1
Q
Loop diuretics
A
- ethacrynic acid, furosemide, bumetamide and torsemide
- inhibit Na-K-2Cl transporter in tALH
- high potency
- necessary for severe HTN, in setting of CHF or cirrhosis and with renal insufficiency (GFR <30-40)
2
Q
thiazide diuretics
A
- hydrochlorothiazide, chlorthalidone, indapamide, metolazone (in order of increasing potency)
- medium potency
- most often used diuretic because they have medium potency and dont have to pee as often
- mild-mod HTN (use for high volume HTN)
3
Q
SE of loops and thiazides
A
- hypokalemia, hypomagnesemia –> cardiac arrythmias)
- impaired glucose tolerance (insulin resistance)
- increased lipids (increased cholesterol and LDL)
- increased uric acid
- ED
- volume depletion
4
Q
SE of K+ sparing diuretics
A
- spironolactone is a competitive antagonism of androgen receptors:
- gynecomastia, ED, loss of libido (men)
- menstrual irregularities, menorrhagia an nipple tenderness (women)
- hyperkaelemia (cardiac probs)
- can’t use with ACEI or ARBs
- cant use with renal failure
5
Q
effects of Angiotensin II
A
- increased sympathetic tone
- increased tubular reabsorption of NaCl and K+ secretion
- aldo secretion
- vasoconstriction
- ADH secretion
6
Q
ACEI
A
- more potent BP than ARBs
- block endothelial ACE and inhibit breakdown of bradykinin which is a potent vasodilator and responsible for cough
- captopril (short acting)
- isinopril, benazepril, quinapril, ramipril (long acting)
- Enalapril (converted to enalaprilat which is more active metabolite)
7
Q
ARBs
A
- competitive receptor binding of angio II to vascular endothelium
- less SE bc they act further downstream but not as potent
- losartan, valsartan, irbesartan
8
Q
SE of ACEI and ARBs
A
- cough (only ACEI)
- hypotension
- decreased renal function (dilation of efferent arteriole decreases GFR)
- angioedema rarely
- hyperkalemia
9
Q
contraindications of ACEI and ARBs
A
- renal artery stenosis (can cause acute renal failure)
- hyperkalemia (angio II promotes NaCl reabsorption and K+ excretion –> block this and you block the ability to rid of K+)
- acute renal failure (decreases GFR)
- pregnancy
10
Q
when to use of ACEI/ARBs
A
- chronic renal kidney disease/proteinuria (ppl with chronic renal failure of worsening GFR –> as glomeruli burn out the remaining ones have increased GFR which causes quicker burn out –> need to block this to preserve remaining nephrons)
- heart failure
- Post MI (LV remodeling post MI and LV hypertrophy)
- diabetes mellitus
11
Q
beta blockers
A
- not very effective in treating HTN
- mechanism: reduce CO (contractility, HR); inhibit renin release, reduce NE release; decrease central vasomotor activity (sympa tone)
12
Q
SE of propanolol
A
non-selective BB
- decreased exercise capacity
- bronchospasm
- bradycardia (neg chronotrope)
- CHF (neg inotrope –> decreased contractility)
- mask sx of hypoglycemia in diabetics
- depression (crosses BBB)
- worsening sx of PVD
13
Q
moderately selective BBs
A
- metoprolol, atenolol
- block B1 and very little B2
- less likely to cause bronchospasm, hypoglycemia and dpression
14
Q
carvedilol and labetalol
A
- potent, some vasodilation (via alpha blocking)
- carvedilol used in setting of CHF or ACS
- labetalol used in CCU for HTN urgency
15
Q
esmolol
A
Unique BB (IV) in it’s short half-life and used mostly for AV nodal blocking in unstable PTs
16
Q
terazosin and doxazosin
A
- alpha1 receptor antagonists –> reduce vascular resistance
- SE: orthostatic hypotension, fluid retention, worsening angina (due to reflexive tachy)
- benefits: help BPH
- 2nd tier meds for HTN bc they are more likely to cause cardiac complications
17
Q
minoxidil and hydralazine
A
- vasodilators –> relax smooth mms of peripheral arterioles
- Min. used for refractory HTN (and is rogaine)
- Hydra. used IV in ICU for acute HTN urgency or in setting of CHF with combined HTN (Lupus SE!)
18
Q
central acting sympathoplegic drugs
A
- reduces sympa outflow from vasomotor centers in brainstem –> decreased renin release too
- clonidine is the only one routinely used
- alpha methyl dopa used in pregnancy
- Guanabenz
- SE: sedation, dry mouth, fatigue, orthostatic hypotension, depression, rebound HTN upon sudden discontinuation
19
Q
ganglion blocking agents (adrenergic neuron blocking agents)
A
- guanethidine – blocks release of NE from post-gang sympa nerve (SE: sympathectomy –> postural hypotension, diarrhea and impaired ejaculation)
- reserpine: deplete NE, DA and 5HT in central and peripheral nerves (SE: sedation, depression, parkinsonism_
20
Q
dihydropyridines
A
- amlodipine and nifedipine
- CCB
- inhibit contraction of vascular smooth mm
- can cause reflex tachycardia and may worsen angina by increasing O2 demand
21
Q
non-dihydropyridines
A
- verapamil and diltiazem
- CCB –> inhibit contraction of vascular smooth mm
- decrease HR –> decreased O2 demand
22
Q
SE of CCBs
A
- constipation (prevent GI motility)
- led edema
- heart failure (non-dihydros are negative ionotropes)
- bradycardia (cardiac pacemaker potential)
- AV nodal block
- reflex tachy for dihydros
- short acting CCBs worsen all of these SE
23
Q
in PTs with comorbid diabetes use…
A
- ACEIs or ARBs
24
Q
in PTs with comborbid BPH use..
A
alpha blockers
25
contraindications 1) depression 2) pregnancy
1. reserpine, BB, central acting alpha2 agonist
2. ACEI, ARB
26
Stage 1 and 2 HTN
1. Stage 1 \> 140/90
2. Stage \> 160/100
27
most significant lifestyle modifications
1. weight loss
2. DASH diet
28
most commonly used meds
* ACEI/ARBS, Thiazides, CCB
29
less commonly used
* BBs and alpha blockers
30
rarely used
central acting alpha agonists, adrenergic blocking agents
31
hydralazine
* direct vasodilator
* used in ICU for acute HTN urgency (IV)
* also used in CHF with nitrates
32
minoxidil
* rogaine
* direct vasodilator
* used for refractory HTN
33
with comorbid..
1. systolic HF (HFrEF)
2. post MI
3. proteinuric chronic kidney disease
4. Afib or Aflutter
1. ACEI/ARB, BB, diuretic
2. ACEI, BB
3. ACEI/ARB
4. BB, non-dihydro CCB
unit 4 pharm
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