Hypertension Management Review

• Classify blood pressure according to the 2017 ACC/AHA Guidelines.

Blood Pressure Categories

• Normal: SBP <120 mm Hg and DBP <80 mm Hg
• Elevated: SBP 120-129 mm Hg and DBP <80 mm Hg
• Hypertension Stage 1: SBP 130-139 mm Hg or DBP 80-89 mm Hg
• Hypertension Stage 2: SBP ≥140 mm Hg or DBP ≥90 mm Hg
• Individuals with SBP and DBP in 2 categories are designated to the higher BP category.
• Classification requires 2 different measurements.
• Diagnosis requires 2 in-office measurements + outside measurements for confirmation.
• White Coat Hypertension: Office readings higher than outside readings.
• Masked Hypertension: Office readings lower than outside readings.

Risk Factors for Hypertension

• Modifiable risk factors include diet (DASH), weight loss, reduced sodium intake, increased physical activity, reduced alcohol, smoking cessation, and stress management.
• Non-modifiable risk factors include age, genetics, race, and family history.

Hypertension Treatment and Monitoring Plan

• Pharmacologic treatments include preferred thiazides, CCBs, ACEi, or ARBs (not combined).
• Non-pharmacologic treatments include diet, exercise, weight management, and lifestyle modifications.
• Follow-up is recommended in 1 month, then every 6-12 months.
• Modify existing antihypertensive regimen based on therapy response and new findings.
• Adding drug therapies improves BP reduction with fewer adverse effects, aiming for an average reduction of 7 mmHg over 4 mmHg.

Special Considerations for Hypertension Management

• Black individuals are more likely to be resistant to ACEi/ARB monotherapy; use CCB, thiazides, or both.
• Pregnant individuals should aim for a BP goal of <140/90 using nifedipine, methyldopa, or labetalol.
• Resistant HTN is defined as being on 3 agents at optimal doses with no BP changes; consider spironolactone.
• Hypertensive emergency is defined as BP >180/120 AND target organ damage while hypertensive urgency does not have organ damage; IV antihypertensives are used.

Blood Pressure Lowering Drugs Comparison

• Thiazides are effective and reduce CV events; chlorthalidone is more potent than hydrochlorothiazide.
• Thiazides can cause HYPOkalemia, HYPOnatremia, HYPERcalcemia, HYPERglycemia, and gout.
• They are first-line for isolated systolic HTN and useful as add-ons.
• ACEIs reduce BP/CV, are renoprotective in TDM/CKD, and improve HFrEF/post-MI, but can cause dry cough, angioedema, and HYPERkalemia.
• ACEIs are first-line with compelling indications but less effective in black patients as monotherapy.
• ARBs are similar to ACEIs, renoprotective without dry cough, better tolerated than ACE, and can cause HYPERkalemia.
• ARBs serve as a first-line alternative to ACEi, preferred in TDM/CKD/HF.
• CCBs include DHPs and non-DHPs.
• DHP CCBs are potent, reduce stroke risk (especially in black and elderly patients), preferred for isolated systolic HTN, and can cause peripheral edema and reflex tachycardia.
• They are first-line for general HTN and safe in pregnancy.
• Non-DHP CCBs lower and control HR (AFib) but can cause bradycardia, AV block, and constipation.
• They are preferred in AFib or angina but should be avoided in HFrEF.
• BBs are less effective than other first-line agents but offer strong CV benefits with CAD/post-MI/HF; they can cause bradycardia, fatigue, sexual dysfunction, and masked HYPOglycemia, and should be avoided in asthma/COPD.
• They are not first-line unless comorbidities exist; carvedilol and metoprolol succinate are preferred in HF.
• MRAs are most effective as add-on therapy for resistant HTN, reduce mortality in HF/HFrEF, and can cause HYPERkalemia and gynecomastia.
• They are used in resistant HTN and HFrEF.

Treatment Decisions for High Blood Pressure Management

• CKD or proteinuria: use ACEi or ARB
• HFrEF: use beta-blockers, ACEi/ARB/ARNI/MRA
• Angina: use BB or CCB
• BPH: use alpha-1 blockers
• Add Spironolactone is effective

Diabetes

• Analyze the indications, contraindications, and potential side effects of each class of diabetes drugs.
• Biguanides (metformin)
  • First-line for T2DM, avoid in severe kidney disease (GFR <30) and severe liver disease.
  • Side effects: GI upset, vitamin B12 deficiency, rare lactic acidosis.
• Sulfonylureas (glipizide, glyburide, glimepiride)
  • Used for T2DM, avoid in severe kidney or liver disease.
  • Side effects: Hypoglycemia, weight gain.
• SGLT2 inhibitors (canagliflozin, empagliflozin, dapagliflozin)
  • Provide heart and kidney protection in T2DM.
  • Contraindicated in severe kidney disease (GFR <30).
  • Side effects: Dehydration, low BP, UTI, increased urination.
• DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin)
  • Used as add-on therapy for T2DM.
  • No major contraindications.
  • Mild side effects: Upper respiratory infections, joint pain.
• GLP-1 RA (semaglutide, liraglutide, dulaglutide)
  • Benefits include weight loss, heart benefits, and strong BG control.
  • Contraindicated in history of thyroid cancer or pancreatitis.
  • Side effects: Nausea, vomiting, delayed stomach emptying.
• Insulin (lispro, aspart, regular, NPH, glargine, detemir)
• Used for T1DM and T2DM when other medications fail, severe hyperglycemia, or DKA.
• Side effects: Hypoglycemia unawareness, hypoglycemia, weight gain, injection site reactions.
• TZDs (pioglitazone)
  • Used for T2DM with insulin resistance.
  • Contraindicated in HF, liver disease, or history of bladder cancer.
  • Side effects: Weight gain, edema/fluid retention, increased risk of fractures.
• GIP/GLP-1 RA (tirzepatide)
  • Used for T2DM, CV/renal protection, and weight loss.
  • Contraindicated in history of medullary thyroid carcinoma or severe GI disease.
  • Side effects: Nausea, vomiting, diarrhea, weight loss, pancreatitis.
• Analyze the clinical evidence supporting the efficacy and safety of the major antidiabetic drug options in managing diabetes, particularly their role in achieving glycemic control and potential benefits in cardiovascular and renal outcome.
• For weight loss: GLP-1 receptor agonists (Semaglutide, Liraglutide), SGLT2 inhibitors (Empagliflozin, Canagliflozin).
• If patient has kidney disease: Avoid Metformin (if eGFR <30 mL/min), SGLT2 inhibitors.
• Common Therapy:
  • Often, ONE DRUG is not enough to control blood sugar.
  • Metformin is the usual first choice.
  • Add GLP-1 receptor agonists or SGLT2 inhibitors if heart/kidney protection is needed.
  • Insulin or Sulfonylureas if stronger sugar control is required.
• A1c Test: Every 3 months to check long-term sugar control.

Blood Sugar Checks

• Fasting Blood Glucose Goal: 80-130 mg/dL
• Post-Meal Blood Sugar Goal: <180 mg/dL
• Watch for signs of low sugar (shakiness, sweating, confusion) and high sugar (thirst, fatigue, frequent urination).

Diabetes Medications Comparison

• Biguanides (metformin)
  • Decreases hepatic glucose production.
  • Onset 1-2 hours.
  • Dosing: BID or QD.
  • Advantages: No hypoglycemia, weight neutral, GI upset.
• Sulfonylureas
  • Stimulates insulin release from beta-cells.
  • Onset 30 mins.
  • Dosing: QD or BID.
  • Disadvantages: Hypoglycemia risk, weight gain; glyburide has long half-life.
• SGLT2 inhibitors
  • Blocks glucose reabsorption.
  • Onset 1-2 hours.
  • Dosing: QD.
  • Advantages: CV/renal benefits, weight loss.
  • Disadvantages: UTIs, DKA risk.
• DPP-4 inhibitors
  • Inhibits DPP-4 that breaks GLP-1.
  • Onset 1-4 hours.
  • Dosing: QD.
  • Advantages: Weight neutral, no hypoglycemia.
  • Disadvantage: Risk of pancreatitis.
• GLP-1 RAs
  • Increases insulin secretion.
  • Onset 1-3 hours.
  • Dosing: QD or weekly.
  • Advantages: Weight loss, CV benefits.
  • Disadvantages: GI effects, risk of pancreatitis, thyroid cancer risk.
• Insulin (basal)
  • Steady insulin release.
  • Onset 1-6 hours.
  • Dosing: QD or BID.
  • Advantages: Less hypoglycemia Disadvantage: Weight gain
• Insulin (bolus)
• Fast-acting insulin.
• Onset 10-30 min;
• TID
• Hypoglycemia risk, mimics endogenous insulin
• TZDs
  • Increases insulin sensitivity in muscles and fat.
  • Onset days-weeks.
  • Dosing: QD.
  • Disadvantages: Fluid retention, HF risk. Advantages: no hypoglycemia
• GIP/GLP-1 RAs
  • Increase Insulin.
  • Onset 1-4 hours. Dosing: weekly. Advantages: Superior weight loss, CV Benefits, Gl effects.

Combination Therapy approach

• Metformin w/ GLP-1 Receptor Agonists --> helps lower blood sugars, and promotes wt loss.
• Metformin w/ SGLT2 --> Protects heart and kidneys while lower blood sugar.
• Metformin w/ Sulfonylurea --> Improves insulin secretion with a risk of low blood sugar

Combination Therapy Benefits

• Improves blood sugar control
• Reduces the need for insulin
• Provides additional health benefits like weight loss and heart protection

Patient Education

• Adherence: Take medications consistently, even you feel fine
• Monitoring: Regularly check blood sugar levels
• Eat regularly, do not skip meals
• Lifestyle tips include 150 mins of exercise, and eat healthy meals: low sugar, high carbs, protein, fiber.

Blood Sugar Readings

• hypoglycemia or hyperglycemia.
• May need adjustments based on weight, kidney function, or Cardiovascular Health
• Start insulin when Alc > 10% or if blood sugars are consistently high despite medications.

Types of Insulin

• Long acting/Basal: Glargine, Detemir, Use once daily to keep sugars steady all day long
• Rapid Acting/Bolus: Lispro, Aspart, Use before meals to control meal-time sugar spikes

Key points

• Type 1 Diabetes: Both BASAL & BOLUS Insulin treatment required
• Dosing Startegy 0.5-1.0 units/kg/day
• ** split into 50% Basal and 50% Bolus Insulin, then divvy up to each MEAL.

Diabetes Practice Exam Notes

• ASCVD = morst relevant in overall disease management
• < 10% use 1 agent A1C results
• Normal: below 5.7%
• Pre-diabetes: 5.7-6.4
• T2DM: 6.5% or above

Fasting blood sugar results

• Normal: below 100mg/dL
• Pre-diabetes 100-125
• T2DM: >126

Postprandial

• Normal: <140
• Pre-diabetes: 140-199
• T2DM: >200

Meds with Side Effects

• Metformin = lactic acidosis
• Pioglitazone = congestive heart faliure CHF
• Liraglutide = thyroid cancer risk
• Efficacy - check at Week 2
• Safety - check at Week 1

Dosing

• Metformin: IR start 500, 2550 max ER start 500 - 1000, MAX 2000-2500
• Glipizide; STAR 5, MAX 40
• Glimepiride: Start 1-2 mAX 8
• Liraglutide: Start 0.6mg, MAX 1.8
• Empagliflozin; STAR 10, MAX 25
• Insulin: Star4 or 10% basal, NO MAX