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Principals of prescription and drug therapy in Hypertension Dr. Firouzeh Moeinzadeh Nephrologist Scopes of this presentation • 1) Problems in HTN treatment • 2) Antihypertensive drugs • 3) Recommendations in treatments 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 3 Reasons for Poor Control • Systolic BP levels are more difficult to bring under control even under the best of circumstances, with fewer than half of patients enrolled in controlled trials having their systolics brought to 140 mm Hg or lower, whereas 80% of diastolics were brought to 90 mm Hg or lower 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 4 Problems with physician • Many practitioners do not recognize their shortcomings. They often underestimate the level of their patient's cardiovascular risk and, even though they are unwilling to intensify therapy to the levels recommended in guidelines, they usually perceive their level of adherence to guidelines as being much better than it is. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 5 • Hypertension “experts” have contributed to practitioners' problems by promoting conflicting positions, often at the same time: diuretics are bad—no, they are good; β-blockers are good—no, they are bad; calcium channel blockers (CCBs) are bad—no, they are good, and so on. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 6 Problems with Patients • Failure to identify and deal with patients' differing perceptions about their disease and beliefs about both the benefits and the problems of therapy. • The largely asymptomatic nature of hypertension, making it difficult for patients to forego immediate pleasures (salt, calories, money, etc.) for distant, unrecognized benefits, even more so if therapy makes them feel worse. • Competing problems such as poverty, psychological depression, or more immediately threatening diseases such as diabetes. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 7 • Inability to access and maintain contact with a health care system that is affordable, available, and appropriate to their long-term needs. • Real and imaginary concerns about the safety of lifelong medication. In the past, many people were willing to take whatever they were prescribed with full confidence in their physician, but there are fewer today. The delayed recognition that a NSAID prescribed by physicians to patients was responsible for heart attacks surely will further damage the patient-doctor relationship. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 8 Problems with the Therapy • Difficulty in changing unhealthy lifestyles, in particular weight gain from too many calories and too little physical activity. • The high cost of most new, patent-protected medications. When available, generic agents that are equally efficacious are more likely to be taken. • The prescription of two or more doses per day when long-acting once-a-day options are available. Even worse is one daily dose of drugs, e.g. atenolol, which lack a 24 hour effect. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 9 • Side effects of antihypertensive drugs, some not predicted such as impotence with diuretics. • Even less obvious but perhaps more critical, the sympathetic nervous system may be chronically activated when the BP is lowered. • Interactions with other medications and substances, NSAIDs the most common, grapefruit juice likely the least recognizable , herbal remedies perhaps the most dangerous . 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 10 • Difficulty in assessment of adherence. Although there are multiple ways to assess the degree of patients' pill taking, few have been found to be accurate. • Variable responses to any dose of any medication. The starting and usual doses are determined by trials in only a limited number of usually uncomplicated patients. In practice, many patients respond either more or less to any drug. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 11 Guidelines to Improve Maintenance of Antihypertensive Therapy • Involve the patient in decision making to the extent desired. • Articulate the goal of therapy: to reduce BP to near normotension with few or no side effects. • Be alert for signs of inadequate intake of medications, e.g., absence of BP response or expected effects, e.g., bradycardia with β-blocker. • Recognize and manage depression 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 12 • Maintain contact with the patient • Keep care inexpensive and simple • Prescribe according to pharmacologic principles – Add one drug at a time – Start with small doses, aiming for 5- to 10-mm Hg reductions at each step, unless more rapid response is indicated – Have medication taken immediately on awakening in the morning. If morning surge of BP (above 160/100) persists, give at least some drugs at 6 p.m. or at bedtime 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 13 Timing of Dosing • The time of day to take one-a-day antihypertensive medications needs to be more carefully considered. • Early morning has usually been recommended but there are two potential problems: – The pills may not exert a full 24-hour effect, as shown for atenolol; solution for the first problem is twofold: first, ensure full 24-hour control by having the patient measure early a.m. BP at home; second, choose intrinsically long-acting medications: metoprolol XL rather than atenolol, amlodipine rather than felodipine 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 14 – second, an even greater effect may be needed in the early morning, before today's therapy has kicked in, to keep the pressure from surging in the immediate postarising time, thereby contributing to the “morning surge” of cardiovascular catastrophes: The solution seems as obvious but has never been definitely proven, i.e., take medications later in the day or even at bedtime. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 15 Follow-up Visits • To achieve and maintain target BP with the lowest possible dosage of medication requires ongoing patient follow-up, preferably with home BPM, and may involve multiple dosage adjustments. • Most patients should be seen within 1 to 2 months after the initiation of therapy to: – – – – – 5/25/2017 determine the adequacy of BP control the degree of patient cooperation in taking pills the need for more therapy the presence of adverse effects. Evaluation of target organ damage, other major risk factors, and laboratory test abnormalities. Drug therapy in HTN, Dr. Moeinzadeh 16 • Once the BP is stabilized, follow-up at 3- to 6month intervals (depending on the patient's status) is generally appropriate. • In most patients, particularly the elderly and patients with orthostatic symptoms, monitoring should include BP measurement in the supine position and after standing for up to 5 minutes, to recognize postural hypotension 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 17 Reduction or Discontinuation of Therapy • Once a good response has occurred and has been maintained for a year or longer, medications may be reduced or discontinued. • In one research from 6,200 hypertensives who had been successfully controlled, only 18% were able to remain normotensive after stopping therapy. • The characteristics that make withdrawal more likely to be successful were lower levels of BP before and after therapy, fewer and lower doses of medication needed to control hypertension, and patient's willingness to follow lifestyle modifications. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 18 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 19 Antihypertensive drugs 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 20 Diuretics • Among the first orally effective drugs to become available, diuretics are being used even more frequently because their effectiveness has been reiterated and, with lower doses, their side effects minimized. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 21 • Treatment is usually initiated with a thiazide diuretic (acting at, the distal convoluted tubule). • If renal function is significantly impaired (i.e., serum creatinine exceeding 1.5 mg/dL) or in overload setting ( like heart failure), a loop diuretic likely will be needed. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 22 • The thiazide diuretics act by inhibiting sodium and chloride cotransport . • Plasma and extracellular fluid volume are thereby shrunken, and cardiac output falls. • Within 3-9 days: balance between Na intake and excretion + decreased body fluid volume. • With chronic use (4-6 weeks), plasma volume returns partially toward normal but, at the same time, peripheral resistance decreases. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 23 • The full antihypertensive effect of low doses of diuretic may not become apparent in 4 weeks, so patience is advised when low doses are prescribed 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 24 Resistance to Diuretics 1) Excessive dietary sodium intake. 2) For those with renal impairment (i.e., serum creatinine >1.5 mg/dL or GFR <30 mL/minute), thiazides likely will not work. 3) Food affects the absorption and bioavailability of different diuretics to variable degrees, so the drugs should be taken in a uniform pattern in terms of the time of day and food ingestion. 4) NSAIDs may blunt the effect of most diuretics 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 25 • With low doses, thiazides have little effect on the blood lipid profile. • However, higher doses may induce significant effects on fat distribution which in turn may be associated with insulin resistance. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 26 • • • • Effects of low dose: No significant hypokalaemia Low incidence of arrhythmia Lower incidence of hyperglycaemia, hyperlipidemia and hyperuricaemia • Reduction in MI incidence • Reduction in mortality and morbidity 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 27 Drug Usual starting dose (mg/day) Dosage forms(mg) Usual dosage range (mg/day) Max. dose (mg/day) dosing frequency Diuretics Hydrochlorothiazide Tab (50) 12.5 12.5-25 50 Daily Amiloride/HCTZ Tab (5/50) - 1 Tab, daily - Daily Triamterene/HCTZ Tab (50/25) 1 Tab, daily 1-2 Tab, daily 2 Tab, daily Daily to BID Furosemide Tab (40) Inj(10 mg/mL; 2,4 mL) Oral:20-40mg/dose 20-80 - Daily toBID* 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 28 α-Adrenergic Blockers • Specific alpha-1 blockers like prazosin and terazosin are used, BUT NOT AS FIRST LINE. • Postural hypotension developing in 30 to 90 minutes may be seen particularly in volumedepleted patients given the shorter-acting prazosin. • The problem generally can be avoided by initiating therapy with a small dose and ensuring that the patient is not volume-depleted as a result of diuretic therapy. • Urinary incontinence in women. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 29 α1-Blockers Drug Dosage forms(mg) Usual starting dose (mg/day) Usual dosage range (mg/day) Max. dose (mg/day) dosing frequency Prazosin Tab (1 , 5) 2 mg, at bedtime 2-20 20 BID to TID Terazosin Tab(2 , 5) 1 mg, at bedtime 1-20 20 Daily to BID* 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 30 Beta-adrenergic blockers • Non selective: Propranolol , labetolol • Cardioselective: Metoprolol, atenolol • All beta-blockers similar antihypertensive effects, irrespective of additional properties. • Initially: reduction in CO and remains lower chronically. • Peripheral resistance, on the other hand, usually rises acutely but falls toward, if not to, normal with time 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 31 Side Effects • • • • • • • • • Fatigue Diminished exercise ability Weight gain Worsening of insulin sensitivity New onset of diabetes Rise in serum triglycerides, fall in HDL-cholesterol Slight rise in serum potassium Increased rate of suicide Worsening of psoriasis 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 32 special problems 1) Insulin-taking diabetics who are prone to hypoglycemia: If these patients become hypoglycemic, β-blockade delays the return of the blood sugar. The only symptom of hypoglycemia may be sweating 2) Coronary patients. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 33 Carvedilol • This “third” generation nonselective β-blocker with only one-tenth as much α-blocking activity has been used mainly for treatment of heart failure. It is also approved for the treatment of hypertension. • In doses starting at 6.25 mg twice a day and proceeding up to 25 mg b.i.d, carvedilol is equal to 50 up to 200 mg of metoprolol b.i.d. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 34 • Unlike traditional β-blockers, carvedilol does not worsen insulin sensitivity or have as much of an adverse effect on lipids. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 35 β-Blockers Drug Atenolol Dosage forms(mg) Tab (50 , 100) Usual starting dose (mg/day) 25 ImmediateMetoprolol release tab (50) 50 tartrate Inj (1 mg/mL; 5 mL) Metoprolol Extended-release succinate tab (47.5 , 95 , 47.5 (MetoHEXAL®) 190) Propranolol Tab (10 , 20 , 40) Inj (1 mg/mL) 40 Usual dosage range (mg/day) Max. dose (mg/day) dosing frequency 25-100 100* Daily to BID 100-400 400 BID 47.5-190 190 Daily 40-160 160 BID * Doses >100 mg are unlikely to produce any further benefit. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 36 Calcium Channel Blockers 1. Dihydropyridines (DHPs) are predominantly vasodilators 1◦ generation: Nifedipin 2nd generation: Amlodipine(amlober®) 2. Non-dihydropyridines: Diltiazem, Verapamil 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 37 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 38 • In hypertensive patients with renal damage, as manifested by proteinuria, DHP-CCBs do not reduce proteinuria, whereas verapamil and diltiazem do about as well as ACEIs. • DHP-CCBs should only be added to an ACEI or ARB if needed to control hypertension in patients with renal insufficiency. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 39 CCBs and salt • CCBs have a mild natriuretic effect more obvious in the presence of a higher sodium diet so that the BP would fall more. With a low sodium intake, this natriuretic effect would not be as pronounced, so the BP would diminish less. • Dietary sodium restriction may reduce (but not abolish) the antihypertensive effect of CCBs, whereas high sodium intake may enhance (or not diminish) their efficacy. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 40 Side effects • Headaches, flushing, local ankle edema due to: vasodilation. Reduce with slow-release and longer-acting formulations. • Dependent edema is related to localized vasodilation and not generalized fluid retention and is not prevented or relieved by diuretics. • If the pedal edema is bothersome, either a nonDHP-CCB should be substituted or the DHP-CCB combined with an ACEI to reduce the edema. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 41 • Gingival hyperplasia • Eye pain, possibly due to ocular vasodilation with nifedipine. • Cutaneous reactions,rarely • Impotence seems, rarely • Gynecomastia 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 42 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 43 • A problem noted with most other classes of antihypertensive drugs—interference from NSAIDs—is usually not seen with CCBs. • Nifedipine but not with amlodipine: an increased plasma level and duration of action when taken along with large amounts of grapefruit juice or Seville orange juice. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 44 • Reduce the risk of coronary disease equally, stroke more, but heart failure less, than other antihypertensive therapies while having similar effects on overall mortality. • A long-acting, second-generation DHP seems the best choice, because it will maintain better BP control in the critical early morning hours and on through the next day if the patient misses a daily dose. • Rate-slowing CCBs, verapamil or diltiazem, may be preferable with concomitant tachyarrhythmias or heavy proteinuria. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 45 Calcium Channel Blockers (CCBs) Non-Dihydropyridines** Drug Diltiazem (Cardizem®) Dosage forms(mg) Usual starting dose (mg/day) Usual dosage range (mg/day) Max. dose (mg/day) dosing frequency Sustained-release Cap. (120) 120-240 180-420 480 Daily Amlodipine Tab (5 , 10) 2.5 2.5-10 10 Daily Amlodipine/ Atorvastatin Tab (5/10 , 5/20) - - - - Nifedipine*** (Adalat LA®) Sustained-release tab(30) 30-60 30-90 90-120 Daily Dihydropyridines 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 46 Angiotensin Converting Enzyme (ACE) Inhibitors 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 47 Captopril, lisinopril., enalapril, ramipril.. • An immediate fall in BP occurs in approximately 70% of patients given captopril, and the decrease is sometimes rather precipitous. • Such a dramatic fall is more likely in those with high renin levels. • Black or elderly hypertensives, with lower renin levels as a group, respond less well to ACEIs than do white or younger patients. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 48 • An initial decline of 25% to 30% in renal function after starting ACEI therapy in patients with mild to moderate renal insufficiency was found to be associated with a better long-term renoprotection , presumably reflecting a beneficial dilation of efferent arterioles which reduces intraglomerular pressure and filtration 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 49 Benefits • • • • • • No postural hypotension Safe in asthmatics and diabetics Prevention of K+ loss Renal perfusion well maintained Reverse LVH No hyperuraecemia or deleterious effect on plasma lipid profile • No rebound hypertension 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 50 Adverse reactions: especially in Captopril • Cough in 20% cases • Hyperkalemia in renal failure patients with K+ sparing diuretics, NSAID and beta blockers • Hypotension – sharp fall may occur – 1st dose • Acute renal failure: CHF and bilateral renal artery stenosis • Angioedema: swelling of lips, mouth, nose . • Rashes, urticaria • Foetopathic: hypoplasia of organs, growth retardation • Neutripenia 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 51 Angiotensin Receptor Blockers (ARBs) • Losartan(Losaver®) is the specific AT1 blocker • Valsartan ( Valsacor®) • Absorption not affected by food but unlike ACEIs its bioavailability is low – Do not enter brain • Adverse effects: – Foetopathic like ACEIs – Rare 1st dose effect hypotension – Low dysgeusia and dry cough – Lower incidence of angioedema 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 52 Drug Usual starting dose (mg/day) Dosage forms(mg) Usual dosage range (mg/day) Max. dose (mg/day) dosing frequency Angiotensin Converting Enzyme Inhibitors (ACEIs) Captopril Tab (25 , 50) 25 50-100 150-200 BID to TID Enalapril Tab (5,20) 5 10-40 40 Daily to BID Lisinopril Tab (5 , 10 , 20) 10 20-40 40 Daily * Starting dose may be decreased 50% if patient is volume depleted, in acute heart failure exacerbation, or very elderly (≥ 75 year). ** In patients with CHF, target dose could be 50 mg, TID. Angiotensin Receptor Blockers (ARBs) Losartan Tab (25 , 50) 50 25-100 100 Daily to BID Losartan/HCTZ Tab (50/12.5) - - - - Telmisartan (Micardis®) Tab (80) 40 20-80 80 Daily Telmisartan/HCTZ (Micardis plus®) Tab (80/12.5) - - - - Valsartan Tab , Cap (80 , 160) 40-80 80-320 320 Daily 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh Starting dose may be decreased 50% if patient is volume depleted, very elderly (≥ 75 year), or taking a diuretic. 53 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 54 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 55 Case 1 • A 65 year-old man visited in office for high blood pressure. His BP is 145/85 mmHg within 3 sessions of visits. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 56 Recommendation 1 • In the general population aged 60 years or older, initiate pharmacologic treatment to lower BP at SBP of ≥150 mmHg or DBP of ≥ 90mmHg . • Treat to a goal SBP <150mmHg and goal DBP< 90mmHg. • This case dose not need to drug therapy. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 57 Case 2 • A new case of hypertension of 45 year-old woman visits in office. Her BP is 150/90 mmHg within 2 weeks ago. After complete evaluation her hypertension is essential HTN. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 58 Recommendation 2,3 • In the general population younger than 60 years, initiate pharmacologic treatment to lower BP at SBP of ≥ 140 mmHg and DBP of ≥ 90 mm Hg. • Treat to a goal SBP < 140 mmHg and DBP of < 90mmHg. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 59 Case 3 • A new case of hypertension of 28 year-old woman visits in office. Her BP is 150/90 mmHg within 2 weeks ago. After complete evaluation her hypertension is essential HTN. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 60 • In adults younger than 30 years, there are no good- or fair quality RCTs that assessed the benefits of treating elevated DBP on health outcomes. • In the absence of such evidence, it is the panel’s opinion that in adults younger than 30 years, the DBP threshold and goal should be the same as in adults 30 through 59 years of age. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 61 • Initiation of antihypertensive treatment at a DBP threshold of 90 mmHg or higher and treatment to a DBP goal of lower than 90mm Hg reduces cerebrovascular events, heart failure, and overall mortality 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 62 Life style modification Modification Approximate SBP reduction (range Weight reduction 5–20 mmHg/10 kg weight loss Dietary sodium reduction 2–8 mmHg Physical activity 4–9 mmHg Moderation of alcohol consumption 2–4 mmHg 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 63 Drug therapy: • Thiazide-type diuretic, • Calcium channel blocker (CCB) • Angiotensin-converting enzyme inhibitor (ACEI) • Angiotensin receptor blocker (ARB). 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 64 • The panel did not recommend β-blockers for the initial treatment of hypertension because in one study use of β-blockers resulted in a higher rate of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke compared to use of an ARB, a finding that was driven largely by an increase in stroke. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 65 • α-Blockers were not recommended as firstline therapy because in one study initial treatment with an α-blocker resulted in worse cerebrovascular, heart failure, and combined cardiovascular outcomes than initial treatment with a diuretic. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 66 Case 4 • A 25 year-old woman is evaluate for paleness and malaise from 6 months ago. In laboratory findings, she had Hb= 8.9mg/dL, serum Cr= 3.2mg/dL. In renal ultrasonography, her kidneys were 7.8 and 8.4 cm. She did not receive any antihypertensive drugs. She had BP= 150/90 mmHg in 2 weeks ago. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 67 Recommendation 4 • In the population aged 18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP 140mmHg or DBP 90 mmHg and treat to goal SBP<140mmHg and goal DBP<90mmHg 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 68 Recommendation 8 • In the population aged 18 years or older with CKD and hypertension, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 69 • Recommendation8applies toadults aged 18 years or older with CKD, but there is no evidence to support renin-angiotensin system inhibitor treatment in those older than 75 years. • Although treatment with an ACEI or ARB may be beneficial in those older than 75 years, use of a thiazide-type diuretic or CCB is also an option for individuals with CKD in this age group. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 70 • Attention to rising serum Cr and hyperkalemia after initiating ACEI/ARB especially in CKD patients. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 71 Case 5 • A 55 year-old man visits in routine check up due to diabetes mellitus. He had DM for 5 years and receive only Glibenclamide and metformine. His BP was 150/85mmHg in last 3 months. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 72 Recommendation 5 • In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 73 • Similar to those for the general population, this recommendation applies to those with diabetes because trials including participants with diabetes showed no differences in major cardiovascular or cerebrovascular outcomes from those in the general population. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 74 • Any of these 4 classes would be good choices as add-on agents. • This recommendation is specific for thiazidetype diuretics, which include thiazide diuretics , chlorthalidone, and indapamide; it does not include loop or potassium- sparing diuretics. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 75 Recommendation 6 • In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 76 Recommendation 7 • In the general black population, including those with diabetes, initial antihypertensive • treatment should include a thiazide-type diuretic or CCB. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 77 Recommendation 9-1 • The main objective of hypertension treatment is to attain and maintain goal BP. • If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). • The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 78 Recommendation 9-2 • If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. • Do not use an ACEI and an ARB together in the same patient. • If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be used. 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 79 Recommendation 9-3 • Referral to a hypertension specialist may be indicated for patients in whom goal BP can not be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 80 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 81 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 82 Thanks 5/25/2017 Drug therapy in HTN, Dr. Moeinzadeh 83