6024 Mod 9 AntiHTN.pdf

-digoxin -NSAIDs -ACEI (good interaction–synergy) First Line Anti-HTN SNS→ baroreceptors -Beta 1–cardiac output -Alpha 1–vasoconstriction -Vascular smooth muscle receptors & Kidneys -RAAS -alpha 1 ● Which medications are First line ○ Start with thiazide diuretics unless CKD, then ACEI or ARBs, th...

-digoxin -NSAIDs -ACEI (good interaction–synergy) First Line Anti-HTN SNS→ baroreceptors -Beta 1–cardiac output -Alpha 1–vasoconstriction -Vascular smooth muscle receptors & Kidneys -RAAS -alpha 1 ● Which medications are First line ○ Start with thiazide diuretics unless CKD, then ACEI or ARBs, then CCB ○ With any CKD, consider ACEI or ARBs regardless of ethnicity ● Which medications are Second line ○ Spironolactone, direct renin inhibitors, vasodilators (if HF or angina for afterload reduction), alpha blockers, beta blockers ● Specialty populations ○ CKD–ACE/ARB ○ diabetes–ACE/RB early ○ HF–ACE?ARB early ○ Pregnant–no ACE/start ARB or renin inhibitor HCTZ ● Look at above in diuretics section ACEi—”pril” Lisinopril, benazepril, enalapril, ramipril, captopril ● MOA ○ Blocks conversion of angiotensin I to II ● SE ○ hyperK+ ○ Angioedema ○ Cough ○ First dose hypotension ● Indications ○ 1st line tx before ARBs in HTN and post MI (helps remodeling) ○ Diabetic nephropathy ● Contraindications ○ HFrEF in AMI (start ARB instead) ○ pregnancy–BBW ○ Renal artery stenosis ○ Concurrent use of spironolactone or lithium ○ Hx of angioedema ● Monitoring ○ Renal function ○ Avoid use with NSAIDs ARB—”artan” Valsartan, Losartan ● MOA ○ Competitively inhibits angiotensin II on smooth muscle, heart, and adrenal glands→ dilation ● SE ○ Angioedema ○ Renal failure ● Indications ○ HTN, HF, diabetic nephropathy/retinopathy, MI, CVA prevention ○ Preferred over ACE with HF ● Contraindications ○ Pregnancy ○ Renal artery stenosis ● Monitoring ○ Renal function ○ Avoid with NSAIDs ● Facts/Population Considerations ○ May have less effect of first dose hypotension ○ No significant hyperK+ CCB—”pine” amlodipine, nicardipine, nifedipine [Dihydropyridines = HTN] ● MOA ○ Blocks Ca channels on peripheral smooth muscle (blood vessels)--> vasodilation ● SE ○ Reflex tachycardia ○ Edema ○ Dizziness, HA, flushing ○ Negative inotropy–will decrease contractility ● Indications ○ HTN, dysrhythmias. Angina, sometimes migraines ● Contraindications ○ Known HF–except amlodipine ○ Avoid immediate release in post MI or unstable angina ● Monitoring ○ BP/MAP ○ renal/electrolytes ● Facts/Population Considerations ○ Non-dihydropyridines don’t end in “pine” and are for arrhythmias Second Line Anti-HTN Renin Inhibitors—Aliskiren (Tekturna) ● MOA ○ Decrease plasma renin activity→ prevents conversion of angiotensinogen to angiotensin I and then angiotensin II→ vasodilation ● SE ● ● ● ● ○ Cough ○ Angioedema ○ Diarrhea ○ hyperK Indications ○ HTN ○ Combined with CCB or HCTZ Contraindications ○ Acute renal failure (CrCl < 30) ○ ESRD ○ Pregnancy ○ Renal artery stenosis Monitoring ○ Renal; liver Facts/Population Considerations ○ Give with low fat meal Alpha 1 Antagonist (blockers) —”zosin” doxazosin (Cardura) Prazosin, Terazosin ● MOA ○ Blocks vascular alpha 1 receptors on smooth muscle→ vasodilation ● SE ○ HA, dizziness ○ Nausea ○ Postural hypotension ● Indications ○ HTN ○ Off label use: BPH, PTSD nightmares, Raynaud’s, Dermal necrosis r/t IV infiltration ● Contraindications ○ Use with PDE5I like sildenafil ○ Use with TCAs (triptylines) ● Monitoring ○ Renal; liver, BP Alpha 2 Agonist (centrally acting) Clonidine, Methyldopa, Guanfacine ● MOA ○ Reduce sympathetic outflow from vasomotor centers in brainstem & increase parasympathetic outflow→ blocks NE availability→ vasodilation ● SE ○ Sedation, euphoria, crosses BBB ○ Nasal congestion, dry mouth ○ HA, dizziness, weakness ○ Rebound HTN ● Indications ○ HTN ○ Off label: pain, opioid withdrawal, smoking cessation, tourette’s, ADHD, delirium ● Contraindications ○ Substance use with other stimulants ○ pregnancy ● Monitoring ○ Potential for abuse ○ Methyldopa→ anemia & liver toxic ○ Clonidine→ vivid dreams/nightmares, xerostomia Beta Blockers ● 1st Generation BB (non cardiac selective) ○ Propranolol, sotalol, timolol, nadolol ● MOA ○ Blocks beta 1 to decrease HR & contraction and blocks beta 2 ● SE ○ Bradycardia ● ● ● ● ○ Hypotension ○ Hypoglycemia ○ Fatigue; dizziness Indications ○ HTN, pheochromocytoma, afib ○ Off label: anxiety, angina, elevated intraocular pressure/glaucoma Contraindications ○ Asthma; COPD ○ 2nd or 3rd degree heart block ○ Pregnancy→ propranolol Monitoring ○ BG; HR; BP; overdose Facts/Population Considerations ○ Reversal agent: glucagon 2nd Generation BB ● Atenolol, metoprolol, esmolol, bisoprolol ● MOA ○ Same as 1st gen–blocks beta 1 ○ Renal beta 1 = decreases renin ○ No effect on the lungs ● SE ○ Same as above ● Indications ○ HTN, HF, dysrhythmias, angina/MI ● Contraindications ○ Pregnancy ○ Heart blocks ● Monitoring ○ Same as above ● Facts/Population Considerations ○ Safer for asthmatics, diabetics, and PVD ○ Metoprolol has 2 types: tartrate (HTN) & succinate (HF) 3rd Generation BB ● Labetalol; carvedilol ● MOA ○ Blocks alpha 1→ vasodilation ○ Blocks beta 1 & 2 ● SE ○ Same as above ● Indications ○ HTN, MI, HF ● Contraindications ○ Abruptly stopping→ increase risk of MI ○ Caution with digoxin & CCBs ○ CHB ● Monitoring ○ Same as above **Meds to avoid in pregnancy -ACE/ARB/RI -propranolol -atenolol, metoprolol, bisoprolol First line tx for pregnancy -labetalol & methyldopa 2nd line tx -nifedipine -HCTZ