pharm: antihypertensives

CO =

SV x HR

BP =

CO x SVR

normal bp

less than 120

\---------------

less than 80

elevated bp

120-129

\---------

less than 80

stage 1 bp

130-139

\---------

80-89

stage 2 bp

140 or higher

\---------------

90 or higher

hypertensive crisis

higher than 180

—————————

higher than 120

what affects bp?

• smoking

• obesity

• lack of exercise

• salt

• alcohol

• older age

• genetics

• CKD

• adrenal/thyroid disorders

• sleep apnea

bp classification meds

• angiotension-converting enzyme inhibitors (ACE)

• angiotensin II receptor blockers (ARBs)

• direct renin inhibitors

• calcium channel blockers

• centrally acting alpha2 agonists

• beta adrenergic blockers

• hydralazine (vasodilator)

• meds for hypertensive crisis

ACE inhibitors patho

stops angiotensin I from converting to angiotensin 2

• vasodilates

• excretion of sodium and water

• reduces damage in the blood vessels and heart from angiotensin 2 and aldosterone

ACE inhibitors uses

• HTN

• HF

• MI

• diabetic and nondiabetic nephropathy

• pt at high risk of cardiovascular event

ACE inhibitors meds

-prils

• enalapril (vasotec)

• lisinopril (prinival)

• captopril

administration: PO

ACE inhibitors complications

• orthostatic hypotension

  • stop diuretic temp. 2-3 days before starting ACE inhibitors

  • assess orthostatic hypotension after meds

• dry, persistent cough

  • if develop, switch ACE to ARBs

• hyperkalemia

  • priority for heart dysrhythmias

  • risk for renal pt.

    • monitor urine output

  • less potassium in diet

  • monitor for muscle wkns

• angioedema

ACE contrindications

• cautious with pts with renal impairment

• DO NOT TAKE BOTH ACE AND ARBs TOGETHER

• potassium supplements and potassium sparing diuretics inc hyperkalemia risk

• NSAIDs dec effect of ACE

angiotensin II receptor blockers (ARBs) patho

• blocks the action of angiotensin II in the body

• vasodilates arterioles and veins

• excretes sodium and water (by decreasing release of aldosterone)

• an alternative to ACE inhibitors if these are not tolerated by the patient

DO NOT TAKE BOTH ACE AND ARBs TOGETHER

ARBs uses

• HTN

• HF

• stroke prevention

• MI prevention

• reduces mortality following MI

ARBs meds

-sartans

• losartan (cozaar)

• valsartan (diovan)

• irbesartan (avapro)

ARBs complications

• no dry cough or hyperkalemia

angioedema

• treat with subQ epinephrine

• discontinue med

fetal injury

• use contraceptives while on med

hypotension

dizziness, lightheadedness

what do ARBs do to bp?

decreases bp by decreasing vasocontriction, vascular resistance, afterload

direct renin inhibitors patho

• stops initiation of RAAS system

• binds with renin to inhibit production of angiotensin I

direct renin inhibitors med

aliskiren (tekturna)

direct renin inhibitors complications

• hyperkalemia

• hypotension

• angioedema

• rash

• cough

• diarrhea

direct renin inhibitors contraindications

• pts with hyperkalemia

• inc hyperkalemia w/ ACE, potassium sparing supplements, potassium sparing

• cautious with older adults

• cautious with pts w/ asthma, other resp. disorders, hx of angioedema, diabetes mellitus, kidney/hepatic disease, hypotension

• high fat foods dec absorption

calcium channel blockers (CCBs) patho

• blocks calcium, dec. contractility and blood vessels dilate

• cause contraction of heart and vessels

• blocks calcium channels in blood vessels

• vasodilation of vascular smooth muscle in the peripheries & arteries/arterioles of the heart

DON’T GIVE TO HF PTS

CCBs meds

IV or PO

• verapamil (verelan)

• diltiazem (cardizem)

• amlodipine (norvasc)

CCBs uses

• angia

• hypertension

• a-fib

• SVT (supraventricular tachycardia)

diltiazem is used for

a-fib

CCBs complications

• orthostatic hypotension

• peripheral edema

  • diuretics will not help

• suppression of cardiac function

if their heart is weak, what type of med make it worse?

CCBs

for HF pts with inc bp, do not give

CCBs

CCBs interactions

• verapamil can increase digoxin levels

• concurrent use of beta blockers

• NO GRAPEFRUIT!!!

CCBs nursing interventions

• verapamil: administer inj. slowly over 2-3 mins

• monitor BP & HR

  • pulse <60 bpm

  • systolic BP <90 bpm

centrally acting alpha2 agonists patho

• dec sympathetic outflow, thus dec stimulation of adrenergic receptors of both the heart and peripheries

• dec HR and CO

• vasodilates

centrally acting alpha2 agonists uses

• migraine headache

• anxiety management

• management of ADHD

centrally acting alpha2 agonists complications

• dry mouth

• drowsiness

centrally acting alpha2 agonists contraindications

• avoid using during lactation

• pts w/ bleeding disorder or are on anticoags

• cautious in pts w/ stroke, asthma, COPD, MI, diabetes, depressive disorder, CKD

centrally acting alpha2 agonists meds

• clonidine (catapres)

  • patch or PO

• methyldopa (aldomet)

centrally acting alpha2 agonists nursing interventions

* 2x/day
* larger dose at bedtime to dec daytime sleepiness

beta adrenergic blockers patho

aka beta blockers

• sympatholytic

  • dec. sympathetic stimulation

• dec HR

• dec myocardial contractility

• dec cardiac output

• dec rate of conduction thru AV node

cardioselective

• affects beta1

• only the heart

• does not affect lungs

• choose beta1 to block

non-cardioselective

• blocks beta1 & beta2

• affects heart and lungs

• don’t give to COPD, asthma pt b/c bronchospasms

BB uses

• hypertension

• angina

• tachy-dysrhythmias

• HF

• MI

• treatment of hyperthyroidism, migraines

• cardio-protective

BB complications

• bradycardia

• dec CO

• orthostatic hypotension

• can cause an AV block

what to check when taking BB?

apical pulse for 1 min

* do not give if less than 60 bpm

BB meds

-lol

• metoprolol (lopressor)

  • cardioselective

• atenolol (tenormin)

  • cardioselective

• propanolol (inderal)

  • non-cardioselective

    • contraindicated for patients w/ asthma

• carvedilol (coreg)

• labetalol

BB contraindications

• diabetes

  • produces glycogenolysis: breakdown glycogen

• lung diseases

• pts with hypotension, renal, angina, older adults

BB cannot increase

blood sugar

→

can mask tachycardia and signs of hypoglycemia

BB nursing interventions

• PO

• 1 or 2x/day

• take with food to inc absorption

How and when is hydralazine given?

given for hypertensive crisis thru ^^IV^^

hydralazine

• vasodilator → dec PVR

• direct acting smooth muscle relaxant

• dec peripheral resistance

• PO or IV

• can elicit a reflex sympathetic stimulation of the heart, so it is not a primary drug for hypertension

  • has a rebound effect

  • not for 1st line of HTN

hypertensive crisis meds

• nitroprusside (centrally acting vasodilator)

• nitroglycerin (vasodilator)

• nicardipine (CC blocker)

• esmolol (BB)

nitroprusside effect on bp

dec bp to prevent sudden spike in bp

* commonly IV

action of emergency drugs for a hypertensive crisis

• direct and immediate vasodilation

• rapid reduction in BP

  • monitor for hypotension

    • lightheadedness

    • dizzy

    • n&v

    • dec LOC

    • chest pain ***

• monitor ECG and BP cont.

• keep pt supine

• must have its own dedicated IV line if it is an IV drip

• nitroprusside: protect IV container from light

  • sensitive to light b/c deactivates drug

hypertensive crisis med complications

• excessive hypotension

  • rapid administration can dec BP rapidly

  • monitor BP and ECG

  • supine during administration

• bradycardia, tachycardia, ECG changes

hypertensive crisis med contraindications

• pts w/ HF, dec PVR, AV shunt

• cautious w/ pt w/ liver & kidney disease, hypothyroidism, hypovolemia, fluid and electrolyte imbalances, older adults

• do not administer nitroprusside in the same infusion as any other medications

hypertensive crisis med nursing interactions

• dilute for IV infusion

• protect IV container from light

• discard after 24 hrs

• monitor vitals and ECG cont.

meds affecting urinary output

• loop diuretics

• thiazide diuretics

• potassium sparing diuretics

• osmotic diuretics

meds affecting urinary output uses

• manage blood pressure

• excrete fluid causing edema for HF, kidney and liver disease

• prevention of kidney failure

• dec SV, CO, preload

loop diuretics

PO, IV, IM

• used for hypertensive crisis too

• work in the ascending limb of loop of henle

• blocks reabsorption of sodium, chloride and water

  • K, Ca wasting

• causes extensive diuresis

• used in emergent situations and daily maintenance

  • furosemide is not used for daily maintenance if pt only has HTN

    • daily use for renal & HF pts

loop diuretic meds

PO, IV, IM

• furosemide (lasix)

• bumetanide (bumex)

• torsemide (demedex)

loop diuretic complications

• dehydration

• hypotension

• ototoxicity

• hypokalemia

  • monitor K

  • T wave depression

  • muscle wkns

• hypomagnesemia

• hypoglycemia

• hyperuricemia

• hypocalcemia

• dec HDL, inc LDL

furosemide

* monitor for ototoxicity
* esp. if giving thru rapid IV push
* give over 2 mins
* if given fast will experience tinnitus and damage ears

loop diuretic contraindications

• avoid during pregnancy

• pt w/ anuria

• cautious in pts w/ diabetes, dehyration, CV disease, gout electrolyte depletion

• cautious w/ pts taking digoxin, lithium, ototoxic meds, NSAIDs, antihypertensives

loop diuretic interactions

• digoxin toxicity can occur in presence of hypokalemia

• concurrent use of antihypertensives

• NSAIDs reduce diuretic effect

loop diuretic nursing considerations

• BP

• K (3.5-5.1)

  • hypokalemia

• monitor I/O’s

  • 30mL/hr OR 0.5mL/kg/day

  • furosemide: expect urine output in 15 mins

• give in the morning

  • avoid late in the day to prevent nocturia

• advise pt about orthostatic hypotension

  • no sudden changes in movement

  • sit, dangle before getting up

foods high in potassium

• avocado

• banana

• potatoes

• spinach

• beans

• citrus juices

• fish

thiazide diuretics patho

• K wasting

• con be given with ARBs or others

• works in the early distal convoluted tubule

• blocks reabsorption of sodium, chloride and water at this site

• promotes diuresis

  • less compared to loop diuretics

  • less reabsorption on kidneys

• may be used with other antihypertensive agents for BP control

thiazide diuretics meds

• hydrochlorathiazide (HCTZ)

• metolazone

thiazide diuretic uses

FIRST LINE FOR ANTIHYPERTENSIVE MANAGEMENT

• edema

• may be used with other antihypertensive agents for BP control

• reduce urine production in diabetics

• Ca wasting

thiazide diuretic complications

• dehydration

• hyponatermia

• hypokalemia

• hyperglycemia

• hyperuricemia

• hypomagnesemia

• inc lipids

thiazide diuretic contraindications

• void during preg

• if taken during lactation, do not breastfeed

• renal impairment

• cautious in pts w/ diabetes, dehyration, CV disease, gout electrolyte depletion

• cautious w/ pts taking digoxin, lithium, ototoxic meds, NSAIDs, antihypertensives

thiazide diuretic interactions

• digoxin toxicity can occur in presence of hypokalemia

• concurrent use of antihypertensives

• NSAIDs reduce diuretic effect

thiazide diuretic nursing considerations

• BP

• K (3.5-5.1)

  • hypokalemia

• monitor I/O’s

  • 30mL/hr OR 0.5mL/kg/day

• give in the morning

  • avoid late in the day to prevent nocturia

• advise pt about orthostatic hypotension

  • no sudden changes in movement

  • sit, dangle before getting up

• don’t give to pt with high calcium

  • monitor Ca levels (hyperparathyroidism, cancer)

thiazide diuretic effectiveness

• dec BP

• dec edema

• inc urine output

potassium sparing diuretics patho

• blocks aldosterone action resulting in K retention and excretion of Na and H2O

• often combined w/ other diuretics

• useful in HF

• therapeutic effect can take up to 12-48 hrs

potassium sparing diuretics meds

PO

• spironolactone (aldactone)

• triamterene

• HCTZ/triam

  • combo drug

potassium sparing diuretics uses

• hypertension

• edema

• HF

potassium sparing diuretics complications

• caution with ACE, ARBs, and renin inhibitors

  • all causes changes in K+ levels

• hyperkalemia

  • elevated T waves

  • wkns

  • fatigue

  • dyspnea

  • dysrhythmias

• endocrine effects

  • deep voice

  • hirsutism

• drowsiness, metabolic acidosis

potassium sparing diuretics contraindications

• don’t give to pts w/ hyperkalemia, potassium supplements, or other potassium sparing diuretic

• don’t give pts w/ severe kidney failure and anuria

• cautious w/ pts that have kidney or liver disease, electrolyte imbalances, metabolic acidosis

potassium sparing diuretics interactions

• concurrent use of ACE inhibitor, ARBs, direct renin inhibitors inc risk for hyperkalemia

• concurrent use of potassium supplements, salt substitutes, another potassium sparing diuretic inc risk for hyperkalemia

potassium sparing diuretics nursing administration

• daily weight

• monitor BP & I/O’s

• ECG periodically

• monitor K levels

• avoid salt substitutes that contain potassium

• dec potassium foods

• triamterene turns urine bluish color

osmotic diuretic

• reduces ICP and intraocular pressure (IOP)

• draws fluid back into the vascular and extravascular space

  • initially will inc blood volume

  • not used for HTN crisis

  • affects heart diseases and kidney

• IV infusion only

• filter needle used

• monitor dehydration and edema

  • monitor serum osmolarity q6h = >300 then stop mannitol b/c dehydrated

• monitor for inc ICP

• seen mostly in ICU and neuro ICU

osmotic diuretic med

mannitol (osmitrol)

mannitol is a

potent diuretic

mannitol uses

• prevents kidney failure in hypovolemic shock and severe hypotension

• decreases ICP caused by cerebral edema

  • draws fluid from brain into the blood stream

• dec IOP by drawing ocular fluid into the bloodstream

• for hyponatremia and fluid volume excess

  • promotes sodium retention and water excretion

• administered for the oliguria phase of acute kidney injury

  • ensuring pt has adeq. renal perfusion

mannitol complications

• HF

• pulmonary edema

• rebound inc intracranial pressure

• fluid and electrolyte imbalances, metabolic acidosis

mannitol interactions

• lithium excretion thru kidneys inc

• inc risk for hypokalemia w/ cardiac glycosides

mannitol nursing administration

• cont. IV infusion

• use a filter needle

• daily weight

• I/O’s

• blood electrolytes

• monitor K levels

mannitol effectiveness

• normotensive BP

• absence of cardiac dysrhythmias

• absence of chest pain

• control of heart failure manifestations

• normal kidney function AEB normal lab values

• dec in IOC or IOP

• dec in pulmonary or peripheral edema

• weight loss

• inc in urine output