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Download The Pharmacological Management of Hypertension
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Altaz Dhanani Medicines Management Pharmacist, Supplementary Prescriber Drug Treatment of Hypertension General points on treating Hypertension Questions??? A modifiable risk factor Do not view in isolation Don’t forget lifestyle advice Intervention Avg reduction in % with 10mmHg SBP & DBP reduction in SBP (<1 year) Other Comments (from NICE 2006) Diet (Healthy, Low calorie) 5-6mmHg ~40% Avg wt changes 29Kg Exercise (Aerobic, 30-60mins, 35x/week) 2-3mmHg ~30% Relaxation Therapy (Structured) 3-4mmHg ~33% Cost & availability to PCO unknown Multiple Interventions 4-5mmHg ~25% Education alone unlikely to be effective Alcohol Reduction 3-4mmHg ~30% Salt Reduction (<6g/day) 2-3mmHg ~25% Effects diminish over time (2-3yrs) Other: Caffeine (> 5cups/day inc BP by ~2-1mmHg, Smoking (per se) no effect on BP. BP consistently ≥ 160/100 BP consistently ≥ 140/90 AND ◦ with existing CVD or ◦ target organ damage or ◦ raised CVD Risk of 20% or more NICE 140/90 140/80 for type 2 diabetics 135/75 for type 2 diabetics with microalbuminuria or proteinuria 135/85 for type 1 diabetics (130/80 with nephropathy) Step 1 <55 years A ≥55 years or Black C or D Step 2 A + C or A + D Step 3 A+C+D Step 4 A+C+D + Further diuretic therapy or α-blocker or β-blocker Consider specialist advice A=ACEi (ARB if intolerant), C= calcium channel blocker, D = thiazide diuretic Ramipril, lisinopril, perindopril and others Works by manipulating the renin-angiotensin system Renin to angiotensin to angiotensin 2 via angiotensin Angiotensin 2 = potent vasoconstrictor converting enzymes Hence ACEi’s inhibit the action of the angiotensin converting enzymes and prevent the conversion of angiotensin to angiotensin 2 Persistent dry cough Hyperkalaemia Worsening renal failure Angiodema Hypotension (1st dose) Rash, neutropenia.... Hypersensitivity to ACEi (incl. Angiodema) Pregnancy Renal insufficiency Hyperkalaemia K+ sparing diuretics and aldosterone antagonists (spironolactone) – severe hyperkalaemia Lithium – lithium excretion ↓ Ciclosporin - ↑ risk of hyperkalaemia K+ salts - ↑ risk of severe hyperkalaemia Generally recommended for people < 55 yrs and Caucasian In diabetes, ACEi’s are an appropriate 1st line choice Caution when initiating, 1st dose hypotension esp. with pts on concomitant diuretic therapy first dose at night Monitor U&E’s before initiation and regular monitoring during treatment Preferred Rx’ing drugs...... Losartan, Valsartan, Irbesartan etc Effects similar to ACEi’s Works by blocking angiotensin 2 (potent vasoconstrictor) from entering receptors in the smooth muscles of blood vessels Primarily SHOULD only be considered where an ACEi is indicated but not tolerated Hyperkalaemia Angiodema Symptomatic hypotension – dizziness or light-headedness Contra-indications Pregnancy Hepatic impairment for some agents Much the same as the ACEi’s Telmisartan ↑ plasma concentration of digoxin SHOULD only used where an ACEi is indicated but not tolerated NO compelling evidence to suggest they offer any clinical advantage over ACEi’s No compelling evidence that there are differences between individual agents Considerably more costly than ACEi’s Monitoring as per ACEi’s Preferred Rx’ing drugs..... Amlodipine, Felodipine, Nifedipine etc Can be split into 2 groups dependant on their properties: ◦ Dihydropyridines (e.g. amlodipine) ◦ Non-dihydropyridines (diltiazem, verapamil) Dihydropyridines potent vaso-dilators, relax the vascular smoothe muscle and dilates the arteries Flushing Headache Dizziness Ankle swelling Theophylline - ↑ plasma conc of theophylline Ciclosporin – plasma conc ↑ Digoxin – plasma conc ↑ Antifungals - ↑ plasma conc of dihydropyridines Grapefruit Juice - ↑ plasma conc of dihydropyridines (though not as significant an interaction as with simvastatin) Equal 1st line choice with thiazide diuretics for pts ≥ 55yrs or pts who are of African or Caribbean descent What about previous concerns over CCB’s re: that CCB’s increase risk of CV events independent of their BP lowering effect? Immediate release formulations should be avoided (e.g. Non m/r nifedipine) m/r formulations should be Rx’ed by brand name (nifedipine and diltiazem versions) Bendroflumethiazide, Indapamide e.t.c. Stop the resorption of sodium hence promoting its excretion leading to more urine being produced. Flushes excess fluids and minerals from the body Act within 1-2 hours of administration and generally have a duration of action of 12-24 hours Hypokalaemia Postural hypotension Impotence Mild GI effects Cardiac glycosides – hypokalaemia caused by diuretics increases cardiac toxicity Ciclosporin - ↑ risk of nephrotoxicity Lithium - ↑ plasma conc. Considered as equal first line choice with CCB’s for black pts or aged 55 yrs and over Due to low acquisition costs of these drugs, may be used preferentially over CCB’s Low doses of thiazides produce maximal or near-maximal BP lowering with little biochemical disturbance (higher doses confer little advantage in BP control but disturbs plasma concs of K+, Na+, uric acid, glucose and lipids!) Atenolol, metoprolol e.t.c. Not exactly known how they work in hypertension – but they ↓ cardiac output, and block the action of stress hormones that constrict the blood vessels in the heart, brain and body Bradycardia Shortness of breath Coldness of extremities CNS effects with lipid soluble drugs (propranolol) Impotence Asthma/severe COPD Marked bradycardia Severe peripheral artery disease Heart Block No longer recommended first line treatment BUT they are an option for: ◦ Younger patients with C/I’s for ACEi’s or ARB’s ◦ Women of child bearing potential ◦ Pts with compelling indications for their use (e.g. ischaemic heart disease) Best avoided in combination with thiazide diuretics NICE If BP controlled....no absolute need to replace the BB with an alternative If BP not controlled, revise treatment according to treatment algorithm When a BB is withdrawn, step the dose down gradually Do not withdraw if there are compelling indications for being treated with one NICE guidance on drug treatment NOT based on large clinical outcome studies – based on sound pathophysiological grounds and expert opinion Do not forget lifestyle advice – to be offered on an ongoing basis If drug intervention is needed, follow NICE algorithm unless there are compelling indications to do otherwise Most patients will need more than 1 drug to control BP?? Β-Blockers do have a role in hypertensive therapy, but in limited circumstances Remember treatment targets – but bear in mind it won’t be possible for all pts to achieve Any lowering of BP is beneficial – esp. those at highest baseline CVD risk Account for patients’ tolerability and concordance when reviewing treatment response All patients should have at least an annual review of care Does the pt really need drug therapy 1. ◦ ◦ ◦ ◦ 2. ◦ Check your measuring technique Measure several readings over a period of time Review all potential drug causes and try non-drug therapies first (unless BP really high) Attend to other risk factors – smoking, lipids etc If treatment is necessary, getting the pressure down is more important than worrying too much about which drug to use Thiazides are first choice for most people, CCB’s probably less so, doxazosin (α-blocker) first choice for almost no one! Treat the patient, not the blood pressure 3. ◦ ◦ A drug that is not taken will not work and is the most expensive medication Potential benefits of aggressive therapy with multiple drugs must be weighed against the acceptability to the patient of such therapy