pharm wks 1 & 2 (quiz 1)

GERD, PUD, & Stress Ulcers: Overview

• This document covers gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), and stress ulcers.

Protein Pump Inhibitors (PPIs)

• Medications include:

  • Dexlansoprazole (Dexilant)

  • Esomeprazole (Nexium)

  • Lansoprazole (Prevacid) - OTC (30 mg BID)

  • Omeprazole (Prilosec) - OTC (20 mg BID)

  • Pantoprazole (Protonix) - OTC (40 mg BID)

  • Rabeprazole (Aciphex) - (20 mg BID, nonpreferred option due to weaker acid inhibitory effect)

• Mechanism of Action (MOA):

  • Inhibit proton pumps (H+/K+-ATPase pumps) which leads to decreased gastric acid secretion.

• Important Note:

  • PPIs only work when H+ is actively being pumped out.

• Warnings:

  • Associated with C. difficile infection (C. diff), increased risk of fractures, decreased magnesium levels, and decreased vitamin B12 absorption.

Vonoprazan

• Brand Name: Voquezna

• MOA: Potassium-competitive acid blocker (PCAB), does not require gastric acid activation like PPIs.

• Standard Dose for H. pylori: 20 mg PO BID.

• Dual Therapy:

  • Vonoprazan + amoxicillin for 14 days.

  • Combination product: Vonoprazan BID + amoxicillin TID (Voquezna Dual Pack).

  • Warning: Monitor for penicillin allergy.

• Triple Therapy:

  • Vonoprazan + amoxicillin + clarithromycin (Voquezna Triple Pack) BID.

  • Warning: Monitor for penicillin allergy and macrolide resistance.

• Additional Warnings:

  • C. diff, fractures, decreased magnesium levels, decreased vitamin B12, plus adverse reactions such as derm reactions, fundic gland polyps, and tubulointerstitial nephritis.

Histamine-2 Receptor Antagonists (H2RA)

• Medications:

  • Famotidine (Pepcid; Zantac 360).

• Warnings:

  • Associated with C. diff, thrombocytopenia, and neurotoxicity.

• Pearl:

  • Requires renal dose adjustments (e.g., if creatinine clearance < 50, decrease famotidine dose by 50%).

Antacids

• Available in many combinations and variations.

• MOA: Directly neutralizes stomach acid and may also increase lower esophageal sphincter (LES) tone.

• Adverse Drug Effects (ADEs):

  • Aluminum can cause constipation.

  • Calcium can cause constipation.

  • Magnesium can cause diarrhea.

  • Sodium may lead to hypernatremia (Note: avoid in patients with heart failure, hypertension, chronic kidney disease, edema, or cirrhosis).

• Usage Recommendation:

  • Take after meals and at bedtime.

  • Typically used as needed (PRN), with or without PPI/H2RA.

  • Separate by > 2 hours from other medications to prevent decreased absorption (binding and pH changes), particularly for tetracyclines, fluoroquinolones, ferrous sulfate, and levothyroxine.

Sucralfate (Carafate)

• MOA: Creates a paste-like protective barrier in the stomach.

• ADE: Commonly causes constipation.

• Pearls:

  • Used in GERD, pregnancy, or for ulcers.

  • Available as tablets or oral suspension.

  • Daily dosing: 4 times a day (BID for maintenance).

  • Separate by at least 2 hours from other medications.

Treatment Guidelines for GERD

• Mild, Intermittent Symptoms (< 2 times/week and not troublesome):

  • Use PRN antacids only.

  • Use H2RA BID (or PRN) +/- PRN antacids.

  • Use PPI daily +/- PRN antacids (PPI OTC treatment max duration is 2 weeks; consult a provider if symptoms persist beyond 2 weeks).

• Moderate-Severe, Persistent Symptoms (> 2 times/week or troublesome):

  • Use PPI daily for 4-8 weeks (+/- PRN antacids) or

  • Use H2RA BID for 6-12 weeks (+/- PRN antacids).

• Preferred Prescription Treatment:

  • PPI for 4-8 weeks (not infrequently, requires long-term treatment).

  • PPI is noted to be more effective than H2RA.

  • Generally, do not combine PPI with H2RA unless the patient has refractory symptoms.

  • Antacids may still be used PRN.

Special Populations and Considerations

• Alarm Symptoms: Indicates the need for further work-up.

• Extraesophageal Symptoms: Initiate PPI for 8-12 weeks (may require long-term treatment).

• Pregnancy:

  • First-line approach is to try antacids PRN or sucralfate.

  • Alternatives may include PPI or H2RA.

Bismuth Subsalicylate (Pepto Bismol)

• ADE: Can cause bleeding, black-colored stools, or tongue discoloration.

• Usage: Always used in combination with PPI and antibiotics for H. pylori treatment.

• Optimized Bismuth Quadruple Treatment:

  • PPI + bismuth subsalicylate + tetracycline + metronidazole for 14 days, avoiding concerns about macrolide resistance or penicillin allergy.

• Combo Products:

  • Combination of bismuth, tetracycline, and metronidazole (Helidac; Pylera) QID; note that this does not include a PPI.

Misoprostol (Cytotec)

• MOA: Synthetic prostaglandins used to prevent NSAID-induced ulcers.

• ADE: Can cause intolerable diarrhea.

• Black Box Warning: Use is contraindicated during pregnancy.

Peptic Ulcer Disease (PUD)

• Pharmaceutical treatments depend on the identified cause (NSAID or H. pylori).

NSAID-Induced

• Causes:

  • Decrease in gastrointestinal protective prostaglandins, mucus production, bicarbonate production, blood flow, inflammation, and subsequent epithelial injury.

• Direct Irritation Prevention Strategies:

  • Take NSAIDs with food.

  • Switch to COX-2 selective NSAIDs (e.g., Celecoxib or Celebrex).

  • Co-administer with PPI or misoprostol since H2RAs are ineffective.

• Treatment:

  • Use PPI daily for 4 weeks as this is most effective.

  • Make NSAID changes alongside PPI use.

• Reminders:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit the production of protective prostaglandins which can lead to gastrointestinal bleeding.

H. Pylori-Induced

• Causes:

  • Inflammation and epithelial injury leading to increased acid secretion.

• Testing:

  • Urea breath test;

  • Hold PPIs for 1-2 weeks before testing.

  • Hold bismuth and antibiotics for 4 weeks prior to testing.

• Treatment Approaches:

  • Simple Treatment:

  • Optionally use rifabutin.

  • Three-part regimen:

  • PPI + rifabutin + amoxicillin for 14 days.

  • Combo Product Example:

  • Omeprazole + amoxicillin + rifabutin (Talicia) administered TID.

  • Note: check for penicillin allergies.

Stress-Related Mucosal Damage (SRMD)

• Risk Factors Include:

  • Respiratory failure (patients on mechanical ventilation for >48 hours).

  • Coagulopathy.

  • ICU stays greater than 7 days.

• Goal: Maintain gastric pH > 4.

• Prophylaxis: Options include PPIs or H2RAs.

• Discontinuation: Should occur upon discharge from the ICU and/or when the risk factors are alleviated.

Constipation, Diarrhea, & Inflammatory Bowel Disease (IBD) Overview

• Types of Constipation:

  • Caused by decreased peristalsis and fluid secretion.

• Common Medication Causes Include:

  • Iron, verapamil, opioids, antacids, anticholinergics, sucralfate.

Constipation Treatments:

• Bulk Forming Agents:

  • Examples:

  • Calcium polycarbophil (FiberCon).

  • Psyllium (Metamucil).

  • Wheat dextrin (Benefiber).

• MOA: Increases stool bulk and absorbs water to promote peristalsis.

• ADE:

  • Excessive intake can result in constipation.

• Recommendations:

  • Takes 12 hours to 3 days to work; best for maintenance/prevention.

• Stool Softeners (Mush):

  • Docusate (Colace, DocQLace).

  • MOA: Decreases oil-water surface tension allowing water incorporation into stool.

  • ADE: Generally well tolerated.

  • Dosage: 50 to 100 mg PO daily; takes 12 to 3 days to work.

• Stimulants (Push):

  • Bisacodyl (Dulcolax), Senna (Ex-Lax; senokot).

  • MOA: Irritates smooth muscles to enhance peristalsis and encourages ileal secretion of water/electrolytes.

  • ADE: Senna can alter urine color to red-orange.

  • Timing: Takes 6 to 12 hours to work; dependency may develop if used long-term.

• Osmotic Agents (Gush):

  • PEG 3350 (Miralax), recommended dose is 17 g PO daily.

  • MOA: Draws fluid into the colon via osmosis, increasing peristalsis.

  • Pearls:

  • PEG/lactulose takes 1 to 4 days to work; glycerin/sorbitol works quickly (15-60 minutes).

• Lubricants:

  • Example: Mineral oil.

  • MOA: Decreases water absorption and lubricates intestines.

  • ADEs: Can cause anal leakage and pain, and risk of aspiration (advise patients to stay upright).

  • Precautionary Note: Decreased absorption of fat-soluble vitamins (ADEK), avoid in pregnancy, children <6 years, the elderly, bedridden individuals, and those with dysphagia.

  • Onset of Action: Works within 6-8 hours, not intended for regular use.

Diarrhea

• Common Causes Include:

  • Laxatives, magnesium, antibiotics, metformin, GLP-1 receptor agonists, chemotherapy.

• Exclusions for Self-Treatment:

  • Fever, recent antibiotic use (risk of C. difficile infection), pregnancy, age <6 months, blood/pus in stool.

• Non-Pharmacologic Options:

  • Address the cause; replace fluids and electrolytes; dietary modifications; probiotics; non-infectious diarrhea typically resolves on its own.

OTC Treatment Options:

• Loperamide (Imodium A-D):

  • MOA: Slows gastric transit time.

  • BBW: Risk of torsades de pointes, cardiac arrest, and death if overdosed.

  • Pearls:

  • Administer for acute diarrhea or traveler's diarrhea; avoid in C. diff cases.

  • Dosage: 4 mg PO once, then 2 mg after each loose stool (max 16 mg/day).

• Diphenoxylate/Atropine (Lomotil):

  • MOA: Diphenoxylate is a mu receptor agonist that inhibits GI motility, while atropine is added to prevent abuse and can produce anticholinergic effects if misused.

  • Pearls:

  • Avoid in children <6 due to risk of respiratory depression, controlled substance (Rx only).

Irritable Bowel Syndrome-Diarrhea (IBS-D)

• Initial Treatment: Start with soluble fiber and loperamide.

Traveler’s Diarrhea

• Major Concern: Dehydration.

• Goals: Prevent/treat dehydration; reduce symptom severity and duration.

• Self-Limiting Treatment:

  • Oral rehydration therapy;

  • Use loperamide (Imodium) or bismuth for mild symptoms;

  • Avoid if blood in diarrhea or fever;

  • Antibiotics can shorten infection duration by 1-2 days;

  • First-line: ciprofloxacin or levofloxacin;

  • Alternative: azithromycin, which is a better choice for pediatric patients.

C. difficile Infection

• Risk Factors:

  • Recent antibiotic use (e.g., fluoroquinolones, clindamycin, 3rd/4th generation cephalosporins, broad antibiotics); use of acid suppression agents (PPIs like omeprazole and H2 blockers like famotidine).

• First-Line Treatment:

  • Fidaxomicin; may help reduce recurrence but is cost-prohibitive.

  • Alternative: Vancomycin given orally or via rectal route (not IV!); possible side effects include gastrointestinal issues and bitter taste.

  • Note: Metronidazole will not be the answer in exams according to the instructor.

Inflammatory Bowel Disease (IBD)

• Medications:

  • Mesalamine (available PO, as rectal enema, or as a suppository).

• Induction: Used to induce remission, short-term for controlling acute symptoms.

• Remission/Maintenance: Used long-term to maintain symptom-free periods.

Corticosteroids:

• Examples Include: Budesonide (Uceris, Entocort), hydrocortisone, prednisone, and methylprednisolone.

• MOA: Exhibit anti-inflammatory properties.

• ADE: Can cause elevated blood glucose, blood pressure, increased appetite, weight gain, insomnia, central nervous system effects, fractures, infections, leukocytosis, etc.

• Indications: Primarily used for induction in ulcerative colitis (UC) or Crohn’s Disease (CD).

• Pearls:

  • Prednisone is discouraged for long-term use due to adverse effects.

  • Budesonide undergoes extensive first-pass metabolism, resulting in fewer systemic effects and can be used long-term.

• Rectal Forms for UC Only: Budesonide as foam, hydrocortisone in suppositories, foams, and enemas.

• Systemic Options for UC or CD: Prednisone, methylprednisolone, and budesonide in extended-release/delayed-release formulations.

5-Aminosalicylic Acids (5-ASA):

• Examples: Sulfasalazine (PO), olsalazine (PO), balsalazide (PO).

• MOA: Antiinflammatory, noted for potential nephrotoxicity/interstitial nephritis.

• Content: All contain sulfa (except for Mesalamine) and salicylate, used for mild to moderate UC induction or maintenance.

Rectal Mesalamine

• Options: Mesalamine suppositories (works in rectum; retain for 1-3 hours) and mesalamine enemas (works up to the splenic flexure; retain for 8 hours).

Immunosuppressants/Immunomodulators:

• Examples: Azathioprine, mercaptopurine, and methotrexate.

• Azathioprine: Oral option for UC & CD; metabolized to mercaptopurine. Requires genotype testing for TPMT and NUDT15 enzymes due to higher risk of hematologic toxicity.

• Pearls: Used for maintenance in UC & CD, steroid-sparing, can combine with biologics for decreased immunogenicity, specific monitoring needed including CBC, SCr, LFTs, and TPMT activity.

• Methotrexate: Also an immunosuppressant with numerous BBW such as pregnancy, serious adverse drug events, hepatotoxicity, and others.

Biologics:

• Example: Infliximab (Remicade) → TNF inhibitor for moderate or severe UC or CD, both induction and remission.

• BBW: Infections, lymphoma, and TB reactivation risk.

• Natalizumab: Risk for progressive multifocal leukoencephalopathy (PML) makes it less favorable in therapy.

JAK Inhibitors

• Examples: Tofacitinib (Xelijanz) and Upadacitinib (Rinvoq).

• BBWs: Infection, death, malignancy, major adverse cardiovascular events (MACE), thrombosis.

• Pearls: Typically an alternative to TNF inhibitors, not to be combined with biologics, indicated for moderate-severe UC or CD (induction or maintenance) but often costly.

Treatment Principles for IBD

• General Recommendations: Use topical formulations when appropriate; topical can be combined with oral therapies; use systemic corticosteroids for the shortest duration and lowest effective dose.

• Important Notes: Budesonide avoids significant systemic effects; avoid combining biologics or JAK inhibitors; keep vaccines up to date and avoid live vaccines during immunosuppressive therapy.

Diverticular Disease

• Mild Diverticulitis (Outpatient Care): Focus on fluids and rest.

• Suspected infections (Outpatient, PO):

  • Use Augmentin, Ciprofloxacin + Metronidazole, Levofloxacin + Metronidazole, or TMP/SMX + Metronidazole.

• Suspected Infection (Inpatient, IV): Use Piperacillin/Tazobactam (pip/tazo) to cover Gram-negative rods (e.g., E. coli) and anaerobes (e.g., Bacteroides fragilis).

Hypertension Overview

• Understanding Renin-Angiotensin-Aldosterone System (RAAS):

  • Angiotensin II:

  • Causes vasoconstriction and increases blood pressure short-term by:

    • Reabsorbing sodium and water.

    • Causing vasoconstriction.

  • Long-term Actions include: Intraglomerular hypertension leading to vascular hypertrophy and myocardial hypertrophy.

• Medications that Affect RAAS: ACE inhibitors, ARBs, direct renin inhibitors.

Angiotensin-Converting Enzyme Inhibitors (ACEI)

• Example Medications:

  • Benazepril (Lotensin)

  • Captopril (Capoten)

  • Enalapril (Vasotec) and enalaprilat IV (Vasoretic)

  • Fosinopril (Monopril)

  • Lisinopril (Prinivil, Zestril)

  • Moexipril (Univasc)

  • Perindopril (Aceon, Coversyl)

  • Quinapril (Accupril)

  • Ramipril (Altace)

  • Trandolapril (Mavik)

• MOA: Prevents the conversion of angiotensin I to angiotensin II, leading to vasodilation, decreased systemic vascular resistance (SVR), decreased aldosterone secretion (decreased stroke volume), and inhibits bradykinin metabolism which promotes vasodilation.

• ADEs: Can increase serum creatinine (up to 30%), potassium levels, lead to angioedema, and cause a cough due to bradykinin accumulation.

• Contraindications include: Pregnancy and renal artery stenosis.

Angiotensin Receptor Blockers (ARBs):

• Example Medications: Azilsartan (Edarbi), candesartan (Atacand), irbesartan (Avapro), losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis), valsartan (Diovan).

• MOA: Block angiotensin II (AT1) receptors, resulting in vasodilation and decreased aldosterone action.

• ADEs: Elevated serum creatinine (up to 30%), elevated potassium levels, and angioedema (lower risk than ACEIs) with no associated cough.

• Contraindications include: Pregnancy and renal artery stenosis.

Angioedema Risk

• High Risk: Seen with ACE inhibitors and ARNI (sacubitril/valsartan - Entresto).

• If angioedema occurs with ACEI or ARNI, do not attempt another of those medications; cautiously attempt an ARB if angioedema occurred with ARB.

Direct Renin Inhibitor

• Medication: Aliskiren (Tekturna).

• BBWs: Pregnancy - cannot be combined with ACEI or ARB.

• Additional contraindications include diabetes mellitus.

• Question of Usage: Clinical benefits are unclear, prompting skepticism about its utility.

Addressing the Cough Issue

• Cough Types:

  • Associated primarily with ACEIs (due to bradykinin accumulation) and possibly with direct renin inhibitors, but NOT with ARBs.

• Dry Cough: Generally not harmful, though a transition to an ARB is often recommended.

Hyperkalemia

• Attribution: All RAAS drugs can potentially lead to hyperkalemia due to decreased aldosterone levels.

Diuretics Overview

• Cover types: Carbonic anhydrase inhibitors, osmotic diuretics, loop diuretics, thiazide diuretics, potassium-sparing diuretics.

Anatomy Recap:

• Vascular Components:

  • Afferent arteriole: Carries blood to glomerulus.

  • Glomerulus: Filters protein-free plasma into tubular components.

  • Efferent arteriole: Carries blood away from glomerulus.

  • Peritubular capillaries: Supply renal tissue, engage in exchanges with tubular fluid.

• Tubular Components:

  • Bowman’s capsule: Collects glomerular filtrate.

  • Proximal tubule: Unrestricted reabsorption and secretion of specific substances occurs here.

  • Loop of Henle: Establishes osmotic gradient crucial for urine concentration.

  • Distal tubule & collecting duct: Controlled reabsorption of sodium & water alongside potassium and hydrogen secretion occurs here; final urine exits through the renal pelvis.

Carbonic Anhydrase Inhibitors

• Example: Acetazolamide (Diamox).

• Administration: Available PO/IV but not frequently used as a diuretic.

• MOA: Inhibits carbonic anhydrase in the proximal convoluted tubule, promoting sodium bicarbonate excretion, thereby reducing sodium and bicarbonate reabsorption, and encouraging an increase in urine alkalinity and mild to moderate metabolic acidosis.

Osmotic Diuretics

• Example: Mannitol (given IV).

• Main Sites of Action: Proximal convoluted tubule, loop of Henle, collecting tubule.

• Primary Use: Rapid treatment for increased intracranial pressure.

Loop Diuretics

• Examples Include:

  • Bumetanide (Bumex), ethacrynic acid (Edecrin), furosemide (Lasix), torsemide (Demedex) all available PO & IV.

• Most potent diuretics.

• MOA: Inhibits Na+/Cl-/K+ transporter in ascending loop of Henle and proximal/distal renal tubules to increase natriuresis and diuresis (increased sodium, water, magnesium, calcium, chloride, and potassium excretion) alongside worsening metabolic alkalosis, dehydration, and potential ototoxicity.

• PO Equivalency:

  • Bumetanide 1 = Ethacrynic acid 50 = Furosemide 40 = Torsemide 20 (implying Bumetanide is 40 times more potent than Furosemide).

Thiazide Diuretics

• Examples Include: Chlorothiazide (Diuril) (IV/PO), chlorthalidone, hydrochlorothiazide (HCTZ), indapamide (Lozol), methylclothiazide, metolazone (Zaroxolyn).

• MOA: Inhibit sodium and chloride reabsorption in distal convoluted tubules by blocking the Na-Cl transporter leading to increased calcium reabsorption.

• ADE: Can elevate blood glucose, uric acid, and calcium levels while decreasing potassium, magnesium, and sodium levels, and can cause photosensitivity and dehydration; caution advised when treating patients with diabetes or gout.

Combination of Loop and Thiazide Diuretics

• Rationale: Loop + thiazide combination utilized to maximize diuretic efficacy by inhibiting sodium reabsorption at both the ascending loop and the distal convoluted tubule.

Potassium-Sparing Diuretics

• Core Concept: Aldosterone functions to secrete potassium and retain sodium and water.

• Examples Include: Eplerenone (Inspra) and Spironolactone (Aldactone).

• MOA: Competes with aldosterone in distal tubules, resulting in increased sodium and water excretion while preserving potassium.

• Additional Effects: Spironolactone exceeds Eplerenone in blocking androgen receptors, leading to potential for gynecomastia as an ADE.

• Contraindications: When potassium levels ≥ 5.0 or GFR < 30.

Other Potassium-Sparing Diuretics

• Examples Include: Amiloride (Midamor) and triamterene (Dyrenium).

• MOA: Blocks sodium channels in distal convoluted tubule and collecting duct, leading to increased sodium and water excretion while preserving potassium levels.

• ADE: May elevate potassium levels, therefore necessitating a BBW for hyperkalemia.

Calcium Channel Blockers (CCB) Overview

• Impact of Calcium Channels: Increased cytosolic Ca+2 concentration provokes contraction in smooth muscle and cardiomyocyte cells.

• Nodal Calcium Channels Role: Affect the excitability of the SA node, conduction through AV node, and myocardial contractility.

Dihydropyridine Calcium Channel Blockers (CCBs)

• Examples Include:

  • Amlodipine (Norvasc)

  • Clevidipine (Celviprex) (IV)

  • Felodipine (Plendil)

  • Isradipine (DynaCirc)

  • Levamlodipine (Conjupri)

  • Nicardipine (Cardene) (PO & IV)

  • Nifedipine (Procardia)

  • Nimodipine (Nimotop)

  • Nisoldipine (Sular)

• MOA: Dihydropyridines block calcium influx into smooth muscle cells resulting in preferential vasodilation.

• Potential ADEs: Edema, flushing, headache, and reflex tachycardia.

Non-Dihydropyridine Calcium Channel Blockers (CCBs)

• Examples Include:

  • Diltiazem (Cardizem, Cartia, Tiazac) (PO & IV)

  • Verapamil (Calan, Verelan) (PO & IV)

• MOA: Similar calcium blockade with notable effects on myocytes leading to decreased SA node automaticity, reduced conduction through the AV node, and decreased myocardial contractility.

• ADEs: Bradycardia, AV block, gingival hyperplasia, and constipation (particularly with Verapamil).

Adrenergic Agents Overview

• Includes: Beta blockers, alpha-2 agonists, and alpha-1 blockers.

Beta Blockers

• Suffix: (-lol).

• ADEs:

• Bradycardia, AV block (consider potential interactions with other medications).

• Elevated blood glucose levels.

• Bronchospasm risks (non-selective) > interactions with albuterol or long-acting bronchodilators.

• Fatigue, depression, and erectile dysfunction may also occur.

Unique Beta Blockers

• Specific Examples:

  • Sotalol (Betapace): Characterized as a racemic mixture; L-sotalol is non-selective beta blocker and D-sotalol qualified as a classified III antiarrhythmic.

  • Acebutolol and pindolol: Have intrinsic sympathomimetic activities (ISA); partially stimulate (agonize) beta receptors at rest, functioning as conventional blockers during elevated sympathetic activity.

Central Alpha-2 Agonists

• Examples Include: Clonidine (transdermal/PO), guanfacine, and methyldopa (IV/PO).

• ADEs: Notable for orthostatic hypotension and CNS depression side effects.

Alpha-1 Blockers (Vasodilators)

• Examples Include: Doxazosin, prazosin, terazosin, and phentolamine (IV/IM).

• ADEs: Probable orthostatic hypotension.

Direct Vasodilators

• Examples Include:

  • Hydralazine (IV/IM/PO) for hypertension, Minoxidil (IV) primarily for hair growth (Rogaine), nitroglycerin (IV) for angina, and nitroprusside (IV) for acute heart failure, acute stroke, and hypertensive emergencies.

• MOA: Interferes with calcium dynamics resulting in direct relaxation of vascular smooth muscles, ultimately reducing systemic vascular resistance and blood pressure.

• Notable ADEs: Risk of edema and tachycardia may accompany the usage of these vasodilators.

Hypertension: Target Organ Injury

• Affected Organs: Heart, brain, kidneys, peripheral arteries, and retinopathy.

Hypertension: Symptoms and Signs

• Symptoms include: Headaches, dizziness, visual changes, chest pain, fatigue, nosebleeds, tinnitus, and confusion.

• Symptoms of Hypotension may include: Dizziness, syncope, clammy skin, fatigue, blurred vision, and confusion.

Common Non-Pharmacological Recommendations for Hypertension:

• Dietary Recommendations: DASH diet and limit sodium intake to <1.5 g daily; potassium-rich diet; limit alcohol consumption (2/day for men; 1/day for women).

• Exercise: 150 minutes of aerobic activity weekly.

• Weight Management: Aim for weight loss of at least 5%.

• Lifestyle Adjustments: Smoking cessation will further benefit overall health.

Hypertension Categories and Treatment Thresholds:

Hypertension Management Recommendations:

• 1st line therapies include various agents;

• Use specific combinations of medications of synergistic effects;

• Encouragement to switch to combination tablet options (i.e., 2 drugs in 1 tab).

Geriatric Considerations in Hypertension:

• Generally similar treatment as non-elderly adults but initiate therapy at lower doses;

• Titrate doses slower based on considerations of frailty and potential risks like falls while decreasing polypharmacy practices.

Pediatric Considerations for Hypertension:

• First-line medications include ACEI/ARBs, CCBs, or thiazides, with caution advised concerning contraindicated medications during pregnancy:

  • ACEIs, ARBs, direct renin inhibitors, atenolol, mineralocorticoid receptor antagonists (MRAs), and nitroprusside.

Hypertensive Crises:

• Severe Hypertension: SBP ≥ 180 and/or DBP ≥ 120 without target organ damage; adjust current medications P.O. and consider common agents like captopril or labetalol but avoid rapid BP reductions.

• Hypertensive Emergency: BP readings reflect severe increases with organ damage; typically treated IV in an ICU setting, opting for nicardipine or labetalol while adjusting PO agents once the patient stabilizes.