327 Hyper tension

Normal BP

120/80

Elevated BP

120-129/80

Stage 1 Hypertension

130-139/80-89

Stage 2 Hypertension

140/90

Classes of Hypertension Drugs

Diuretics, ACE inhibitors, Calcium channel blockers, Beta blockers

Examples of Thiazide Diuretics

HCTZ, Chlorthalidone, indapamide, metolazone

Examples of Loop Diuretics

Furosemide, Torsemide, Bumetanide

Examples of Potassium-Sparing Diuretics

Amiloride, triamterene

Examples of Aldosterone antagonist’s diuretics

Spironolactone, eplerenone

Side effects of thiazide diuretics

Hypokalemia, hyperglycemia, hyperlipidemia, hyperuricemia, polyuria, photosensitivity due to sulfonamide group.

Chlorthalidone

Hygroton, 6.25-25 mg/day, 1x/day, thiazide diuretic

Hydrochlorothiazide

HydroDiuril, 12.5/50 mg/day, 1x/day, thiazide diuretic

Loop Diuretics

Not used for hypertension, does lower blood pressure, good for people whose CrCl is less than 30mL/min, edema, or HF

Side effects of Loop diuretics

Similar to thiazide drugs. Hypercalcemia due to the blocking of both sodium and calcium reabsorption. 

Side effects of Potassium Sparing Diuretics

Hyperkalemia, drug interactions 

Spironolactone

Aldosterone Antagonist, may decrease mortality in heart failure, associated with gynecomastia. Additive hypotensive effects when used in combination with thiazide or loop agent.

Eplerenone (Inspra)

Selective aldosterone receptor antagonist (SARA). FDA indicates for monotherapy or combination therapy of hypertension. Dosing 50mg/day up to 2x a day. Four weeks for full effect.

Eplerenone (Inspra) Side Effects

Cleared through CYP3A4, Headache, dizziness, gynecomastia, breast tenderness, menstrual irregularities, avoid if CrCl<50 mL/min

Angiotensin Converting Enzyme (ACE) Inhibitors

All are equally effective, differ in duration of effect and tissue penetration. Adverse drug reactions are similar. Slow progression of Heart Failure, Beneficial most MI, slows progression of diabetic nephropathy. Avoid in pregnancy (developmental anomalies), renal insufficiency, hyperkalemia

Side effects of ACE inhibitors

Hypotension- Common in sodium or volume depleted individuals, DC or decrease dosage of other diuretics and drugs before starting ACE inhibitors, start with low dose especially if HF is present; Cough, Rash, Renal Effect (acute renal failure)

Angioedema: facial and respiratory inflammation due to fluid retention,

SCr of 35%

If there is a 35% increase in serum creatinine from baseline OR a 1mg/dl increase above baseline, then stop med or reduce dose 

Angiotensin II Receptor Blockers (ARBs)

Relatively flat dose-response relationship. Avoid in pregnancy (teratogenicity, acute renal failure in neonates), Orthostatic hypertension, renal insufficiency, hyperkalemia, angioedema (less likely than ACE use) 

Examples of ARBs

Lorsatan (Cozaar), Valsartan (Diovan), Olmesartan (Benicar); Diovan and Cozaar require renal adjustment.

Can you use ACE inhibitors and ARBs together

No

Calcium Channel Blockers

All equally effective as antihypertensive agents. We use Dihydropyridines over non-dihydropyridines. Decreased risk of stroke, but not as much as ARBs, no pro/con for risk of HF or CHD

Dihydropyridine CCBs

Amlodipine, felodipine, nifedipine, etc.

Non-dihydropyridine

Diltiazem, verapamil. Can cause bradycardia, affects AV conductions, contraindicated in pts. with AV block

Side effects of non-dihydropyridines

Dizziness, flushing, headache, peripheral edema

Side effects of dihydropyridines

Reflex tachycardia, dizziness, flushing, headache, edema, drowsiness

General CCB side effects

Lower extremity edema, constipation, gingival hyperplasia

CCB counseling points

Report weight gain and peripheral edema to prescriber, may use a stool softener if constipation occurs

Diltiazem

180-240mg/day once a day

Verapamil

180-240mg/day once a day

Beta Blockers

Equally effective in HTN, Ancillary benefits. Can be cardioselective, dose dependent

Side effects of beta blockers

Hypotension, bradycardia, fluid retention, fatigue, increased triglycerides, weight gain, decrease in endurance. Contraindicated in HR<60, SBP<100. Proceed with caution in patients with Asthma, COPD.

Beta Blocker Counseling points

Use with caution with positional changes, especially initiation of medication. Fatigue may improve with time and steady state levels of medication. Do not abruptly DC medication, risk of MI/Angina/death.

Examples of Beta blockers

Atenolol, Metoprolol, Bisoprolol