RxPrep: Ch. 28 - HTN
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What is the classification of BP in adults, according to JNC7?
- *Normal: <120/<80
- *Pre-HTN: 120-139/80-89
- *Stage 1: 140-159/90-99
- *Stage 2: >/= 160/100
Which drug class is not considered 1st line in CAD prevention?
How much Na+ should an adult consume?
In healthy adults, less than or equal to 2.4 g/d. But, in hypertensive, < 1.5 g/d.
Where do thiazides work in the kidney? Where do loops work?
Thiazides work in the distal convoluted tubule of the nephron, while loops work in the ascending loop of Henle.
- *Microzide (caps), Oretic, Esidrix
- *12.5-25 mg, max: 50 mg/d
What are the side effects of thiazides?
- *Electrolyte imbalances (hypokalemia, hyponatremia, hypercalcemia, hypomagnesemia)
- *Hyperglycemia, elevated lipids
What are the CIs of thiazides?
Anuria, renal decompensation, and sulfa allergy (maybe?)
Thiazides do not work as well when there are kidney problems, but which thiazide is the exception and may work in reduced renal function?
Which diuretic class is good to use in kidney dysfunction?
What are the oral loop dose equivalencies?
- Bumetanide (Bumex) = torsemide (Demedex) = furosemide (Lasix)
- 1 mg = 20 mg = 40 mg
- *20-80 mg daily, or divided (can go higher)
What are the side effects of loops?
- *Orthostatic hypotension
- *Electrolyte imbalance (hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia) (metabolic alkalosis)
- *Ototoxicity (more w/ethacrynic acid (Edecrin))
What are the CIs of loops?
Anuria and sulfa allergies (maybe?)
Which loop does not have a sulfa in it and could use in sulfa allergies?
What are the monitoring parameters of loops?
- *Fluid status (weight)
- *Renal function (SCr, BUN)
- *Hearing with high doses or rapid IV administration
How should you store IV Loops?
In amber bottles b/c they're light-sensitive
- *Dyrenium (Dyazide, Maxzide)
- *50-100 mg BID, max 300 mg/d
- *NYHA 3 and 4 HF: 25-50 mg/d
- *HTN: 50-100 mg/d
What is a BBW of Aldactone?
What are the side effects of K+-sparing diuretics?
Hyperkalemia, increased SCr, gynecomastia and breast tenderness w/Aldactone, and hyperchloremic metabolic acidosis
What are the CIs of K+-sparing diuretics?
- *K+>5.5 at initiation
- *Concomitant use of 3A4 inhibitors (w/Inspra or eplerenone)
What are the monitoring parameters of K+-sparing diuretics?
K+, BP, SCr/BUN
Can you take Li+ with diuretics?
No b/c it will cause Li+ toxicity
When are ARBs given?
When pt is intolerant to ACEIs (dry cough)
Angioedema is common in what population?
Can those using ACEI/ARBs use salt substitutes?
No! They have KCl
Why do less pt's take captopril (Capoten)
- *More side effects (taste perversion, rash)
- *Must take on empty stomach, 1 hr AC
Can you take ACEI/ARBs/Renin Inhbitors in pregnancy?
What is the MOA of ARBs?
Blocks AII from binding to AT Type 1 receptors on vascular smooth muscle
- *Cozaar (only generic right now)
- *25-100 mg/d
What are the side effects of ARBs?
Hyperkalemia, hypotension, angioedema (?)
What are the CIs of ARBs?
Bilateral renal artery stenosis and angioedema (?)
What do you monitor with ACEIs, ARBs, and Renin Inhibitors?
BP, K+, renal function
Enalapril, Enalaprilat IV
- *Prinivil, Zestril
- *10-40 mg/d
What are the side effects of ACEIs?
Dry cough, hyperkalemia, hypotension, angioedema
What are the CIs of ACEIs?
Hx of angioedema, bilateral renal artery stenosis
- *150-300 mg/d
- *Avoid high fat meals, but may take with/without food and take the same way everyday
What are the side effects of Renin Inhibitor, Tekturna?
Hyperkalemia, angioedema, hypotension
What are the CIs of Tekturna?
Angioedema, bilateral renal artery stenosis
Which CYP enzyme metabolizes Tekturna?
What beta blockers are used in HF?
Carvedilol, metoprolol XL, and bisoprolol (nebivolol or Bystolic is off-label)
Which beta blockers have ISA activity? When do you use a beta blocker w/ISA?
CAPP: carteolol, acebutolol, penbutolol, pindolol. It's used when pt needs a BB, but gets excessive bradycardia from BBs.
Which beta blockers are beta-1 selective?
AMEBBA: atenolol, metoprolol, esmolol, betaxolol, bisoprolol, acebutolol
Which BB is the most lipid soluble?
Can you convert Coreg CR to Coreg IR on a mg per mg basis?
No. Coreg CR is less bioavailable than the IR
What antiHTNs can you use in pregnancy?
Labetolol (Normodyne), hydralazine, nifedipine, methyldopa (but a lot of side effects)
What is the problem with BBs and diabetics?
BBs can cover up the sxts of hypoglycemia (no shakiness, no anxiety), esp. with the non-selective ones. But they'll still get sweaty and hungry.
What are the CIs of beta blockers?
- *Severe bradycardia
- *2nd/3rd degree heart block
- *Cardiogenic shock
- *Active asthma brochospasm
- But caution w/:
- *Asthma (use B-1)
- *COPD (use B-1)
- *Resting limb ischemia
Metoprolol tartrate or succinate ext rel
- *Lopressor (ER: Toprol XL or Lopressor XL)
- *HTN: 25-400 mg/d
- -IR: BID; ER: daily
- *HF: 12.5-25 mg/d (max: 200 mg/d)
What are the side effects of BBs?
- Decreased HR, fatigue, hypotension, dizziness
- Less common: depression, decreased libido
How often do you titrate BBs?
Q 2 wks (as tolerated)
What do you monitor with BBs?
What drugs can you not d/c abruptly?
BBs and central alpha-2 agonists (e.g., clonidine)
What makes nebivolol (Bystolic)'s MOA unique?
B-1 selective and Nitric Oxide producer
- *5-40 mg/d
- *If CrCl<30 or liver impairment, start with 2.5 mg/d
- *Inderal LA, InnoPran XL
- *40-480 mg/d
Should Coreg be taken with food?
- *Coreg, Coreg CR
- *HTN: 20-80 mg CR, or 6.25 mg BID
- *HF: Start 3.125 mg BID (max: 50 mg BID) or CR 10 mg/d (max: 80 mg/d)
- *Take w/food!
- *Normodyne, Trandate
- *200-2400 mg/d
What kind of "tropes" are diltiazem and verapamil?
Negative inotropes (decrease contraction force) and negative chronotrope (decrease HR)
Diltiazem and verapamil interact with what CYP enzyme and how?
CYP3A4, inhibitor and substrate
What CCBs leave "ghost shells?"
Sular, Adalat CC, Covera HS
Which DHP CCB is CI in soy/egg allergy?
- *Procardia XL, Adalat CC, Afeditab CR (but nifedipine IR is just Procardia)
- *30-90 mg/d
What are the side effects of DHP CCBs?
D/t peripheral vasodilation: flushing, reflex tachycardia. Also: gingival hyperplasia, peripheral edema
What happens when you take nifedipine SL?
Increase risk of MI
- *Cardizem, Cardizem CD, Cardizem LA, Dilacor XR, Dilt-CD, Dilt-XR, Cartia XT, Tiazac, Taztia XT
- *QD: 120-420 mg
- *BID: 60-240 mg
- *TID: 30-120 mg
- *Calan, Calan SR, Isoptin SR, Verelan, Verelan PM, Covera HS
- *QD: 100-300 mg
- *BID: 120-180 mg
- *TID: 40-120 mg
What are some major side effects of non-DHP CCBs?
AV block, bradycardia, hypotension, constipation w/verapamil
What are CIs of non-DHP CCBs?
2nd/3rd degree heart block, cardiogenic shock, SSS
What CCB is only available as IV?
Clevidipine (Cleviprex) - in 20% intralipid
What are the CIs of Cleviprex?
Soy/egg allergy, acute pancreatitis, severe aortic stenosis
Can you take grapefruit juice with verapamil and diltiazem?
No - please avoid
When is clonidine used?
Resistant HTN and/or pt cannot swallow (comes as patch)
What is one off-label use of clonidine?
What will happen if you d/c clonidine abruptly? Over how long must you taper?
Rebound HTN (sweating, anxiety, tremors, HA). Must taper over 2-5 days.
What is the MOA of central alpha-2 agonists?
Reduce sympathetic outflow from CNS
How often is the clonidine patch changed?
- *Catapres, Catapres-TTS patch
- *0.1-0.3 mg BID
- *Catapres TTS-1 = 0.1 mg/24 hr
- *Catapres TTS-2 = 0.2 mg/24 hr
- *Catapres TTS-3 = 0.3 mg/24 hr
What are the major side effects of central alpha-2 agonists? How about methyldopa?
Bradycardia, dry mouth
, drowsiness, fatigue, depression, impotence.
- For methyldopa: all the above and drug-induced fever
- and lupus-like syndrome, hemolytic anemia
How do hydralazine and minoxidil work?
- *10-75 mg TID, 20 mg/mL inj
What are the side effects of hydralazine (Apresoline)?
Lupus-like syndrome (dose/duration-related, report fever, fatigue, jt/muscle ache), reflex tachycardia
Which direct vasodilator is used for hair growth?
When do you use alpha-blockers?
What are the side effects of alpha-blockers?
Orthostatic hypotension, syncope in 1st dose, dizziness, fatigue
When using alpha-blockers, be cautious with what class of drugs?
PDE-V inhibitors like Viagra b/c may lower BP more, dizziness
What is the difference between hypertensive urgency and emergency?
- *Urgency: High BP w/o target organ damage
- *Emergency: High BP w/organ damage (e.g., stroke, MI, eclampsia, encephalopathy, unstable angina, pulmonary edema, aortic dissection)
- (In both cases, BP generally greater than or equal to 185/110)
How do you treat hypertensive urgency?
: Reduce BP gradually over 24-48 hrs
- *Capoten 25 mg, repeat in 1-2 hrs PRN
- *Catapres 0.1-0.2 mg, repeat in 1-2 hrs PRN
- *Normodyne 100-400 mg, repeat in 2-3 hrs PRN
Do not use nifedipine SL!
What drugs are used in hypertensive emergencies?
- *Fenoldopam (DA1 agonist)
- *Sodium nitroprusside (vasodilator)
Found a Coop that has a HEN with LENS
Why does clevidipine (Cleviprex) need to be discarded after 4 hrs?
It is in intralipids
Why is NTG kept in glass bottles?
B/c it will absorb in plastic - do not use PVC tubing
What do you need to tell diabetics that will be taking diuretics?
Monitor their glucose levels more often in the beginning
What happens if you miss your BB dose?
Take it as soon as you remember, but if next dose < 8 hrs away, skip it and take the next one
Where should you apply the Catapres-TTS patch?
On hairless skin, upper outer arm or chest, every 7 days. Do not put on broken, irritated skin. Rotate areas.
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