Module 4- Pharmacology

Hypertension Medications

Medication Classes for Hypertension

1. Renin-angiotensin Aldosterone System Suppressants (RAAS)

2. Calcium Channel Blockers

3. Sympatholytic (Antiadrenergic)

4. Direct-acting Vasodilators

Renin-angiotensin Aldosterone System Suppressants (RAAS)

Renin-angiotensin Aldosterone System Suppressants (RAAS) Medication Classes

Angiotensin-converting Enzyme (ACE) Inhibitors

Angiotensin II Receptor Blockers (ARBs)

Aldosterone Antagonists

Direct Renin Inhibitors (DRIs)

Angiotensin-converting Enzyme (ACE) Inhibitors

Think: pril

Captopril, Benazepril, Enalapril, Lisinopril, Ramipril

These medications are given for hypertension, heart failure, post MI, and renal impairment (diabetic nephropathy)

Always monitor BLOOD PRESSURE before administering these medications! Check CBC, CMP, or BMP labs; potassium levels

Start low and go slow, do not stop this medication abruptly!

Captopril

The prototype ACE inhibitor that is used for daily therapy

Always give WITH food!

Adverse effects of ACE inhibitors

Hyperkalemia, Angioedema, dry/non-productive cough, dizziness, Orthostatic hypotension, metallic taste in the mouth, rash, neutropenia

Precautions for ACE Inhibitors

Pregnancy and lactating women- there can be teratogenic effects

This medication is LESS effective in African Americans! Increased risk of angioedema

What medication is often given alongside ACE inhibitors AND ARBs to increase efficacy?

Diuretics

Angiotensin II Receptor Blockers (ARBs)

Think: sartan

Losartan, Irbesartan, Valsartan, Telmisartan

Used for hypertension, heart failure, Diabetes neuropathy

Daily therapy, with maximum effects in 3-6 weeks

Always monitor BLOOD PRESSURE before administering! Assess electrolytes and renal function

BLACK BOX WARNING! (Injury and death to developing fetus)

What ARB is the prototype?

Losartan

Which ARB is given for heart failure?

Valsartan

Adverse effects of ARBs

Dizziness, hypotension, muscle weakness, cramps, heartburn, diarrhea, CNS effects, headache, insomnia

Many interactions with herbal, foods, and meds!

Aldosterone Antagonists

Eplerenone & Spironolactone

Given for hypertension and symptoms of heart failure following an MI

Therapeutic effects may take up to 4 weeks!

Give PO only, give alone or combined with other anti hypertensives

Adverse effects of Aldosterone Antagonists

Hyperkalemia (report any signs, palpitations, muscle twitching, weakness, or parenthesis in extremities to the provider)

Interactions and Teaching for Aldosterone Antagonists

NSAIDs may decrease the effectiveness (they could cause lithium toxicity!)

Do NOT take potassium supplements or use potassium containing salt substitutes or drugs unless prescribed due to the adverse effect of Hyperkalemia with this drug!

Direct Renin Inhibitors (DRIs)

(RAAS)

Aliskiren (only drug on the market!)

Used for hypertension

Taken by mouth

Adverse effects & Precautions of DRIs

Hyperkalemia

Diarrhea

Abdominal pain (more likely in high doses)

Pregnancy RISK! (Teratogenic effects), Hyperkalemia, hypercalcemia or dehydration

*Do NOT take potassium supplements, or use potassium-containing salt substitutes or drugs unless prescribed

Calcium Channel Blockers

Prototype Calcium Channel Blockers

Nifedipine

Calcium Channel Blockers

Nifedipine

Verapamil

Diltiazem

Amlodipine

Felodipine

Nicardipine

Given for hypertension, angina pectoris (relieves coronary spasms), exercise-induced angina (reduces oxygen demand), verapamil/diltiazem dysrhythmias (a fib, a flutter, SVT)

Give PO with or without food, IV push or IV drip, many will also take with beta-blockers to prevent reflex tachycardia

Monitor EKG and HR, DilTIAZem and Verapamil is approved for atrial tachycardia-dysrhythmias (have Cardioversion equipment close for toxicity and pacing)

Who are calcium channel blockers best for?

African American patients (first line blood pressure treatment!)

Patient teaching for calcium channel blockers

Lifestyle

Check blood pressure and pulse

Avoid grapefruit juice!

Good dental hygiene! This med can discolor the teeth

Look out for edema in the legs

What can Nifedipine potentially cause?

Cardiogenic shock

Reflex tachycardia, acute toxicity, Orthostatic hypotension, peripheral edema

What can Verapamil potentially cause?

Hypotension, heart block, dig toxicity, severe heart failure, lactation

Adverse effects of verapamil and diltiazem

Peripheral edema, constipation, cardiac function, dysrhythmias, acute toxicity

Sympatholytic (Antiadrenergic)

Types of Sympatholytic Meds

Beta Blockers

Alpha-Adrenergic Blockers

Centrally Acting Alpha-2 Agonists

Beta blocker prototype

Propanolol

Beta1 Beta Blockers

Affect the heart

Metoprolol

Esmolol

Atenolol

Beta1 and Beta2 Beta Blockers

Affects the heart AND the lungs

Propanolol

Nadolol

Alpha and Beta Blockers

Cervedilol

Labetalol

Beta Blockers

Given for hypertension, tachycardia, angina, tachycardia-dysrhythmias, MI, heart failure, hyperthyroidism, migraines, glaucoma

Take PO and IV at the same time daily, do NOT stop without approval (must be tapered over 1-2 weeks)

Avoid activity requiring mental alertness for the first 12-24 hours; change positions SLOWLY, lie down if dizzy or faint

Monitor HR and BP DAILY!

Monitor signs of heart failure

Adverse effects of Beta Blockers

Bradycardia, decreased cardiac output, SOB, Edema, cough, CHD, angina, MI if sudden withdrawal from a client with coronary heart disease, Orthostatic hypotension, AV block

Signs of LEFT heart failure

Dyspnea ,worsening cough at night, crackles, fatigue, pallor

Signs of RIGHT heart failure

JVD, edema, abdominal distension, nocturia, weight gain

Alpha-Adrenergic Blockers

Prazosin

Doxazosin

Terazosin

Given for primary hypertension

Monitor BP for 2-6 hours after the first dose

Give first dose at bedtime

Avoid activity requiring mental alertness for the first 12-24 hours, slow position change, lie down if dizzy or faint

Risk of: FIRST DOSE PHENOMENON, Orthostatic hypotension, palpitations, dizziness, and syncope, Sodium retention and fluid retention

First dose phenomenon

severe and sudden drop in blood pressure after the administration of the first dose of an alpha-adrenergic blocker and Centrally acting alpha-2 agonist

Centrally Acting Alpha-2 Agonists

*Clonidine

Guanfacine

Methyldopa

Given for hypertension alone with a diuretic or with another anti hypertensive, also given for severe cancer pain via a epidural infusion

Give PO twice a day at bedtime to decrease sleepiness, can be given via a patch that is reapplied every 7 days to a dry and hairless skin on the torso or upper arm and rotate the sites

FIRST DOSE PHENOMENON

Direct Acting (centrally acting) Vasodilators

Nitroprusside

Nitroglycerin

Given for a hypertensive CRISIS, a medical emergency that shows a sudden/severe elevated BP of 180-120 or greater, may lead to heart attack or stroke

Headache, chest pain, SOB, nausea, vomiting, vertigo

What is the antidote for nitroprusside?

Thiosulfate

Do not mix nitroprusside with what?

Do not mix in the same infusion with ANY other medications

the solution should be a light brown color that is administered slowly, supine during administration

Discard med after 24 hours

Which medications can be given for a hypertensive crisis?

Nitroprusside

Nitroglycerin

Nicardipine

Clevidipine

Enalaprilat

Esmolol

Adverse effects of hypertensive crisis meds

Excessive hypotension

Cyanide poisoning

Bradycardia

Tachycardia

ECG changes

How can you reduce the risk of Cyanide Poisoning?

Give hypertensive crisis meds LESS than 3 days at a rate of 5 mcg/kg/min or less

Diuretics

What are the 3 MAIN types of diuretics?

Thiazide Diuretics (potassium wasting)

Loop Diuretics (potassium wasting)

Potassium Sparing Diuretics

Thiazide Diuretics

Think: thiazide!

Hydrochlorothiazide and Chlorothiazide

Works at an early distal tubule; blocking reabsorption of sodium and chloride, preventing H2O reabsorption; promotes diuretics when there is a good renal function

FIRST LINE for hypertension along with antihypertensives

Given for edema, heart failure, liver and kidney disease, decreased urine production with diabetes insipidus

Side effects of thiazide diuretics

Dehydration and Hyponatremia

Hypokalemia and hypochloremia

Hyperglycemia, hypercalcemia

Hyperuricemia

Increased LDL

Hypomagnesemia

Teaching while taking thiazide diuretics

Take in the morning, before 2pm

Do NOT take while pregnant

Decrease sodium intake

Daily weights

Monitor blood sugars and BP

Take potassium supplements or foods

Loop diuretics

Furosemide

Torsemide

Bumetanide

Ethacrynic Acid

Use when RAPID and EXTENSIVE diuretics is needed

Use for pulmonary edema

Use when the body is non responsive to other diuretics

Teaching for loop diuretics

Routine BMPs

Baseline BP

Take I&O and daily weights

Assess manifestations of dehydration or thromboembolism

Monitor for oliguria (stop meds and notify doctor)

Monitor blood sugars

Avoid in pregnancy

Sulfonamide allergy cross-sensitivity

Potassium Sparing Diuretics

Spironalactone

Triamterene

Amiloride

Works at distal tubule, blocking the action of the aldosterone (sodium and water retention), resulting in potassium retention and excretion of sodium and H2O

Give for hypertension and edema with other diuretics for potassium sparing effects

Treats heart failure, blocks the actions of aldosterone by retaining potassium and excreting sodium, therapeutic effect can take 12-48 hours

Complications of potassium sparing diuretics

Hyperkalemia, endocrine effects, deepened male voice, impotence, irregular menstruation, drowsiness, metabolic acidosis

Patient teaching in potassium sparing diuretics

Reduce sodium diet (NO salt substitutes!)

No potassium supplements

No potassium rich foods (bananas, oranges, dates)

Report cramps, diarrhea, changes in periods, or voice deepening

Triamterene can turn urine what color?

Blue

Cardiac Glycosides

Cardiac Glycosides

Digoxin

Second-line treatment for heart failure and dysrhythmias like A-fib

Can REDUCE the manifestations but does not prolong a person's life!

What are some important considerations when administering Digoxin?

Administer at the same time each day, do NOT double up the dose if missed!

Check apical pulse and rhythm for 1 minute before giving, if less than 60 bmp for adult, less than 70 bpm for a child, and less than 90 bpm for an infant TELL THE PROVIDER!

IV infuse over 5 mins for those with a pulmonary edema, monitor for dysrhythmias

Monitor potassium and digoxin levels

What do you treat dysrhythmias with?

Phenytoin or lidocaine

What do you treat bradycardia with?

Atropine

What is the therapeutic level of Digoxin?

Maintain levels between 0.8-2 to avoid toxicity

Excessive toxicity may require activated charcoal and cholestryamine Digibind (binds digoxin and prevents reabsorption

Digoxin interactions

If on thiazides or loop diuretics, it can lead to Hypokalemia and dysrhythmias!

ACE and ARBS can lower the effects of digoxin and risk Hyperkalemia

Quinidine and Verapamil put the pt at risk for high digoxin levels and toxicity

Antacids decrease the absorption of digoxin

Adrenergic Agonists

Adrenergic Agonists

Catecholamines

Epinephrine

Dopamine

Dobutamine

Isoproterenol

Norepinephrine

Albuterol

Ephedrine

Administer by IV on a continuous infusion, can be controlled by an IV pump

The dose is titrate based on BP

Always monitor for chest pain, urine output, ECG, BP, perfusion to extremities, cardiac output, pulmonary capillary wedge pressure, central venous pressure, hyperglycemia

Adrenergic Agonists can cause what?

Necrosis which can occur from extravastation

Administer phentolamine (alpha blocker) to counteract the alpha mediated vasoconstriction

Dopamine Low Dose USES

DOPAMINE RECEPTOR

Renal blood vessel dilation, shock, heart failure, acute kidney injury

What is a moderate dose of dopamine used for?

BETA1 RECEPTOR

Renal blood vessel dilation

Increase HR

Increase myocardial contractility

Increase rate of conduction through the AV node

Shock

Heart failure

What is a high dose of dopamine used for?

DOPAMINE, BETA1, ALPHA1 RECEPTORS

Renal blood vessel CONSTRICTION

High heart rate

High myocardial contractility

High rate of conduction through AV node

Vasoconstriction

Pupil dilation

Shock

Heart failure

Who should you NOT give dopamine to?

Pt with tachydysrhythmias and v-fib

Use cautiously with hypovolemia, angina, history of MI, HTN, and DM, older clients

Epinephrine has what 3 categories?

Alpha 1 receptors

Beta 1 receptors

Beta 2 receptors

What do Epinephrine Alpha 1 receptors do?

Vasoconstriction

Used for anaphylactic shock, lowers the