DIURETICS (only those used for antihypertensive therapy) SYMPATHOLYTICS Peripheral adrenergic receptor blockers Centrally acting RENIN-ANGIOTENSIN SYSTEM INHIBITORS Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II receptor blockers VASODILATORS Ca 2+ -channel blockers Others Antihypertensive Drugs Treatment Guidelines from The Medical Letter Drugs for Hypertension January 200 Fall ‘09
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DIURETICS (only those used for antihypertensive therapy) SYMPATHOLYTICS Peripheral adrenergic receptor blockers Centrally acting RENIN-ANGIOTENSIN SYSTEM.
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DIURETICS(only those used for antihypertensive therapy)
Careful consideration should be taken when patients present with co-morbidities:
diabetes, lipid disorders, ischemic heart disease and failure, migraines, asthma,
etc...
Specific patients may respond better to certain therapies (factors include; ethnicity, age, etc…)
AM Meds:Digitek (digoxin) 250 mcgVerapamil SR Tab, 180 mgHydralazine 25mgFish Oil 1000 units Enalapril Mal Tabs (5 mg in AM, 5mg in PM)ASA 350mg Chlorathalidone 25mgMultivitamin Ester C 1000 units/ MSM 1000 unitsGlucosamine/chondroitin/MSM 1000 unitsAcetaminophen 1000 mg (for arthritis discomfort)
PM Meds:Terazosin (5 mg at noon, 5mg in PM)Hydralazine 25mg Lipitor 10mgFish Oil 1000 unitsFlomax .4mg Singulair 10mgAcetaminophen 1000 mg (for arthritis discomfort)Glucosamine/chondroitin 1000 units/ MSM 1000 units
For allergies/ asthma:Advair Discus 100/50, 1 one puff in AM, PMFluticasone, 2 puffs each nostril once a dayMaxair Autohailer, q4-6hr (rescue only)Claritin (generic) 10mg
JDM is an 81 year old caucasian male who has been active until the last 6 months. He lives in New England for 4 months of the year, and in the Bahamas for the remainder of the year. He exercises every day (typically a long walk), fishes and gardens. His longstanding PCP retired last year, and complains to his new PCP that he has bouts of light headedness and elevated heart rates. His wife is a retired nurse so she makes him take his blood pressure and heart rate often. Systolic pressure is usually normal, but diastolic pressure is low.
Can you identify potential interactions among the drugs based on sympotoms?
Brenner Fig 10-1
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SYMPATHOLYTICSVASODILATORSANGIOTENSIN INHIBITORSAngiotensin Converting Enzyme (ACE) InhibitorsAngiotensin II receptor blockersRenin inhibitorDIURETICS
Typically reserved for patients who do not tolerate ACE-I Some evidence ACE2 metabolizes AngII to Ang1-7 (a vasodilator), and there are non-ACE sources of AngII, therefore ARB’s might be more effective than ACE-I (stay tuned, more data is needed)Less effective antihypertensive in blacks (same as with ACE-I)
Aliskiren:Direct renin inhibitor (DRI)New class of nonpeptide, oral inhibitorBinds to a site on renin, preventing formation of angiotensin (Ang) ILowers plasma renin activity, Ang I, Ang II, and aldosterone
Safety and tolerance appear similar to ACE-I and ARBs
Significance of inhibiting renin?ACE-I and ARBs may increase renin
(because no negative feedback)Hydrochlorothiazides also increase renin
Pro(renin) receptors were recently identified• Activate MAP kinases and profibrotic signaling• May be involved in vascular remodeling (e.g., with
Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Arch Int Med 2008, 168(2) update
Thiazides are DOC in hypertensive patients with metabolic syndrome
No evidence that ACEI, CCB, alpha blockers offer any advantage of clinical outcomes over thiazides in these patients (particularly in blacks with metabolic syndrome)
chlorthalidone, lisinopril, amlodipine, doxazosin
Doxazosin arm stopped early because of increased CV events, with 2x more HF compared to thiazide group
Clinical considerations:Most effective treatment, ethnicity differences*Least side effects (most patients are
asymptomatic)Frequency of dosingCost
Fixed-drug combinations:-blocker and thiazide diureticACE inhibitor and thiazide diureticAII receptor blocker and diureticCa2+ channel blocker and ACE inhibitor
What are advantages and disadvantages of fixed-drug combinations?
Thiazide diuretics and -blockers:• Often used in combination• However, both may adversely affect lipid profiles
and insulin sensitivity (exaccerbate CAD, atherosclerosis, type 2 diabetes)
Presence of co-morbidities (considerations)
ACE inhibitors:• May also be beneficial for diabetic nephropathies
-blockers or Ca2+ channel blockers:• Useful for patients with angina
ACE inhibitors and diuretics:• Useful for patients with CHF
Diuretics and Ca2+ channel blockers:• Blacks respond better to each, rather than
Guidelines for treatment and prevention of hypertensionare published by the Joint National Committee (JNC) on the Detection, Prevention and Treatment of Hypertension
Guidelines and updates (including power point presentations, treatment algorhythms, etc…) can be found (free) through the NHLBI website