Exam 3 extra information

HTN counseling: DASH diet

Dietary Approaches to Stop Hypertension: less sodium; more potassium, calcium, magnesium (fruits, veggies, low-fat dairy); whole grains; lean protein; limit saturated fat/red meat/sweets; limit alcohol & caffeine

HTN counseling: exercise goal

30 min/day most days of the week = 150 min/week (maintain/lose weight)

Orthostatic hypotension

Lightheadedness/dizziness when standing up

OTCs that can raise blood pressure

NSAIDs and decongestants (~19% of HTN patients take a med that can raise BP)

Normal BP / treatment goal

Normal 120/80 mmHg; treatment goal 130/80 mmHg

Thiazide diuretics (HCTZ, chlorthalidone)

Give in the morning (diuresis); hypokalemia (muscle cramps, weakness, dizziness, orthostatic hypotension); possible 'sulfa' allergy -> photosensitivity; take with food or milk if GI upset

Loop diuretics (Lasix, Demadex)

Take in the morning; used more for edema/fluid retention than BP; lose potassium (cramps, weakness, dizziness, hypotension); sulfonamide allergy -> sun sensitivity; take with food/milk if GI upset; potential ototoxicity

Dyazide vs Maxzide

Dyazide = capsule; Maxzide = tablet (both triamterene/HCTZ)

Dyazide/Maxzide (triamterene/HCTZ) counseling

Take in the AM; triamterene alone = risk of hyperkalemia (esp. with K-sparing meds & K supplements); also contains HCTZ (loses K); Dyazide commonly used for hypertension

Aldactone (spironolactone) counseling

Take in the AM; risk of hyperkalemia; used for heart failure; used in resistant HTN (effect on aldosterone, less a diuretic)

Spironolactone anti-androgenic effects

Causes gynecomastia (breast enlargement from estrogen/testosterone imbalance); used for hair loss or acne

Beta blockers: clinical uses

Main: blood pressure, rate control/antiarrhythmic, chronic stable angina; also heart failure (some agents), post-MI

Beta blockers: side effects

Slow heart rate, dizziness

Cardioselective beta blockers (beta-1)

Atenolol (Tenormin), metoprolol (Toprol XL/Lopressor), nebivolol (Bystolic = vasodilatory beta-1-selective blocker)

Lopressor vs Toprol XL

Lopressor = metoprolol tartrate = short-acting (dosed twice daily, e.g. 'bid'); Toprol XL = metoprolol succinate = long-acting (once daily)

Inderal (propranolol): non-cardioselective

Blocks beta-1 & beta-2 (heart AND more); other uses: anxiety, tremor, migraine HA prevention, acute thyrotoxicosis (storm); stronger warning in asthma/COPD and diabetes

Alpha-1 blockers (-azosin) e.g. Minipress

Cause dilation; used for blood pressure, BPH (dilates bladder neck), PTSD nightmares

Prazosin (Minipress) counseling

Start with low dose at bedtime; avoid activities requiring alertness for 12 h after first dose; hypotension, esp. with other antihypertensives; light-headed/dizzy; additive hypotension with Viagra-type vasodilators

Coreg (carvedilol)

Dual alpha & beta blocker; take with food; used for heart failure; dosed twice daily

Labetalol

Dual alpha & beta blocker; pregnancy-safe BP control

Alpha-blocker side effects

Light-headedness, dizziness (hypotension)

Alpha-2 agonists (clonidine, guanfacine)

Decrease norepinephrine release (blunt fight-or-flight); taken daily - don't abruptly discontinue (rebound hypertension); significant hypotension & sedation/dizziness; also used for ADHD

ACE inhibitors (-pril) counseling & SE

Prevent constriction (lower BP); persistent cough (most characteristic); can raise potassium (avoid salt substitutes); angioedema risk (facial swelling, difficulty breathing); beware NSAIDs

ARBs (-sartan) counseling & SE

Prevent constriction; raise potassium (avoid K salt substitutes); angioedema much lower but can occur; no/low cough (safe alternative to ACE-I cough); report neutropenia signs; beware NSAIDs

DHP calcium channel blockers (-dipine)

Amlodipine (Norvasc), nifedipine (Procardia XL): promote vasodilation (coronary & peripheral arteries)

Non-DHP calcium channel blockers

Diltiazem (Cardizem CD), verapamil (Calan): decrease contractility/cardiac output AND promote vasodilation

Calcium channel blockers: side effect & other uses

Gingival hyperplasia (gum overgrowth); verapamil (Calan) -> constipation; other uses: rate control/antiarrhythmic, angina, migraine HA prevention

CCB drug interaction

Avoid grapefruit, especially nifedipine (Procardia)

Hydralazine: how it works & SE

Directly relaxes vascular smooth muscle (peripheral vasodilation); SE: lightheadedness/dizziness/headache, fast heart rate, lupus-like reaction (joint pain/swelling, fever)

Combination antihypertensives

Lotrel = amlodipine + benazepril; Zestoretic = lisinopril + HCTZ; Hyzaar = losartan + HCTZ; Diovan HCT = valsartan + HCTZ

Why use combination antihypertensives?

Different mechanisms add up for better BP lowering, and one pill is easier for adherence

Entresto (valsartan/sacubitril) counseling

Heart failure; increases K+; angioedema risk; do not take within 36 h of an ACE inhibitor; avoid NSAIDs; low sodium diet; weigh yourself daily - gain of 2-3 lb in a day or 5 lb over baseline -> talk to doctor

Nitrostat (nitroglycerin) dosing & counseling

Rapid-acting (acute angina); 1 tab sublingual every 5 min x 3; sit down; SE: bitter taste, headache, dizziness, flushing; watch other vasodilators

Nitrostat storage

Keep in original container; replace every 6 months once opened

Imdur (isosorbide mononitrate)

Long-acting nitrate (prevention); don't crush or chew; headache, dizziness, flushing; watch other vasodilators

Ranexa (ranolazine)

Long-acting non-nitrate (prevention); improves metabolism of ischemic heart cells; SE: lightheadedness, dizziness, HA, N/V; ER - don't crush/chew/break; avoid grapefruit juice (3A4)

Lanoxin (digoxin)

Cardiac glycoside; slows rate (negative chronotrope) + stronger contraction (positive inotrope); uses: heart failure, A-fib; narrow therapeutic index -> blood levels; SE: rhythm disturbances, GI, visual disturbances (blurred, green-yellow, halos)

Cordarone (amiodarone)

Large iodine load (watch allergy); monitor thyroid, lung & vision changes, LFTs; sun sensitivity (skin turns blue-gray); avoid grapefruit; part of FFFAB 5

Betapace (sotalol)

Beta-blocking activity: caution/avoid in asthma/COPD & diabetes; SE: lightheadedness/dizziness, slow heart rate; avoid antacids within 2 h

Anticoagulants & antiplatelets: general counseling

Increase risk of bleeding; seek help for excessive bleeding; many drug interactions; caution with history of GI bleed/ulcer; tell providers before dental work/surgery; avoid OTCs that increase bleeding (esp. NSAIDs/ASA)

Plavix (clopidogrel)

Prevents platelets sticking together; uses: after heart attack, after coronary stent, stroke prevention; SE: bleeding; Prilosec & Nexium can reduce effectiveness

Coumadin (warfarin)

Vitamin K antagonist - inhibits vitamin K-dependent clotting factors; SE: bleeding; INR monitoring; keep vitamin K intake consistent; many drug interactions (FFFAB 5)

Warfarin uses

A-fib, venous thromboembolism (DVT/PE), mechanical valve replacement, stroke prevention in high-risk patients, MOST COMMON SIDE EFFECT—Bleeding

Eliquis / Xarelto (Factor Xa inhibitors, DOACs)

Uses similar to warfarin; routine INR monitoring NOT required; most common adverse effect = bleeding; Xarelto 15 mg or higher doses need food (food OK with all doses)

Statins: class counseling & SE

May cause myopathy & rhabdomyolysis (muscle pain/tenderness - report); liver issues - avoid in active liver disease, limit alcohol, monitor LFTs; diet & exercise; some must be given at bedtime; grapefruit juice interaction (SIM, ATR, LOV)

Crestor (rosuvastatin)

Space out from antacids

Zetia (ezetimibe)

Inhibits dietary cholesterol absorption; 2nd-line oral agent for high cholesterol (next oral option for statin-intolerant patients); myopathy - much less risk

Niaspan (niacin ER)

Most concerning/bothersome SE = flushing; also myopathy; take with food, at bedtime, with an NSAID (to reduce flushing)

Welchol (colesevelam)

Bile acid sequestrant; SE: GI distress - constipation; decreases absorption of other drugs - space out from all other meds; lowers blood sugar (used in DM); can be used for chronic diarrhea

Tricor (fenofibrate)

Fibric acid derivative; lowers triglycerides 30-50% (pancreatitis prevention); limited CV benefit; safer with statins than gemfibrozil

Lopid (gemfibrozil)

Fibric acid derivative for triglycerides; riskier with statins than fenofibrate

Lovaza (omega-3 acid ethyl esters)

Lowers triglycerides 20-45%; no CV benefit; may increase LDL; SE: fish burp - reduce by freezing capsules or taking with food; high-dose Rx omega-3s: small bleeding & A-fib risk