Transcript Initial Drug Choices

Selection of
Antihypertensive Drug
Selection of Antihypertensive
Drug
Alpha Blocker
 - agonists
Dr. Rx
Ganglionic
Rational
blockers
Vasodilators Drug of choice
Ca++ Antagonist
Selection of Antihypertensive
Drug
1
Level of blood pressure
+
Presence of other risk factors for CVD
2 & target organ damage
+
3
Coexisting diseases
Antihypertensive Therapy
Pharmacotherapy of
Hypertension
Pharmacotherapy of
Hypertension
Target organ damage/clinical CVD
• LVH - Heart failure - Angina - Prior MI
or revascularization
• Stroke or TIA
• Nephropathy
• Retinopathy
• Peripheral vascular disease
Blood Pressure Classification
JNC 7
SBP
DBP
mm Hg
mmHg
<120
and
<80
• Prehypertensive
120-139
or
80-89
• Stage 1 Hypertension
140-159
or
90-99
> 160
or
> 100
• Normal
• Stage 2 Hypertension
Goal Blood Pressure
SBP
JNC 7
DBP
mm Hg
mmHg
• Most patients
< 140
< 90
• Diabetes
< 130
< 80
• Chronic Renal Disease
< 130
< 80
JNC 7
Lifestyle Modifications
Approximate SBP Reduction
mmHg
•Weight reduction
5 – 20
• DASH eating plan
8 – 14
• Reduced Sodium Intake
• Physical activity
•Moderation of alcohol
consumption
2–8
4–9
2–4
JNC 7
Algorithm for
Treatment of Hypertension
Lifestyle
Modifications
Not at Goal Blood Pressure
Initial Drug
Choices
Algorithm for
Treatment of Hypertension
JNC 7
Initial Drug
Choices
“Excellent clinical trial outcome data prove
that lowering BP with several classes of drug,
including ACE inhibitors, angiotensin receptors
blockers (ARBs),”beta-blockers”, calcium channel
blockers (CCBs) and thiazide-type diuretics
will reduce the complications of hypertension.”
Algorithm for
Treatment of Hypertension
Initial Drug
Choices
Without
Compelling
Indication (s)
With
Compelling
Indication (s)
JNC 7
Algorithm for
JNC 7
Treatment of Hypertension
Initial Drug Choices
Stage 1- Hypertension 140-159 / 90-99 mmHg
Without Compelling Indication
Thiazide-like diuretics for most,
ACEI, ARB, BB or CCB
May consider combination
Algorithm for
Treatment of Hypertension
JNC 7
Initial Drug Choices
Stage 2 - Hypertension >160 / > 100 mmHg
Without Compelling Indication
2-drug combination for most
Usually thiazide-like diuretic plus ACEI,
or ARB, or BB or CCB
Algorithm for
Treatment of Hypertension
JNC 7
Initial Drug Choices
Without
Compelling Indication (s)
With
Compelling Indication (s)
Not at Goal Blood Pressure
Optimize dosage or add additional
drug until goal BP is achieved. Consider
consultation with HNT specialist
Clinical trial and guideline basis for compelling
indications for individual drug classes
Compelling
Indication* Diuretic BB ACEI ARB CCB ALD & ANT
Heart failure
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Postmyocardia
l infarction
High coronary
disease risk
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Diabetes
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Chronic kidney
disease
Recurrent
stroke
prevention
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Class
Drug (Trade Name)
Thiazide
diuretics
chlorothiazide
chlorthalidone
hydrochlorothiazide
polythiazide
indapamide
metolazone
metolazone
Loop
diuretics
Usual Dose
Range in
mg/Day
Usual Daily
mg/Day
Frequency*
125–500
12.5–25
12.5–50
2–4
1.25–2.5
0.5–1.0
2.5–5
1–2
1
1
1
1
1
1
bumetanide
furosemide
torsemide
0.5–2
20–80
2.5–10
2
2
1
Potassiumsparing
diuretics
amiloride
triamterene
5–10
50–100
1–2
1–2
Aldosterone
receptor
blockers
eplerenone
Spironolactone
50–100
25–50
1
1
Class
Drug (Trade Name)
Usual Dose Usual Daily
Range in
mg/Day
mg/Day
Frequency*
BBs
Atenolol
Propranolol
propranolol long-acting
25–100
40-160
60-180
1
2
1
Combined
alpha- and
BBs
Carvedilol
labetalol
12.5–50
200–800
2
2
ACEIs
enalapril
ramipril
5-40
2.5-20
1-2
1
Angiotensin II
antagonists
losartan
25-100
1-2
CCBs—
nondihydropyr
idines
diltiazem extended release
diltiazem extended release
verapamil immediate release
verapamil long acting
Verapamil
180-420
120-540
80-320
120-480
120-360
1
1
2
1-2
1
Class
Drug (Trade Name)
CCBsdihydropyridi
nes
amlodipine
nifedipine long-acting
Alpha-1
blockers
doxazosin
prazosin
terazosin
Central alpha2 agonists
and other
centrally
acting drugs
clonidine
clonidine patch
methyldopa
reserpine
guanfacine
Direct
vasodilators
hydralazine
minoxidil
Usual Dose
Range in
mg/Day
Usual Daily
mg/Day
Frequency*
2.5-10
30-60
1
1
1-16
2-20
1-20
1
2-3
1-2
0.1-0.8
0.1-0.3
250-1000
0.1-0.25
0.5-2
2
1 wkly
2
1
1
25-100
2.5-80
2
1-2
Hypertension in Elderly
 Pharmacological treatment:
- Lower initial doses (1/2 dose than in younger patients)
- The reduction in BP should be gradual
- Greater caution in patients with co-existing diseases or
orthostatic hypotension.
 Choice of therapy:
- Thiazide diuretic (hydrochlorothiazide, HCTZ 12.5 mg)
- STOP-Hypertension trial: ACE inhibitors, long-acting
calcium antagonist and beta- blockers may provide
the same protection as diuretics.
Hypertension in Elderly
 Choice of therapy: special considerations
 A diuretic should be used for heart failure or edema
 A beta-blocker should be used for patient with coronary
heart disease, tachyarrhitmias or migraine
 An ACE inhibitors in patients with heart failure
 Calcium antagonist should be used in patients with
angina pectoris,and peripheral vascular disease
 Alpha-blocker in patient with benign prostatic
hyperplasia
Hypertension and Diabetes
Treatment:
•
Early treatment to prevent cardiovascular disease
and minimize progression of renal and retinal disease.
•
The benefits of tight blood pressure control in
diabetics may be as great or greater than benefits of
strict glycemic control.
•
Initial therapy should include non-pharmacological
methods.
•
ACE Inhibitors, ARBs, C++ Channel Blockers,
Hypertension and Diabetes
•
Kidneys in diabetic patients are more sensitive
to any increase in blood pressure
• Proteinuria
is not only the marker of renal
Pathogenesis:
damage,
but also risk factor for progression of renal
disease
Asthma COPD and
Hypertension
•
Beta-blockers (i) increase bronchial obstruction,
(ii) increase in airways reactivity, and (iii) inhibit the
bronchodilatatory effects of beta agonist
•
Cardioselective, beta-blockers none should be considered
safe.Even topical administration for the treatment of
glaucoma may led to asthmatic exacerbations.
•
ACE inhibitors are not contraindicated and may be used;
very rarely worsen airflow obstruction; produce persistent
dry cough and are not first line drug for hypertensive
patients with asthma or COPD.
Asthma COPD and
Hypertension
•
Diuretics: can be effectively used but there is an
increased risk of hypokalemia (inhaled b-2 agonist drive
potassium into cell and orally administered
corticosteroids mildly increase urinary potassium
excretion).
•
Only low dose (12.5-25 mg) of thiaizides to be used.
•
In patients with COPD and chronic hypercapnia,
diuretics-induced metabolic alkalosis may suppress the
ventilatory drive and exacerbates the hypoxia.
Asthma, COPD and
Hypertension
Calcium channel blockers (CCB) are preferred for
treatment of hypertension in astma & COPD. May
be combined with diuretics
Short-acting CCB (niphedipine) should not be used
because they increase CV risk.
Only long-acting CCB or slow-release niphedipine
formulation should be used.
Ischemic Heart Disease and
Hypertension
•
IHD is the most common form of target-organ damage
associated with hypertension.
•
Beta blockers and long acting Ca++ channel blockers
are the first choice in HTN patient with stable angina
pectoris.
•
HTN patients with unstable angina or MI should be
treated with beta blocker or ACE inhibitor.
•
In patients with post-myocardial infarction, ACE
inhibitors, beta blockers and aldosterone antagonists;
all reduce progression of left ventricular dysfunction
and mortality.
Hart Failure and Hypertension
–
ACE inhibitors and beta blockers are recommended
for HTN patients with asymptomatic ventricular
dysfunction
–
In HTN patients with symptomatic ventricular
dysfunction (NYHA III and IV) in addition to ACE
inhibitors and beta blockers, treatment with diuretics,
Ang II receptor antagonists and aldosterone
antagonists.
–
In hypertensive HF patient, if volume depleted, ACE
inhibitors may induce hypotension and acute renal
failure. Beta blockers may induce initial/transient
worsening of HF.
Pharmacotherapy of
Hypertension
-Pregnancy : Methyl Dopa, Hydralazine
- Gout & Dyslipidemia: Avoid diuretics
- Benign prostatic hypertrophy: Alfa-1 adrenergic
blockers
Pharmacotherapy of
Hypertension
Alpha Blocker
 - agonists
Dr. Rx
Ganglionic
Rational
blockers
Drug
of
Vasodilators
choice
++
Ca Antagonist