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220 Cards in this Set
- Front
- Back
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Primary HTN (Essential)- Etiology
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idiopathic- may be due to increased secretion of renin
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Secondary HTN etiology
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secondary to another disease:
renovascular HTN: stenosis of renal artery medications, etoh, renal dysfunction etc. |
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"silent killer"
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HTN
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Normal Blood pressure:
1. systolic 2. diastolic |
1. <120
2. AND <80 |
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Pre HTN bp:
1. systolic 2. diastolic |
1. 120-129
OR 2. 80-89 |
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Stage I HTN bp:
1. systolic 2. diastolic |
1. 140-159
OR 2. 90-99 |
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Stage II HTN bp:
1. systolic 2. diastolic |
1. > or equal to 160
OR 2. > or equal to 100 |
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CVD: Common risk factors
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1. DM
2. HTN 3. Obesity 4. dyslipidemia 5. smoking 6. sedentary lifestyle |
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family hx risk factor for CVD
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M : <55 yo
F: <65 yo |
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What is the key for treating CVD
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PREVENTION: lifestyle changes in the mid-late 20s-30s
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Describe some end-organ damages that can occur with CVD
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1. retinopathy
2. Chronic Kidney Disease 3. Stroke 4. Transient Ischemic Attack 5. Pulmonary Artery Disease |
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What is the general goal for a blood pressure for a NORMAL patient?
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130/80
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If a patient has diabetes or chronic kidney disease, what is the bp goal?
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< 130/80
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If a patient has HF, what is the bp goal?
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< 120/ 80
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What non-pharmacologic treatment measure has the greatest potential to reduce blood pressure?
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weight loss
(reduction: 5-20mmHg/10kg lost) |
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What are 5 non pharmacologic treatments for HTN
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1. weight loss
2. DASH diet (low sodium, healthy) 3. decreased dietary sodium 4. physical activity 5. alcohol (2/d M; 1/d F) |
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What are 6 compelling indications for increased risk of CV disease or stroke when accompanied with a dx of HTN
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1. DM
2. CKD 3. HF 4. MI 5. Stroke 6. High risk of CAD |
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What stage of HTN do you incorporate treatment without a compelling indication?
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stage I or stage II
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What class of HTN do you incorporate pharmacological treatment with a compelling indication?
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Pre HTN, Stage I, AND Stage II
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If a patient has no compelling indications and Stage I HTN:
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Thiazide (most)
Consider ACEI, ARB, beta blockers, CCB, or combination therapy |
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If a patient has no compelling indications and Stage II HTN
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2 drug combo for both: Thiazide + (ACEI, ARB, beta blocker, OR CCB)
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When doing a combo therapy for a Stage II HTN without compelling indication, how do you start the treatment regiment
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start on 1 drug- get to max dose.
then, add the second medication to the therapy program |
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What are 2 functions of Angiotensin II and the ultimate downstream effect?
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1. increase aldosterone 2. vasoconstriction
Ultimate function: increase blood pressure |
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Describe the normal function of bradykinin
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bradykini binds with BK receptor-- leads to vasodilation and decreased vascular resistance--leads to a decrease in blood pressure.
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What signalling molecule turns the Bradykinin pathway OFF
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ACE
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Describe the Angiotensin II pathway
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ATII-- binds to AT1 Receptor--leads to vasoconstriction and increased vascular resistance, increased aldosterone, and increased sodium and water retention--leads to elevation in blood pressure
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What is the end effect of bradykinin
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decrease in blood pressure
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What is the end effect of angiotensin II
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increase in blood pressure
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How does ACE affect the ATII system?
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turns it on
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ACEI drugs typically have a common ending of :
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"pril"
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Name three most commonly prescribed ACEI
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1. Lisinopril
2. Ramipril 3. Captopril |
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MOA of ACEI
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inhibits ACE, which converts ATI into ATII; dilates efferent arterioles in nephrons--resulting in a decrease glomerular capillary pressure.
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Why is an ACEI potentially helpful for a HTN DM patient?
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Potential renal benefit: in dilating the efferent arterioles of the nephrons of the kidney, there is a resulting decrease in glomerular capillary pressure. This can help prevent kidney damage that is often associated with DM.
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the HOPE trial looked at what particular end points?
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reduction in nonfatal stoke rates, CV death, Acute MI
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What did the HOPE trial find?
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that Ramipril is a better treatment than: Aspirin, beta blockers, anti-lipids (statins), diuretics, and calcium-channel blockers.
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What did the Micro-HOPE trial find?
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that Ramipril is good for patients with DM
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A lower mg of an ACEI is usually associated with what type of potency?
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higher potency
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How is ACEI dose adjusted?
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Based on renal CL; dose adjust or avoid based on the degree of kidney problems.
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What are some ADEs associated with ACEI?
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1. cough
2. angioedema 3. rash 4. hypotension with 1st dose 5. increased K/BUN/Cr 6. Photosensitivity 7. Acute Renal failure |
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acute renal failure is an ADE of ACEI. As such, it should be avoided in what types of patients?
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1. elderly
2. CHF |
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What is the pregnancy category of an ACEI?
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2nd trimester: C
3rd trimester: D |
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What is an important counseling point of ACEI for a woman of child-bearing age?
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That if she decides she wants to try to become pregnant, that they must change her anti-HTN medicine.
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Which ADE of ACEI makes tolerability an issue in some patients?
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cough
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What DDIs are associated with ACEI?
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1. Antacids: reduce clearance
2. NSAIDS, Aspirin: reduce response 3. K+ sparing diuretics and K+: increased risk of hyperkalemia |
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Since there are many different dosings available for the ACEI drugs for HTN, what is one benefit of a drug that is available for QD taking?
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increased patient compliance: patient only has to take the medication at one time in the day
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Which two ACEI drugs must be taken 1 hour after eating?
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1. Captopril
2. Moexpipril |
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Why does captopril have a general decreased rate of patient compliance?
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The drug is usually taken up to 3 times per day, which is difficult for some patients to do effectively.
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For the most part, Angiotensin II Receptor blockers (ARB) generic names end in what?
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"artan"
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What is the MOA for AT1 Receptor antagonists?
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competes angiotensin AT1 receptor
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What are some common ADEs of AT1 receptor antagonists?
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1. increased K+/BUN/Cr
2. cough 3. angioedema |
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When prescribing an ARB to a female patient, what is one imporatant counseling point?
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If you are planning to try and become pregnant, then you need to come to the clinic ahead of time and change your medications that you are on.
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what is the Pregnancy category of ARB?
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2nd trimester: C
3rd trimester: D |
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What is the typical dosing of an ARB?
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QD; some can be BID
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Esprosartan has a max response that can be measured in ________ amount of time
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2-3 weeks
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A patient is taking Telmisartin to control his HTN. He is currently taking 80mg QD. Your drug handbook says that this drug can be prescribed up to 160 mg QD. 80mg is not proving to be effective, so what do you do?
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you do NOT increase his dose- Telmisartin does not have a significant increase in efficacy above 80mg-- so you'd have to try another drug for HTN management.
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Aliskiren (Tekturna) is an example of a ______
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direct renin antagonist
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MOA of Aliskiren (Tekturna)
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inhibits renin--which decreases plasma renin activity.
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Pregnancy category of Aliskiren(Tekturna)
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C/D; 2nd & 3rd trimester, respectively
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What are some common ADEs associated with use of Aliskren(Tekturna)?
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1. GERD
2. increased BUN/Cr/K+ |
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What must you monitor when prescribing Aliskiren (Tekturna) to a patient?
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K+ levels and renal function
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What are some rare, yet severe side effects of Aliskiren (Tekturna)?
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1. angioedema
2. nephrolithiasis (kidney stones) 3. seizure |
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What is one pertinent + of taking Aliskiren (Tekturna)?
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no need to adjust renal dosing
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Aldomet is what class of drug?
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Renin-Suppressor
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Clonidine (Catapres) is what class of drug?
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Renin-Suppressors
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Propranolol (Inderal) is what class of drug?
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Renin-Suppressors
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What is the end result of using Methylodopa (Aldomet) or Clonidine (Catapres)?
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decreased plasma renin activity
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What is the function of Propranolol(Inderal)?
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potentially suppresses renin release via the B1 receptor blockade.
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Renin-suppressors work similarly to what other class of anti-HTN drugs?
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Renin antagonists (both decrease renin activity)
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ATII stimulates the synthesis and release of what molecule
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aldosterone
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How does aldosterone function?
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stimulates sodium reabsorption, resulting in sodium and water retention.
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What are some net effects of aldosterone function?
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1. decreased K+ and Mg2+
2. decreased myocardial NE uptake 3. decreased baroreceptor sensitivity 4. change in Na-channel expression |
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Spironolactone(Aldactone) is an example of a
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Aldosterone antagonist
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Eplerenone (Inspra) is an example of a
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Aldosterone antagonist
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What is the MOA of Spironolactone or Eplerenone?
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Antagonize the aldosterone receptors in the distal convoluted tubule
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Which aldosterone antagonist has a BBW? What is it?
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Spironolactone (Aldactone)-- tumor risk
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What are 3 contraindications for aldosterone antagonists?
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1. anuria
2. renal impairment 3. hyperK+ |
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What type of diuretic is an aldosterone antagonist considered? Why is this relevant?
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K+ sparing diuretic- so you have to monitor K+ levels because you can retain too much K+
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What is one of the more frequently seen ADEs of aldosterone antagonists?
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hyperK+
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What are 4 ADEs that are unique to Eplerenone (Inspra) and not found in the aldosterone antagonist Spironolactone (Aldactone)
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1. hypoNa
2. MI 3. Arhythmias 4. < sexual desire |
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What is the typical dosing schedule of Spironolactone (Aldactone)?
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QD- but can divide up BID
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How should Spironolactone (Aldactone) be adjusted for dosing?
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Renally, if a patient has significant decreased renal function
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Spironolactone (Aldactone) has a pregnancy category of:
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D-- avoid in pregnancies
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What elements should you monitor in a patient who is prescribed Spironolactone (Aldactone)?
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K and Renal Function
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What is the recommended monitoring schedule for Spironolactone (Aldactone)?
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1 week after initiation of therapy; then every month for 3 months, then every 3 months for a year, then every 6 months thereafter.
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Why is hyperK+ problematic as it is associated with Spironolactone (Aldactone)?
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It can cause arrhythmias if K+ levels get too high.
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Where do loop diuretics function?
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in the Loop of Henle
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Chlorothizaide (Diurel) is an example of a
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thiazide diuretic
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Chlorthalidone (Hygroton) is an example of a
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thiazide diuretic
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Hydrochlorothiazide (Microzide, HydroDiuril, Esidrix) is an example of a
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Thiazide diuretic
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what is the MOA of thiazide diuretics?
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inhibits sodium and chloride reabsorption in the distal convoluted tubule.
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what is a contraindication to using thiazide diuretics?
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anuria
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What molecular concentrations decrease when taking a thiazide diuretic?
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K, Cl, Na, Mg
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what elements increase in concentration when taking a thiazide diuretic?
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lipids, uric acid, Ca, BG
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What are some common, less severe, ADEs associated with taking thiazide diuretics?
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1. rash
2. sexual dysfunction 3. weakness 4. cramps |
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What are some severe, less common, ADEs associated with taking thiazide diuretics?
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1. Acute Renal Failure
2. interstitial nephritis 3. pancreatitis 4. SLE exacertbation |
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what pregnancy category do thiazide diuretics fall into?
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Category B
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What class of anti-HTN diuretics are safest for pregnancy?
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thiazide diuretics--- must counsel them to stay hydrated though
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When is the best time to take a thiazide diuretic?
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in the morning
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What does "ceiling effect" mean?
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That once you reach a certain dose of a medication, increasing the dose does not have an increased benefit level that would outweigh the increased SEs associated with that higher dose
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Bob takes hydrochlorothiazide (Microzide, Esidrix). He takes 25mg QAM. He is not having adequate benefits. The max prescribable dose is 100mg. What should you do?
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don't increase his dose. Ceiling effect exists- after 25mg, the potential benefits of a higher dose do not outweigh the increased side effects associated with the higher dosing levels.
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Indapamide (Lozol) is usually prescribed how?
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QAM
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Describe the MOA of loop diuretics
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inhibit loop of henle, proximal & distal convoluted tuble reabsorption of Na+ and Cl-.
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What is the most commonly prescribed loop diuretic?
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Furosemide (Lasix)
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What are 4 names of loop diuretics?
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1. bumetanide (Bumex)
2. ethacrynic acid (Edecrin) 3. Furosemide (Lasix) 4. Torsemide (Demadex) |
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what is the BBW associated with loop diuretics?
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fluid & electrolyte depletion
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What are 3 contraindications for using a loop diuretic?
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1. anuria
2. hepatic coma 3. electrolyte deficiencies |
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What pregnancy category do loop diuretics fall under?
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Category C
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What must you monitor when taking a loop diuretic?
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1. BUN/Cr
2. electrolytes 3. CBC 4. LFTs 5. urine/blood glucose |
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DDI of loop diuretics?
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aminoglycosides-- leads nephro and ototoxicity
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A loop diuretic may have a DDI that is pertinent in a psychiatric patient if that patient takes
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Lithium-- reduces the body's ability to clear lithium, so its concentrations will incease
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If you have a pregnant patient who needs to be placed on a loop diuretic, which one should you use?
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Torsemide (Demadex)- because it is Preg Cat B
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What is the MOA for a potassium-sparing diuretic?
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inhibit DCT aldosterone-induced Na-resorption
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What is the most commonly prescribed potassium-sparing diuretic?
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spironolactone (Aldactone)
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Amiloride (Midamor) is an example of a
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potassium-sparing diuretic
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Triamterene (Dyrenium) is an example of a
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potassium-sparing diuretic
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BBW of potassium-sparing diuretics
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hyperkalemia
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CI for potassium-sparing diuretics?
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1. hyperK
2. anuria 3. severe renal dysfunction |
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What are some common (2) ADEs associated with potassium-sparing diuretics?
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1. azotemia
2. cramps- dehydration can contribute- drug also acts to alter the [Mg] in the muscles, which contributes to cramping. |
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What is a more severe, less common ADE associated with potassium-sparing diuretics and what causes this?
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ventricular arrhythmias- due to increased K+ concentrations in the body
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Amiloride (Midamor) - do you take this drug before/after eating?
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take after eating OR with food
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What pregnancy category is amiloride (Midamore)?
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B
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If you have a pregnant woman who needs to be on a K+ sparing diuretic, which should you consider prescribing?
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Amiloride (Midamor)
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Triamterene (Dyrenium) is normally prescribed for
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peripheral edema
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In regard to meals, how should you take triamterene (Dyrenium)?
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after eating
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What pregnancy category does Triamterene (Dyrenium) fall under?
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D
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Describe the MOA of CCBs
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bind L-type calcium channel which results in closing the channel, and decreased calcium enters during depolarization
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What are three end effects of CCBs
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1. decrease cardiac contractility
2. dilate coronary arteries to increase oxygen supply 3. peripheral & coronary vasodilation & decreased contractility. |
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Dihydropiridines have what effect on rate?
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little-none
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DHPs should be used to treat
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HTN or angina
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Non DHPs have what effect on heart rate?
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decrease heart rate-- decrease the rate of the SA and AV nodes
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Non-DHPs are good for treating:
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1. HTN
2. angina 3. supraventricular arrhythmias |
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What effects do CCBs have on smooth muscles?
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relaxes them
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what effect do CCBs have on peripheral vascular resistance?
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decreases it
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What effect do CCBs have on coronary arteries?
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dilates them (to decrease blood pressure)
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What effect do CCBs have on the AV node refractory period?
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prolongs it
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What 3 ways do CCBs work to decrease bp
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1. decrease heart rate of the sinus node
2. decrease the rate of AV impulse conduction to the ventricles 3. decreases contractility of the ventricular muscle |
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Verapamil is an example of a
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Non-DHP CCB
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Calan IR should be dosed
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TID- three times a day
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Calan SR/Isoptin SR: should be dosed
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up to BID
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If you are dosing a non-DHP CCB QD and it is SR, you should give that dose
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in the morning
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Verapamil can be given in pill form but also in
|
IV
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When writing a prescription for Verapamil, you need to remember to record what 2 things especially
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The release you want (ie IR, SR, ER)
The time of day you want your patient to take it (ie AM, PM) |
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Verapamil- Class
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Non-DHP Calcium Channel Blocker
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CI of Verapamil
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1. Severe LV dysfunction
2. HypoTN (systolic bp <90) |
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Cautions of Verapamil
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1. sinus bradycardia
2. 1st degree AV block 3. HF 4. HypoTN or syncope 5. neuromuscular blockade |
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ADE that are common with use of Verapamil
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1. Headache
2. Constipation 3. Gingival hyperplasia |
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Less common ADEs of Verapamil (4)
|
1. Edema: peripheral or pulmonary
2. HypoTN 3. Bradycardia 4. Rash |
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Calan SR and Isoptin SR (versions of Varapamil) should be taken: with/without food?
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WITH food
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Verelan & Verelan PM: what is one plus that these formulations have in regard to taking meds with/without food
|
can open capsule and sprinkle on 1 tsp of applesauce
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What is an important counseling point if you have a person on Verelan or Verelan PM who plans on opening & sprinkling the capsule contents on applesauce?
|
DO NOT CHEW- must swallow immediately. The capsule is full of mini coated beads- chewing these will cause IR instead of the SR.
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Cardizem & LA formulations of Diliazem are different in that they
|
are in capsule form- so can cut these as needed.
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ADEs of Diltiazem
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1. Edema
2. Headache 3. AV block 4. Bradycardia 5. HypoTN 6. flushing 7. NVDC |
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Diltiazem has SEs and ADEs that are more pronounced than those of other CCBs. What are these?
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1. edema
2. headache 3. flushing 4. NVDC |
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Diltiazem IR:
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take before eating
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Dilacor XR, Dilt-XR, and Diltia XT: take with/without food?
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on empty stomach- WITHOUT food
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Taztia XT, Tiazac- with/without food?
|
open capsule and sprinkle on applesauce- not hot, and DON'T chew
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A patient on CCBs should have what type of mointoring?
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1. LFTs
2. BP 3. EKG 4. HR |
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What is an important counseling point for a woman taking a CCB?
|
it can be excreted in breastmilk
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What are the most frequently prescribed DHP CCBs?
|
1. Amlodipine
2. Felodipine 3. Nicardipine 4. Nifedipine |
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DHP CCBs have a common ending of:
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"dipine"
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What is the primary treatment for HTN?
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DHP CCBs
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why are DHP CCBs primary for treatment of HTN?
|
They have high vascular selectivity and little/no effect on rate
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What are DHP CCBs NOT good for?
|
angina
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In regards to potency, name the top 4 prescribed DHP CCBs from most to least potent (ie- most vascularly selective, to least)
|
1. Nifedipine
2. Amlodipine 3. Nicardipine = Felodipine |
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When using a DHP CCB for treatment of HTN, which formulation is best suited? Why?
|
SR- because better compliance and control throughout the day
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What are IR formulations of DHP CCBs NOT suitable for?
|
acute/crisis HTN
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Which DHP CCB is usually tried first line for HTN? why?
|
Amlodipine- because decreased rate and severity of ADEs and SEs.
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Which DHP CCB ha a higher incidence of headache as an ADE?
|
Felodipine
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A patient complains of flushing, headache, and edema and states he just recently started a DHP CCB, but can't remember the name of it. Which drug is most likely the culprit for his ADEs?
|
Nicardipine
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Most DHP CCBs are dosed
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QD
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In addition to increased ADEs, Nicardipine is a DHP CCB that must be taken _____ times per day
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2
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Which DHP CCB has a high rate of ADEs including flushing, headache, and edema?
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Nicardipine
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A patient comes in and complains of flushing, dizziness, and sexual side effects. She says she just started a new DHP CCB, but can't remember the name of the drug. Which drug is most likely the cause of these ADEs?
|
Nifedipine
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Nifedipine
1. IR must be dosed ___ x per day 2. Procardia XL formulation must be dosed ______ x per day 3. Adalat must be dosed ____ x per day. |
1. 3 (TID)
2. 1 (QD) 3. 1 (QD) |
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MOA for a beta adrenergic Receptor antagonist
|
1. decrease mycoardial contractility, HR, and cardiac output
2. decrease renin secretion, leading to a decreased level of circulating ATII |
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If a beta blocker is considered to be "selective", which receptor is it usually selective for?
|
B1
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you have a HTN patient with A fib. What beta blocker is best suited?
|
Sotalol AF
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You have a HTN patient with a ventricular arrythmia, which BB is best suited?
|
Sotalol
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Which two non-selective beta blockers also have alpha-blocking activities?
|
1. labetalol
2. carvedilol |
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When prescribing a B1 selective BB, why must you specify XR or IR if you put the mg dosage on the script?
|
because IR and XR come in the same mg formulations, but are very differently utilized within the body
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Atenolol (Tenormin)
|
B1 selective BB
|
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metoprolol
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B1 selective BB
|
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Nebivolol
|
B1 selective BB
|
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Bisoprolol
|
B1 selective BB
|
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Betaxolol
|
B1 selective BB
|
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Esmolol
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B1 selective BB
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What are the 4 most commonly prescribed selective BB
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1. atenolol
2. metoprolol 3. nebivolol 4. bisoprolol |
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BBW of atenolol, metoprolol, nadolol, propranolol, timolol?
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Do not abruptly discontinue use- must taper off. Will have severe angina, MI, or ventricular arrythmias (angina patients) if you stop taking the drug abruptly
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BBW of sotalol
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initiate & titrate dose while patient is in hospital- use continuous EKG until a stable maintenance dose is found and utilized for 3 days. Must examine RF baseline and during treatment
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CI of BB
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1. severe COPD
2. asthma 3. uncompensated HF 4. sinus bradycardia 5. AV block (2nd or 4rd degree) |
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Why are COPD and asthma CI for using a BB?
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because bronchioles need to be relaxed in these conditions, and BB constrict the bronchioles which may exacerbate pulmonary problems.
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What is one important ADE of beta blockers?
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may mask hypoglycemia (sweating)- DM patients may have difficulty recognizing when their sugars get too low
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Name 5 ADEs associated with BB
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1. Alter lipids- "opposite of what you want"- so you get decreased HDL, increased TG and LDL
2. bronchospasm 3. prolonged hypoglycemia due to increased insulin sensitivity 4. hypoK 5. bradycardia |
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If you have a pregnant woman who has to be on a BB, what options are available?
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1. pindolol
2. sotalol |
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What pregnancy category do Pindolol and Sotalol fall into?
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FDA Preg Cat B
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Most BB fall into what pregnancy category?
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C
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What is the only BB that falls into pregnancy category D?
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Atenolol
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Hydralazine- MOA
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vasodilator- directly dilates peripheral vessels
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ADEs of Hydralazine
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1. headache
2. tachycardia 3. flushing |
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When do the ADEs associated with taking Hydralazine usually set in?
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when you first start taking a drug
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Hydralazine may not be suitable for a non-compliant patient because:
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it is short acting, so must be dosed TID-QID
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Minoxidil- Class
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Vasodilator
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BBW of Minoxidil
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give with beta blocker and loop diuretic- to prevent tachycardia and fluid accumulation
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what is the serious risk associated with use of minoxidil?
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serious CV event
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ADEs of Minoxidil
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1. CHF
2. Edema 3. Tachycardia 4. Weight Gain 5. Headache |
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When do you prescribe Minoxidil?
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After a patient has failed treatment with at least 1 other diuretic and 2 other anti-HTNs at max doses
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In general, why do vasodilators work as anti-HTN agents?
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vessels dilate, so the pressure within the vessels decreases- may result in increased heart rate to compensate for the decreased vessel pressure
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Clonidine: class
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Alpha-agonist
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Catapres-TTS- formulation
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transdermal patch that you change weekly
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MOA of Clonidine
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stimulates alpha 2 adrenergic Receptors in the brain to decrease sympathetic outflow, decrease peripheral resistance, reno-vasc resistance, heart rate, and bp
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Clonidine acts_____
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centrally
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What is an important counseling point regarding terminating clonidine therapy?
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not to abruptly withdraw medication
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Common ADEs of clonidine (6)
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1. Dryness: mouth/eyes
2. mood change 3. drowsiness 4. dizziness 5. decreased appetite 6. headache |
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what additional ADE is associated with Catapres-TTS in addition to those associated with Clonidine?
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Sexual side effects
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If a patient comes in with HTN and is already ADHD, what may a good treatment approach be?
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Clonidine- it is indicated for use in ADHD and as an anti-HTN agent
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A patient is prescribed the Clonidine patch, and complains that her pressure is still high 24 hours later. What should you tell her?
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That the patch may take 2-3 days for full effects
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When you take the patch off, how long does the clonidine remain in your system and provide medication?
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~8 hours
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Clonidine tablets take effect in
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1 day
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Clonidine ER formulations have better compliance because
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they are QD dosing, not BID
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What is some positive effects of prescribing a combination product?
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1. increased compliance- due to decreased pill burden
2. decreased cost 3. helps counteract SEs of another medication |
