goals

First line HTN meds

Other

Normal, Elevated BP, HTN stage 1, HTN stage 2

Ranges

Action to take

Elevated BP: only systolic is high

HTN stage 1: INCLUDES DBP 80

Measuring BP steps: Office, Home

Diastolic, Systolic

Mean Arterial Pressure

Cardiovascular risk factors

Causes of HTN: Medical Conditions

secondary HTN: make sure you treat cause of HTN before adding HTN meds

Renin System - HTN med placement

Nephron - HTN med placement

make sure you locate the PCT first (exam may give you mirror image of nephron)

Loop (thick ascending limb of loop of henle)

Thiazide and thiazide like diuretics (proximal DCT)

K sparing diuretic (distal DCT and collecting ducts)

Diuretics you can use in CrCl <30: lOOp diuretics, and metolazone (thiazide like)

Microzide, Oretic

Generic, Class

Formulation

Dosing

Thiazide Diuretics

HCTZ: Microzide (caps), Oretic (tab)

12.5-25 mg QD, up to 50 mg a day divided into 1-2 doses

minimal response and more electrolyte disturbances seen when dose is higher than 50 mg/day

Diuril

Generic, Class

Formulation

Chlorothiazide, thiazide diuretic

IV (Diuril)

Chlorthalidone

Generic, Class

Initial dosing, max dosing

Comment vs HCTZ

Lozol

Generic

Class

Indapamide

thiazide like diuretic

Zaroxolyn

Generic

Class

Perk

Metolazone

Thiazide like diuretic

Effective in patients with renal failure

Bumex

Generic, Class

Formulation, Max Dosing

Bumetanide

Loop diuretic used for edema

Tabs, max 10 mg day

Edecrin

Generic, Class

Formulation

Unique things vs its whole class

Loop diuretic

Lasix

Generic, Class

Formulation

Indication

Max dose

PO to IV

Furosemide, loops

Comes as tab, oral soln, IM/IV

Indicated for edema, HF

Max 600 mg daily

PO to IV → 2 to 1

Demadex

Generic

Class

Max dose

Torsemide

Loop diuretics

Max dose 100 mg/day

Midamore

Generic

Class

Amiloride

Potassium sparing diuretic

Dyrenium

Generic

Class

Formulation

Triamterene

Potassium sparing diuretic

Caps only

Aldactone

Inspra

Class

Generics

When to use what

Max dosing in CHF

DDI

Potassium sparing diuretic (both aldosterone antagonists)

Spironolactone (Aldactone)

Eplerenone (Inspra)

-

Spironolactone: improve morbidity/mortality in CHF

usually will write Rx for spironolactone but can switch to eplerenone if males have gynecomastia and females have decreased libdo

Spironolactone and Eplerenone: start at lower dose for CHF (25 mg, max 50 mg) than HTN (50-100 mg)

-

Spironolactone - gynecomastia causing meds (any meds that decrease testosterone): ketoconazole, cimetidine (tagamet)

Eplerenone = CYP3A4 substrate

Inderal LA/XL

InnoPran XL

Hemangeol

-

Generic

Formulations

DDI

Unique Indications

BB used for HTN but also passes BBB → good for performance anxiety

BB Side Effects (Memory Tip)

Caution/CI summary

Mask signs of hypoglycemia by decrease HR (wont feel jittery)

Sectral

Generic

Comment

Acebutolol

Can cause drug induced lupus

Tenormin

Atenolol

Levatol

Generic, Class

Penbutolol

BB

Betapace

Betapace AF

Sorine

Sotylize

-

Generic, BB

Formulation

Indication based on brand name

ADE and monitoring

Lopressor

Toprol XL

-

Generic

Toprol XL: formulation, HF initial/max dosing

Regards to food

Other formulations

Corgard

Generic

Excretion pathway

Nadolol

Renal excretion

Kerlone Generic

Betoptic-S formulation

Betaxolol

Ophthalmic: Betoptic-S

Zebeta

Generic

Indication

Excretion pathway

Bisoprolol

HF, HTN

50% renal excretion

Brevibloc

Generic

Formulation

Indication

Bystolic

Generic

DDI

Nebivolol

CYP2D6 substrate

Coreg, Coreg Cr

Generic

Indication and starting doses

MOA

Regards to food

Dose conversion

Trandate

Generic

Formulation

MOA

Excretion

Labetalol

PO and IV

alpha 1 and beta 1 activity

Renal excretion

Intrinsic Sympathomimetic Activity

Beta blockers that come in IV formulation

Propranolol: broad

Esmolol: works FAST, need ADE to stop quickly

Sotalol: only for antiarrhythmic

B1 selective Beta-Blockers

Tryvio

Norvasc

Generic, Class

Unique

Amlodipine, DHP CCB

No cardiac suppressant → Safest CCB choice in HF

Plendil

Generic, class

Formulation

Felodipine (DHP CCB)

ER tabs

Sular

Generic, class

Formulation

Regards to food

Nisoldipine (DHP CCB)

ER tabs

Without food

Cardene

Generic, class

Formulation

IV onset, duration

ADE

Nicardipine, DHP CCB

PO, IV

IV for HTN emergency

• Onset 15 min

• Duration 4-6 hr

Nymalize

Generic, Class

Formulation for what indication

Nimodipine, DHP CCB

Oral solution ONLY for subarachnoid hemorrhage

Cleviprex

Starting rate

Max mL bc…

CI

Formulation

Storage counseling

Lotensin (→ generic)

Benzapril

Capoten

Generic, Class

Unique

Regards to food

Captopril, ACEi

Shortest acting ACEi (TID)

Empty stomach

Vasotec

Epaned

-

Generic, Class

Formulation

Enalapril, ACEi

Vasotec: only IV ACEi, q6h

Epaned: oral solution

Monopril

Unique

Fosinopril

Safest in renal impairment

Prinivil, Zestril

Qbrelis (formulation)

-

Generic, Class

Lisinopril (ACEi)

Qbrelis: oral solution

Univasc

Generic, class

With regards to food

Moexipril, ACEi

Empty stomach

Aceon

Generic, class

Perindopril, ACEi

Accupril

Generic, class

Quinapril

Altace

Generic, class

Formulation

Rampril

Only ACEi that comes in caps

Mavik

Generic, class

Trandolapril (ACEi)

ACEi

Indications

Side Effects Mnemonic

DDI

Tekturna

Generic, class

Side effects

Avoid…

Alpha 1 - adrenergic blockers (brand/generic, specifics)

Minipress

Cardura

Hytrin

Cardura XL

Flomax

Uroxatral

Rapaflo

Tamsulosin: watch out for sulfa allergy

Alfuzosin and Silodosin: Caution/Contra with CrCl <30 mL/min, CYP3A4 substrate

Minipress

Generic, class

Indication

Prazosin (alpha-1 blocker)

Cardura, Cardura XL

Generic, class

Doxazosin, Doxazosin ER

alpha-1 blocker

Hytrin

Generic, class

Administration time

Terazosin, alpha 1 blocker

QHS

Flomax

Generic, class

Allergy

Regards to food

Tamsulosin, alpha-1 blocker

Uroxatral

Generic, MOA

Administration (including regards to food)

Renal

CI…

Alfuzosin ER, alpha 1 blocker

Rapaflo

Administration (including regards to food)

CI

Renal

Silodosin, alpha 1 blocker

Catapres

Catapres-TTS-(1/2/3)

Kapvay

Duracion

-

Generic, class

Formulation

Tenex

Intuniv

-

Generic, class

Indication

Guanfacine, central alpha-2 agonist

Tenex for HTN

Intuniv (ER) for ADHD

Central alpha 2- agonist

ADE

Methyldopa

Formulation

ADE

Indications with HTN

Reserpine

MOA

Indication

ADE

Apresoline

Generic, Class

ADE

Indication

What to use during pregnancy

Methyldopa and Hydralazine falling out of favor bc ADE

Hypertensive emergency

Hypertensive Urgency

Hypertensive Urgency

Captopril

Clonidine

Labetalol

Amlodipine

HTN emergency med summary

3 vasodilators

2 CCB

3 Beta and alpha blockers

1 Dopamine-1 agonist

1 ACEi

Vasodilators

• Sodium Nitroprusside (Nitropress)

• Nitroglycerin IV

• Hydralazine (Apresoline)

CCB

• Nicardipine

• Clevidipine (Cleviprex)

Beta and alpha blockers

• Labetalol (Normodyne)

• Esmolol (Brevibloc)

• Phentolamine (Regitine)

Dopamine 1 agonist

• Fenoldopam (Corlopam)

ACEi

• Enalapril

Preferred Drugs for Select HTN Emergencies

Aortic dissection

Preferred Drugs for Select HTN Emergencies

AMI, ischemia

Nitropress

Works how fast

Administration and storage

ADE

Antidote

Regitine

Generic, MOA

Indication

ADE

CI

BP Meds to choose

General population

DM

S/P MI or CAD

CHF

Preg
raynauds

BPH

CKD

ESRD

CHF: prefer Entresto over ACE/ARB

ESRD: patients on dialysis → already have hyperkalemia, ACEi/ARB would not preserve renal function but will worsen Hyperkalemia meanwhile loops will fix that

BP medications to avoid or caution

If…

asthma/COPD

DM

sulfa allergy

increased sun exposure

ESRD

Raynaud’s

gout/kidney stones

asthma/COPD: non-selective BB will target lung as well as heart

Raynauds: avoid because BB, triptans, and ergots have increase vasoconstriction → make it worse

Summary of thiazide and loop diuretic

ADE

what to watch out for

thaizide also increases risk of allopurinol sensitivity

loops also have ototoxicity (biggest in Edecrin) (caution with aminoglycosides, cisplatin and vanco) and lupus

Summary of DDI with K sparing diuretics

CCB summary

DHP vs non-DHP

CI/Cautions for non-DHP

Indications

ADE

• Verapamil: more effect on heart, less on vessels → least potent CCB vasodilator

  • Less headache, flushing, peripheral edema, and lightheadedness but

  • Most neg chronotropic and inotropic effects

ACEi summary

MOA

Increase and decrease which electrolytes → DDI

ADE

Good in what patients

Preg

IV ACEi

ACEi with shortest t1/2

ACEi whose capsule can be opened

if patient has history of angioedema with ACEi/ARB → use something else in HTN, stick to ARB in HF (benefit > risk). dont use ACEi or entresto though (bc of sacubitril part)

ARB doesnt affect bradykinin

Lifestyle modifications (5)

Medications that can increase BP

Non-DHP increase concentration of what?

CYP3A4 inhibitor →

The concentration of non-DHP is affected by what meds?

Nifedipine Formulations

Nifedipine: put kNIFE through the vessels —> decrease BP more than any other DHP

IR Nifedipine: dosed TID for agina and Raynaud’s, dont use IR for HTN in ER

Diltiazem Brand/Generic

Remember 20 mg IV over 2 min for Afib/flutter

Verapamil Formulations

Remember 5-10 mg IV over 2 min for SVT

Preferred Drugs for Select HTN Emergencies

catecholamine excess

Preferred Drugs for Select HTN Emergencies

Pulm edema

Preferred Drugs for Select HTN Emergencies

Acute renal failure

Preferred Drug for Select HTN Emergencies

Subarachnoid hemorrhage

Preferred Drug for Select HTN Emergencies

Eclampsia or Preeclampsia

Alpha-1 blocker

ADE

Not recommended unless

Corlopam

Generic, class

Indication, MOA

ADE

Fenoldopam (Corlopam)

IV dopamine-1 (D1) receptor agonist, only for hypertensive emergencies

Renal hypertensive emergencies → selectively dilates renal arteries to increase renal blood flow and urine output

Avoid in glaucoma (severe risk of increased intraocular pressure).

Check for sulfite allergy and aggressively monitor for hypokalemia

Which HTN meds shouldnt be taken together

Drugs to avoid in sulfa allergy

Loop Diuretic Equivalence