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Pharm - HTN

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morauch630's version from 2017-12-08 03:10

Section 1

Question Answer
Women have greater prevalence than men until 55False. Men have greater prevalence than women until age 55
Secondary HTN is the most commonFalse. Primary HTN is most common. Less than 5% have secondary HTN
What are some specific cause of secondary HTNrenal disease, Pheochromocytoma, Cushing’s syndrome, Hyperthyroidsim, Primary aldosteronism, Pregnancy, Increased intracranial pressure, Coarctation of the aorta
What is the target SBP & DBP in patients greater than 60SBP <150, DBP <90
What is the target SBP & DBP in patients less than 60SBP <140, DBP <90
What is the target SBP & DBP in patients greater than 18 w/CKDSBP <140, DBP <90
What is the target SBP & DBP in patients greater than 18 w/DMSBP <140, DBP <90
Life style modificationsMaintain dietary K, Ca, and Mg, Reduce intake of dietary saturated fat and cholesterol, Stop smoking, Weight loss, Limit alcohol intake, increase aerobic activity, Reduce Na intake to 2.4 G/d or less
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neuronal and humoral mechanisms

Question Answer
Which receptors are in the PNSalpha and beta
Which areas in the CNS are responsible for BP controlvagal nuclei, vasomotor center
Explain baroreceptor reflexNerve endings in the walls of large arteries. Feedback mechanism triggers vasodilation when BP increases acutely
T/F baroreceptor reflexes may be blunted in the elderlyT
Explain Renal Peripheral autoregulationChanges in Na and water retention
Explain Local tissue peripheral autoregulationThese processes are related to oxygen demand (not as much pressure reg)
Explain the Renin-angiotensin-aldosteroneRegulation of Na, K, and fluid balance
Natriuretic hormoneRegulation of Na balance
Explain how Hyperinsulinemia and insulin resistance affect BPPossible increases in renal Na retention, Possible enhanced sympathetic nervous system activity, Growth hormone like activity
What affect does growth hormone have on the bodycan increase the amount of smooth muscle. More to vasoconstrict causing and increase in BP
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Drug Tx

Question Answer
Initial Tx gen non-black pop.ACEI, ARB, CCB, or Thiazides (Any Ass-whole Cant Try)
Initial Tx gen black pop.CCB OR Thiazides (Can Try)
Tx CKD should includeACEI OR ARB (Kathy's An Ass-whole)
T/F Up-titrate or add tx after 1 mo if BP goal not achievedT.
T/F Use ACEI and ARB togetherF. DON'T USE ACEI and ARB together
T/F If > than 2 drugs are needed refer to a HTN specialistF. >3 drugs refer to HTN specialist
Tx HFDiuretic, ACE1, ARB, BB Aldosterone Antagonist (Dan's Arteries Are Blocked Astronomically)
Tx post MIACEI, Aldosterone antagonist, BB (Andy's Arteries Blocked)
Tx CAD riskBB, ACEI, Diuretic, CCB (Bad Actions Develop Consequences)
Tx DMBB, Diuretic, CCB, ACEI, ARB (Ben's DM Can Attack Arteries)
Tx recurrent stroke preventionDiuretic, ACEI (Don't Attack Brain)
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Special Populations

Question Answer
What med class should you avoid in patients with Asthma, COPD, or PAD? Beta blockers. Because the possibility of bronchospasm. If you must, start low and titrate up
What med class should you avoid in elderly pts?Centrally acting agents and alpha blockers. Elderly are sensitive to sympathetic inhibition leading to postural hypotension
What type of HTN is more common in children?Secondary
What med class should you avoid in pregnancy?ACE inhibitors and ARBs
What med class are known safe in pregnancy?Methydopa (aldomet) and Labetalol (Trandate, Normodyne)
What therapy may African American be more responsive to?Diuretic therapy. May be more Na sensitive
What mono therapy may not be good for African AmericansBeta-blockers, ACE inhibitors, and ARBs
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Misc med ?'s

Question Answer
Which diuretic is usually reserved for volume excessLoop diuretics
T/F Loop diuretics are first line for HTNF. they are second line.
When are Thiazides contraindicated?Creatinine clearance <30ml/min
Which diuretic would be best for patients for patients with decreased renal function?Loop
Which loop diuretic is less bioavailable than othersFurosemide
Define Diuretic resistanceability of a diuretic to increase NaCl excretion declines with time
What can you do for diuretic resistance?may need to add second drug
What are the causes of diuretic resistancepatient non-compliance, impaired bioavailability, renal failure, drugs (NSAIDS, cato-pril, cimetidine, antihypertensives)
What are the 3 classes of CCBDihydropyridines, Phenylalkylamines, Benzothiazepines
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Accrynoms

Question Answer
ACEANGIOTENSIN CONVERTING ENZYME
ARBSANGIOTENSIN 2 RECEPTOR BLOCKERS
CCBCALCIUM CHANNEL BLOCKERS
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Mechanism of Action - Diuretics

Question Answer
Thiazide Diuretic mech of actionInhibition of tubular resorption of Na and Cl ions via inhibition of a NaCl transport mechanism, Act in the ascending limb of the loop of Henle and the early distal tubule, Results in water, Na, and Cl excretion, Some K is excreted
What are the two mechanisms of action for Potassium-sparing diureticsSodium channel blockers and Aldosterone antagonists
What is the sodium channel blocker mechanism of action?Inhibition of Na channel in the collecting duct. Results in excretion of Na and retention of K
What is the mechanism of action of the aldosterone antagonists?Aldosterone receptors located in the collecting ducts. Activation of these receptors leads to: Activation of inactive Na channels & Stimulation of the production of more Na channels. Competitive inhibition of these receptors leads to increased Na excretion
What is the mechanism of action of Loop Diuretics?Acts at loop of Henle. Inhibits the Na-K-Cl channel. Prevents the re-absorption of Na.
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Mechanism of Action

Question Answer
Angiotensin converting enzyme inhibitors mech of actioninhibits the conversion of angiotensin 1 to angiotensin 2, reduces angiotensin 2, results in increased plasma renin which leads to decreased aldosterone secretion. Decreased Na and H2O retention. Prevents breakdown of bradykinin.
T/F angiotensin 2 in a potent vasodialatorF. Angiotensin 2 in a potent vasoconstrictor
T/F Bradykinin is a potent vasodilatorT
ACE inhibitor effects (6)Decreased systemic vascular resistance, no changes in HR, increased renal perfusion, renal vascular resistance decreased, prevention of ventricular remodeling, takes up to four weeks to get full antihypertensive effect.
How many weeks does it take ACE inhibitors to get full antihypertensive effect?Takes up to 4 wks
ARBs - mech of actionblock bings of angiotensin 2 to receptors. Prevent vasocontriction and aldosterone release. AT1 mediates above. AT2 may have anti - proliferative and vasodilatory effects. No effect on brady kinin pathway
Aliskiren (Tekturna)‏ - mechanism of actionDirect renin inhibitor
Calcium Channel Blockers (CCBs) – Mechanism of ActionCalcium needed for muscle contraction, Block slow calcium channels in cardiac and smooth muscle cells which , Blocks influx of calcium which, Decreases muscle contraction. Resulting in vasodialation
CCB effectsDecreased peripheral vascular resistance, Decreased inotropic effects, Decreased automaticity in SA and AV nodes
Beta-blockers mech of actionBlockage of the beta-receptors leading to: Decreased HR, Decreased force of contraction of cardiac muscle, Decreased renin secretion
Beta-Blockers – SelectivitySelective beta – 1 blockade: Atenolol, Metoprolol, Acebutolol, Betaxolol, Bisoprolol (Dose dependent). Increased beta – 2 blockade at higher doses
Define beta-blocker Intrinsic Sympathomimetic Activityessentially partial agonist activity. May decrease bradycardia, bronchoconstriction. Not beneficial for arrhythmias. May negate effectiveness of beta-blockers in secondary prevention of MI (Carteolol, Penbutolol, Pindolol)
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Diuretic Kinetics

Question Answer
Thiazide absorptionGood oral absorption
Thiazide metabolismSome liver metabolism, Longer half-life than loop diuretics
K+ Sparing absorptionGood oral absorption
Potassium sparing metabolismLiver metabolism
Onset of action of IV Loop diureticsShort onset 15 -30 min
Loop diuretic eliminationRenal & hepatic
Which loop diuretic is less renally cleared?Torsemide. Maybe better for those with decreased renal function
Loop diuretic absorptionvariable
Loop diuretic duration6-8hrs
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Kinetics

Question Answer
ACE inhibitor bioavailabilityLow. Large first pass effect
Ace inhibitor protein bindingvariable
ACE inhibitor metabolismmost are prodrugs. Need to be metabolized by the liver to be active
Ace inhibitor excretionrenal
ARB eliminationrenal and hepatic
ARB distributionhigh first pass effect. Highly protein bound
Which ARB is almost exclusively hepatic?Temisartan
Aliskiren (Tekturna)‏ absorptionPoor oral absorption. Decreased by high – fat meal. (probably better to take on empty stomach)
Aliskiren (Tekturna)‏ metabolismCYP3A4 metabolism
Aliskiren (Tekturna)‏ excretionExcreted in urine and feces
CCB onsetRapid onset for IR. (30 minutes to 1 hour for most)
CCB metabolismliver
CCB excretionrenal
BB absorptiongood
Which BB have large first pass effect?Propanolol, labetalol
Which BB have high protein binding?Propranolol, Penbutolol, Carvedilol
Which BB have high lipid solubilityPropranolol, Penbutolol
BB metabolismHepatic
BB excretionrenal
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Diuretics Adverse Effects

Question Answer
Thiazide diuretic adverse effectsElectrolyte imbalances, Elevated glucose levels, Headache, Rash,Orthostatic hypotension, Dizziness, Drowsiness, Nausea, GI irritation
Potassium-sparing diuretics adverse effectsHyperkalemia, Hypotension, Nausea/vomiting, Weakness, Headache, Fatigue, Gynecomastia - spironolactone
Loop diuretic adverse effectshypokalemia, orthostatic hypotension, dehydration, hypomagnesemia, ototoxicity, hyperuricemia
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Adverse effects

Question Answer
ACE inhibitor adverse effectsrash, cough, othostatic hypotension, nausea, diarrhea, constipation, leukopenia, myalgia, HA, hyperkalemia, angioedema, photosensitivity.
T/F adverse effect for ARBs is the same for ace inhibitors but w/o the coughT
Aliskiren (Tekturna)‏ adverse effectsHyperkalemia, Hypotension
CCB adverse effectsRash, Stevens-Johnson syndrome, Hypotension, AV block, Constipation, Arthralgias, muscle cramps Impotence, Ecchymosis (Some antiplatelet effect)
Which CCB is Stevens-Johnson syndrome more commonverapamil and diltiazem
Which CCB is more likely to cause AV blockVerapamil and diltiazem
Which CCB can cause severe constipationverapamil
BB adverse effectsHypotension, Bradycardia, Depression, Impotence, Arrhythmias, Elevated liver enzymes, Dizziness, fatigue, Hyperlipidemia
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Cautions

Question Answer
Thiazide Diuretics - CautionsMay predispose to gout (inhibit uric acid excretion)‏, Women have a greater decrease in serum K than men, May possibly worsen SLE, May lead to hypercalcemia
Potassium Sparing diuretics - cautionsRenal insufficiency, Diabetes, Those on ACE inhibitors, NSAIDS, or K supplements
Loop Diuretic - cautionsGout, impaired glucose tolerance, additive hypotension, renal disease (CrCl <30ml/min)
ACE inhibitor cautionsrenal insufficiency, liver disease
ACE inhibitor - accommodation for renal diseasedecrease dose.
ACE inhibitor - liver diseaseno activation from the prodrug
Which ace inhibitors need to be taken on an empty stomachcaptopril and moexipril
Beta-Blockers - CautionsHepatic or renal impairment , CHF, May decrease contractility, Heart block, Bronchospastic disease, May mask signs and symptoms of hypoglycemia
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Drug interactions

Question Answer
Loop diureticsother ototoxic drugs (aminoglycosides), lithium (changes in Na change Li+ excretion)
Drug lvls increased by ACE inhibitorsdigoxin, lithium, potassium
Drug lvls decreased by ACE inhibitorsantacids and indomethacin
T/F ace inhibitors have interactions with potassium sparing diuretics and potassium supplementsT. Increases hyperkalemic effect.
Telmisartan interacts w/which types of drugs?Other hepatically cleared drugs
Telmisartan may increasedigoxin and warfarin
T/F Unlike ace inhibitors, ARBS do not have interactions with potassium sparing diuretics and potassium supplementsF
Aliskiren (Tekturna)‏CYP. May decrease effect of furosemide
CCB drug interactions Other liver metabolized drugs
Which drugs can CCB Increasedigoxin, statin, and other antiarrhythmics
Which drugs can increased levels of CCBsCimetidine, azole antifungals, antiepileptics
Which drugs should you use with caution in combinationbeta blockers, esp nifedipine and like drugs
If CCB are used in combo w/ BB or nifedipineMay increase CHF symptoms, increased likelihood of hypotension
BB Drug InteractionsOther hepatically metabolized drugs
BB may increase lvlsflecainide, clonidine
Drugs that may increase lvls of BBAntiarrhythmiacs, CCB, Fluoroquinolones, Cimetidine
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