hey everyone this is deanna hunt and i'm one of your professors in the 570 courses and today we're going to do a quick blitz on hypertension medications there are four major categories and treatment options for hypertension that we'll talk about they're listed on the slide and they include thiazide type diuretics ace inhibitors arbs and calcium channel blockers we'll also talk about beta blockers but these are not considered first line therapy in many patients and we'll talk about fifth line options as well when trying to choose which category class of antihypertensive you'll prescribe a patient it's important to note that each of the antihypertensive agents is roughly equally effective in lowering blood pressure and producing a good antihypertensive response in 30 to 50 percent of patients however there is wide inner patient variability and many patients might respond to one drug but not respond to another we know that there's four major treatment option classes or categories in the front line treatment of hypertension and we also know that they're equally effective but there is a high inner patient variability how do we choose a drug so that's what we'll cover next so generally when we're initiating monotherapy we're going to stick to one of the four main classes we know that each of these drugs are equally effective and we know that most likely we're not going to start with a beta blocker so the next few slides we're going to review which type of drug is best to initiate for each individualized person dictated by the race age and other factors when initiating monotherapy age and race matters age is an important factor to consider younger patients less than 50 years old typically respond better to an ace inhibitor own art and as stated multiple times before beta blockers are not commonly used for initial monotherapy in the absence of a specific indication race is another factor to consider generally for caucasian patients of all ages you can start with a thiazide type diuretic an ace inhibitor an arb a calcium channel blocker or a combination of the groups black patients often respond best to a thiazide diuretic or a long-acting calcium channel blocker if monotherapy is insufficient you can use the calcium channel blocker combined with an acer and arb inhibitor it's very important to control hypertension within the black population because the relative risk of a stroke is more than twice as high in a hypertensive black patient aged 45 to 64 compared with a similarly aged hypertensive group in white patients while race and age are important factors to consider there are other factors to consider including specific conditions that might have a more favorable effect on the hypertension which is what we're going to talk about next this slide lists certain medical conditions that are more likely to have a favorable effect when using a certain class or category of antihypertensives for example bph you should probably use an alpha blocker essential tremors you should probably use a beta blocker hyperthyroidism a beta blocker migraine you should probably use a beta blocker or calcium channel blocker osteoporosis remember this one you should use a thiazide diuretic and raynods is most likely going to respond to a calcium channel blocker additionally there are other really good reasons to use drugs they're all listed on the slide but i'll point out a couple of them including atrial fibrillation you should probably use a beta blocker or a calcium channel blocker atrial flutter you should probably use a beta blocker or a calcium channel blocker and a patient who recently had a heart attack you should probably use an ace inhibitor an arb a beta blocker or an aldosterone antagonist there are also certain medical conditions where you absolutely should not use a certain class or category of an antihypertensive drug they're listed on this slide but include angioedema you should definitely not use an ace inhibitor bronchospastic disease you should not use a non-selective beta blocker liver disease you should not use methyldopa pregnancy you should not use an ace inhibitor and arb or renin inhibitor and second or third degree heart block you should not use beta blockers or calcium channel blockers there are also certain conditions where you should avoid certain classes or categories of antihypertensive drugs for depression you should avoid beta blockers and central alpha 2 agonists for gout you should avoid loop or thiazide diuretics for hyperkalemia you should avoid aldosterone antagonists ace inhibitors arbs or renin inhibitors for hypernatremia you should avoid thiazide diuretics and for renal vascular disease you should avoid ace inhibitors arbs and renin inhibitors so we've seen a patient in the office and we've prescribed initial monotherapy based on their age their race and certain conditions but the initial therapy doesn't work now what do we do so we have two options here we can either change the drug or we can increase the the dose of the initial drug that we prescribed we'll talk about both of these options one helpful hint is that you really should wait four to six weeks prior to making any change in therapy to really properly evaluate the response to the initial monotherapy and to evaluate the efficacy i'll learn a lot about the efficacy of increasing the dose of initial monotherapy but first let's talk about changing the drug which may be a better option and we'll talk about why so in a patient who is relatively unresponsive to one drug they have an almost 50 percent likelihood of becoming normal tensive on a second drug additionally it's okay to keep trying different therapies and a patient who has little or no fall in blood pressure after an adequate dose of drug one and drug two switching to a third drug may allow as many as 60 to 80 percent of patients with stage one hypertension to be controlled with a single agent so really the moral of the story is is that you just kind of keep trying until you get it right i'm not talking about trying five ten different drugs but definitely give it you know a couple different tries prior to giving up some may not believe in the idea of changing the drugs until we get it right so they might just jump to increasing the dose which isn't wrong and you'll just kind of figure out your own practice and what's best for the patient but in general the data shows that if a patient is going to respond to the drug the most likely responded a lower dose an example of this is a patient who are responders quote unquote may experience a similar blood pressure response with 12.5 or 25 milligrams a day of hydrochlorothiazide as they do with 50 milligrams of the drug again many patients who respond to atenolol have similar results with 50 milligrams compared to 100 milligrams so a helpful hint is if after a single dose increase fails to produce an adequate blood pressure response i do recommend going ahead and just switching to a different agent at that time another helpful hint is if you do need to increase the dose remember that the side effects do become more prominent but there is an exception with ace inhibitors and arbs another helpful hint or statistic that might help guide you as you go through practice is that studies have shown that increasing the initial dose of a drug on average results in only small reductions of blood pressure and this is at the risk of increasing side effects as a result most experts recommend only increasing doses by one step an example of this is increasing amlodipine from 5 to 10 milligrams yet another helpful hint or statistic is that the evidence suggests that two or even three drugs at a half standard dose might have a greater antihypertensive efficacy and less toxicity than one drug at a standard or twice the standard dose and overall it very well might produce better patient outcomes so the last helpful hint in this section is that generally you really should avoid prescribing ace inhibitors and arbs together so when you are thinking about doing combination therapy try to avoid these classes now that we've learned some helpful hints in whether or not we should increase dose or change dose let's talk about the classes the first class we'll talk about are calcium channel blockers which work by preventing calcium from entering the cells of the heart and arteries calcium in general causes the heart and arteries to contract so by blocking the calcium calcium channel blockers allow blood vessels to relax and open thereby reducing blood pressure there are two types of calcium channel blockers the first type dihydropyridine are potent vasodilators and they are the preferred treatment for hypertension examples are listed here but two common drugs that we use are procardia and amlodipine the second group non-dihydropyridine are less potent vasodilators they have a greater depressive effect on cardiac conduction and contractility examples include varapamil and diltiazem there are a few side effects to be aware of when talking about calcium channel blockers the dihydropyridines may lead to headaches lightheadedness flushing and dose-dependent peripheral edema in as many as 20 to 30 percent of patients the major potential adverse effects with the non dihydropyridines are constipation and this can occur as in as many as 25 percent of patients in both drugs it's important to remember that they are metabolized through the sip p450 enzyme family specifically the 3a4 system and because of this it's important to be aware of potential genetic alterations in metabolism and potential drug interactions examples of calcium channel blockers within each group are listed here along with the average daily dose and the maximum daily dose angiotensin-converting enzyme inhibitors or ace inhibitors work by blocking the enzyme conversion of angiotensin-1 to angiotensin-2 which narrows blood vessels and allows blood to flow through the vessels without putting much pressure on them ace inhibitors can be used as monotherapy or in combination with a diuretic calcium antagonist or a beta blocker most of the side effects caused by ace inhibitors are related to the reduced angiotensin ii formation common side effects include hypotension reduction in gfr acute kidney injury hyperkalemia and cough a reduction in gfr is seen in as many as 5 to 25 of patients hyperkalemia is seen as seen in as many as 3.3 percent of patients and this is in both ace inhibitors and arbs a cough is described in as many as 5 to twenty percent of patients and ace inhibitors and this is something that you absolutely will see in practice the different types of ace inhibitors their daily dose and their maximum dose are listed on this slide the most common drug that you'll see prescribed is lisinopril and the typical dose of this drug is between 5 and 10 milligrams once a day the maximum dose of this drug is 40 milligrams a day the other drugs are listed on this slide for your review arbs or angiotensin ii receptor blockers block the action of angiotensin ii which allows blood to flow through the vessels without putting as much pressure on them arbs are typically well tolerated and have a very similar side effect profile to ace inhibitors this is due to their very similar mechanism of action two types of arms that are commonly prescribed include losartan and valsartan losert is typically dosed between 25 and 50 milligrams per day with a maximum of 100 milligrams a day valsartan is typically dosed between 80 and 160 milligrams per day with a maximum of 320 milligrams per day thiazide and thiazide like diuretics or the next group that we'll talk about now the mechanism of action is not completely understood but it's most likely related to volume loss typical blood pressure loss with these types of diuretics occurs within the first week but they can continue for as long as 12 weeks diuretics are particularly effective in the elderly and black patients and thiazides are preferred over loop diuretics because of longer duration of action common side effects with these drugs are actually quite long and they include hypokalemia hyponatremia hyperuricemia hyperglycemia hyperlipidemia hypomagnesemia and occasionally hypercalcemia other side effects include problems with sexual dysfunction and sleep disturbances three commonly prescribed diuretics are listed on the slide along with the initial dosing and the maintenance dosing most commonly you'll see hydrochlorothiazide and chlorothalidone prescribed the initial dosing for hydrochlorothiazide is 25 milligrams once daily the maintenance dosing is in between 50 and 100 milligrams a day but you can divide this into two doses chlorothalidone initial dosing is 12.5 to 25 milligrams a day and maintenance dosing is between 5 and 100 milligrams per day this image confirms what we talked about earlier and shows that people can continue to have response with thiazide diuretics and thiazide like diuretics weeks after therapy beta blockers work by competing with adrenergic neurotransmitters epinephrine and norepinephrine four adrenergic receptor sites the beta-1 adrenergic receptor sites are located typically within the heart where the typical stimuli results in increased heart rate and contractility by competing with these neurotransmitters the end result is decreased heart rate excitability and blood pressure common side effects of beta blockers include dizziness weakness drowsiness dry mouth headache upset stomach cold hands and feet weight gain and some gi issues commonly prescribed beta blockers are listed on this slide a couple that i'll point out include metapropylenol and propanol metopropyl is typically dosed 12.5 to 25 milligrams a day and propanol is typically dosed 40 milligrams bid with a max dose of 240 milligrams a day the other doses of max doses are listed on this slide now there are other antihypertensive medications available but i don't want to spend too much time talking about them because they're not used often the therapies listed below can be considered fourth line and beyond if needed the last helpful hint of the day time of day does matter and that's because the average nocturnal blood pressure is approximately 15 percent lower than daytime values so usually it's best practice to have the patient take the medication in the morning this was our quick antihypertensive bliss below are my references and please as always reach out to me if you have any questions or concerns thanks