Anti-hypertensive Medication Class Considerations
Audio of Anti-hypertensive Medication Class Considerations (Running Time 4:02)
Thiazides Diuretics
- May be a problem in urine incontinent patients or in elderly who become urine incontinent
- Studies have shown that doses above 25mg a day of HCTZ (hydrochlorothiazide) does not decrease BP or morbidity and mortality
- watch chemistry levels (hyponatremia)
- avoid in gout patients
- start at lower doses in elderly who may be very sensitive
- may slow demineralization in osteoporosis
- monitor electrolytes and creatinine
- start at lower doses in the elderly
Beta Blockers (BB)
- check initial EKG and pulse
- you don’t have to avoid in diabetic patients
- excellent for use in tachyarrhythmias / fibrillation, migraines, essential tremor, and perioperative hypertension
- usually avoided in patients with asthma and 3rd degree heart block
ACE Inhibitors
- watch potassium, sodium, and creatinine levels
- great for renal protection
- reduces microalbuminuria
- first line in diabetes and renal disease
- shown to have direct heart remodeling effects
- a rise of up to 35% above baseline in creatinine is acceptable
- ACE inhibitor cough is common in 15 – 20% of patients due to bradykinin production
- Angioedema is a serious side effect to monitor in patients
- avoid in pregnant women as they are Category C drugs
ARBs (Angiotensin Receptor Blockers)
- reduces microalbuminuria and macroalbuminuria
- shown to have heart remodeling effects
- avoid in pregnant patients as they are Category C drugs
- less bradykinin production
Ca+ Channel Blockers (CCBs)
- may be useful in Raynaud’s Syndrome
- may be useful in certain arrhythmias
- often causes leg edema (15-30% depending on different studies)
- short acting calcium channel blockers are contraindicated for use in essential hypertension and hypertensive urgencies or emergencies
Aldosterone Antagonists and Potassium Sparing Diuretics
- may cause hyperkalemia
- avoid in patients with K > or = to 5 prior to starting meds
- low dose aldosterone antagonists reduce morbidity and mortality in congestive heart failure patients but increase sudden death at higher doses
Alpha Blockers
- no proven decrease in morbidity and mortality demonstrated in research studies
- not mentioned in JNC 7 algorithm for treatment of essential hypertension
- only useful as adjunct in hard to control blood pressure
- may be useful in prostatism but should not be used as a first line anti-hypertensive in patients with BPH
FYI | Why Thiazides?
The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group:
Resistant Hypertension
What is the definition of resistant hypertension as per JNC 7? (Choose the one best answer)
The correct answer is D. Resistant hypertension is defined as the failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic.
Causes of Resistant Hypertension
- Improper BP measurement
- Excess sodium intake
- Inadequate diuretic therapy
- Medication
- Inadequate doses
- Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)
- Over-the-counter (OTC) drugs and herbal supplements
- Excess alcohol intake
- Underlying identifiable causes of hypertension (secondary hypertension)
Referral To Specialists
Would you refer a patient with resistant hypertension to a specialist (nephrologists or cardiologist)?
Although resistant hypertension is defined as the failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic, clinicians should first review the causes of resistant hypertension with their patients before referring to a specialist. A patient who is eating a pork rinds, salted potato chips, and fried chicken and not getting optimal results despite medications will likely not benefit from a specialist. The objective would be nutrition counseling.
Some primary care physicians feel comfortable treating patients on four anti-hypertensive medications before referring to a specialist if they are not getting results. Some would seek the assistance of a cardiologist or nephrologists if they are seeing target end organ damage such as congestive heart failure or hypertensive nephropathy.