ANTI HYPERTENSIVE DRUGS

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ANTI HYPERTENSIVE DRUGS by Mind Map: ANTI HYPERTENSIVE DRUGS

1. ACEi

1.1. first line for non black patients

1.2. also for CKD patients or DM

1.3. AE: cough, angioedema, high K+, dizziness, HA, hypotension, cough, photosensitivity

1.4. CI: pregnancy, angioedema, hypotension, aliskiren, sacubitril

1.5. FIRST LINE

1.5.1. Lisinopril (Prinivil)

1.5.1.1. start 10mg PO qd

1.5.1.1.1. MAX: 80mg/day

1.6. SECOND LINE

1.6.1. Enalapril maleate (Vasotec)

1.6.1.1. start 5mg PO qd

1.6.1.1.1. MAX: 40mg/day

1.6.2. Captopril (Capoten)

1.6.2.1. start 12.5-25mg PO BID/TID

1.6.2.1.1. increase 12.5-25mg/dose q1-2wk

1.6.2.1.2. MAX: 450mg/day

2. THIAZIDES

2.1. first line for black patients

2.2. AE: gout, increase BG, inc lipids, inc K+, lyte imbalances, dizziness, cramps, weakness, rash

2.3. CI: Li, NSAIDs, renal dysfunction, anuria, lyte imbalances, dofetilide

2.4. First Line

2.4.1. Hydrochlorothiazide (Esidrix, Hydrodiuril)

2.4.1.1. most common in combos

2.4.1.2. 12.5-50mg PO qd

2.5. Second Line

2.5.1. Chlorothalidone (Hygroton)

2.5.1.1. most proven, lasts longer

2.6. Third Line

2.6.1. Chlorothiazide (Diuril)

2.6.1.1. 250-500mg PO qd-BID

2.6.1.1.1. MAX: 2000mg/day

3. β BLOCKERS

3.1. SECOND LINE FOR HTN

3.1.1. first line for HTN + comorbidities

3.1.2. almost exclusively treat post MI

3.2. can increase glucose, decrease HR, blocks adrenaline

3.2.1. can decrease panic/anxiety

3.3. taking PM > AM

3.3.1. it will slow you down = better sleep

3.4. NON SELECTIVE FIRST LINE

3.4.1. Propranolol (Inderal)

3.4.1.1. nonselective

3.4.1.2. works well for HA prevention, tremors

3.4.1.3. START: 40mg PO BID

3.4.1.3.1. increase dose q3-7 days

3.4.1.3.2. MAX: 640mg/day

3.4.1.3.3. OR start at 80mg ER PO

3.4.1.4. AE: bronchospasm, bradycardia, heart block, hypotension, fatigue, dizziness, weakness, N/D, alopecia, purpura

3.4.1.5. CI: asthma, abrupt withdrawal, PREGNANCY, DM, thioridazine

3.5. β1 SELECTIVE FIRST LINE

3.5.1. CI: bradycardia, abrupt withdrawal, heart failure, -ibs, -setrons, -ofens,

3.5.2. AE: CHF, bradycardia, MI, bronchospasm, hypotension, fatigue, dizziness, dyspnea, depression, N/D

3.5.3. Atenolol (Tenormin)

3.5.3.1. β1 selective

3.5.3.2. START: 50mg PO qd

3.5.3.2.1. increase dose after 7-14 days

3.5.3.2.2. MAX: 100mg/day

3.5.3.2.3. taper gradually to D/C

3.5.4. Metoprolol (Lopressor)

3.5.4.1. β1 selective

3.5.4.2. START: 25-100mg PO qd

3.5.4.2.1. increase dose qwk

3.5.4.2.2. MAX: 400mg/day

3.5.4.2.3. taper over 1-2 wk to D/C

3.6. SECOND LINE

3.6.1. CI: bradycardia, AV block, asthma, abrupt withdrawal, DM, thyroid dx, COPD

3.6.2. AE: CHF, bradycardia, heart block, angina, bronchospasm, dyspnea, HA, pruritus, raynauds

3.6.3. Can be used for migraine prophyalxis

3.6.4. Timolol (Blocadren

3.6.4.1. non selective

3.6.4.2. START: 10mg PO bID

3.6.4.2.1. increase dose q7 days

3.6.4.2.2. MAX: 60mg/day

3.6.4.2.3. taper over 1-2 wk D/C

3.6.5. Nadolol (Corgard)

3.6.5.1. non selective

3.6.5.2. START: 40mg PO qd

3.6.5.2.1. increase by 40-80mg.day q2-14 days

3.6.5.2.2. MAX: 320mg/day

3.6.5.2.3. taper over 1-2 wks to D/C

3.6.6. Acebutolol (Sectral)

3.6.6.1. β1 selective

3.6.6.2. don't decrease in pulse

3.6.6.3. START: 400mg PO qd

3.6.6.3.1. MAX: 1200mg/day

3.6.6.3.2. MAX in elderly = 800mg

3.6.6.3.3. taper over 2wk to D/C

4. α BLOCKERS

4.1. for HTN + comorbidities

4.1.1. BPH

4.2. for dyslipidemia + HTN

4.3. alpha 1 = BPH

4.4. CI: elderly, hypotension, cataract surgery, -zosins, -alafil

4.5. AE: orthostatic hypertension

4.6. take PM - caution orthostasis

4.7. FIRST LINE

4.7.1. Prazosin (Minipress)

4.7.1.1. START: 1mg PO BID-TID

4.7.1.1.1. MAX: 20mg/day

4.7.1.2. AE: hypotension, syncope, priapism, asthenia, dizziness, HA, palpitaitons, nausea, edema, dyspena

4.7.2. Terazosin (Hytrin)

4.7.2.1. START: 1mg PO qhs

4.7.2.2. MAX: 20mg/day

5. LOOPS

5.1. more effective in patients with poor kidney function

5.2. helps with edema and CHF

5.3. NOT HTN ONLY TREATMENT

5.4. Titrate until you pee like a racehorse

5.5. AE: dehydration, gout, kidney dysfunction, hypokalemia, ototoxicity, dizziness, N/V/D, orhtostatic hypotension, blurred vision, itching

5.6. CI: anuria, lyte imbalances, DM, arrhythmias, SLE, hepatic impairment, urinary retention, gout, elderly, -mycins, lithium, amikacin,

5.7. FIRST LINE

5.7.1. Furosemide (Lasix)

5.7.1.1. "lasts six hours"

5.7.1.2. start 40mg PO BID

5.7.1.2.1. OR start 10-20mg PO BID

5.7.1.2.2. MAX: 600mg/day

5.8. SECOND LINE

5.8.1. Bumetanide (Bumex)

5.8.1.1. start .5mg PO qd

5.8.1.1.1. MAX: 10mg/day

6. α & β BLOCKERS

6.1. FIRST LINE

6.1.1. CI: bradycardia, heart block, shock, hepatic impairment, abrupt withdrawl, --dines, -profen, -insulin,

6.1.2. AE: CHF, bradycardia, heart block, bronchosapsm, dizziness, fatigue, diarrhea, hypotension, HA, N/V, syncope

6.1.3. MONITOR: BUN/Cr, BP, HR,

6.1.4. Carvedilol (Coreg)

6.1.4.1. mostly CHF and post MI

6.1.4.2. START: 6.25mg PO BID

6.1.4.2.1. increase q1-2 wks to 12.5 PO BID

6.1.4.2.2. then 25mg PO BID

6.1.4.2.3. MAX: 50mg/day

6.1.4.2.4. give with food

6.1.4.2.5. taper dose over 1-2 weeks to D/C

6.1.5. Labetalol (Trandate)

6.1.5.1. used for refractory HTN and post MI

6.1.5.1.1. used for substance abuse + HTN

6.1.5.1.2. can be used in pregnancy

6.1.5.2. START: 100mg PO BID

6.1.5.2.1. increase by 200mg/day q2-3 days

6.1.5.2.2. MAX: 2400 mg/day

6.1.5.2.3. taper over 1-2 weeks to D/C

7. ARBs

7.1. first line for non black patients

7.2. no risk of cough

7.3. CI: PREGNANCY, renal impairment, hepatic impairment, volume depletion, CHF, aliskiren

7.4. AE: angioedema, hypotension, hyperkalemia, rhabdo, hepatitis, diarrhea, fatigue, CP, cough, dyspepsia

7.5. FIRST LINE

7.5.1. Losartan (Cozaar)

7.5.1.1. start 50mg PO qd

7.5.1.1.1. MAX: 100mg/day

7.5.2. Valsartan (Diovan)

7.5.2.1. start 80-160mg PO qd

7.5.2.1.1. MAX: 320 mg/day

8. CCB's

8.1. first line for black patients

8.2. decreased peripheral resistance

8.3. AE: dizziness, edema, constipation, bradycardia, CHF, AV block, hypotension

8.4. CI: AV block, hypotension, bradycardia, hepatic/renal impairment, MG, GERD, dofetilide, eliglustat, fibanserin, lomitapide, pimozide, thioridazine, timolol,

8.5. can use with beta blockers

8.6. dihydropyridines for raynauds

8.7. FIRST LINE

8.7.1. VERAPAMIL (Isoptin)

8.7.1.1. non-dihydropyridine

8.7.1.1.1. do not use with beta blockers

8.7.1.2. cardio selective (drop HR)

8.7.1.3. tx angina

8.7.1.4. IR: 80-120mg PO TID

8.7.1.4.1. start 80mg PO TID

8.7.1.4.2. MAX: 480mg/day

8.7.1.5. 12hER: 120-480 mg/day divided into QD-BID

8.7.1.5.1. start 180mg ER PO qAM

8.7.1.5.2. MAX: 480mg/day

8.7.1.6. 24hER:

8.7.1.6.1. AM start 240mg ER PO qAM

8.7.1.6.2. PM start 200mg ER PO qPM

8.7.2. DILTIAZEM (Cardizem)

8.7.2.1. both dihydro/non dihydro

8.7.2.2. for AFIB + HTN

8.7.2.3. 12hER - 120-180mg ER PO BID

8.7.2.3.1. start 60-120mg, titrate over 7-14 days

8.7.2.3.2. MAX: 360mg/day

8.7.2.4. 24hER - 180-480mg ER PO qd

8.7.2.4.1. start 120-240mg ER PO qd, titrate over 7-14 days

8.7.2.4.2. MAX: 540mg/day ER

8.7.3. AMLODIPINE (Norvasc)

8.7.3.1. dihydropyridine

8.7.3.2. start 5mg PO qd

8.7.3.2.1. 2.5mg PO qd if elderly or second agent

8.7.3.2.2. increase after 1-2 weeks

8.7.3.2.3. MAX: 10mg/day

8.7.3.3. CI: simvastatin, griseofulvin, ceritinib, dangtrolene, elglustat, oxcarbazepine

8.7.3.4. AE: angina, MI, hypotension, hepatitis, edema, fatigue, palpitations, nausea, flushing

8.8. SECOND LINE

8.8.1. NIFEDIPINE (Procardia)

8.8.1.1. dihydropyridine

8.8.1.2. raynaud's

8.8.1.3. start 30-60mg ER PO qd

8.8.1.3.1. increase dose q7-14 days

8.8.1.3.2. MAX: 120mg/day

8.8.1.4. CI: HTN, elderly, hepatic impairment, CHF, aortic stenosis, hypotension, sartans, barbitals, -nibs, rifampin

8.8.1.5. AE: CHF, MI, hypotension edema, HA, dizziness, flushing, weakness, nausea, constipation, palpitations, dyspnea

9. CENTRAL SYMPATHOLYTICS

9.1. FIRST LINE

9.1.1. CLONIDINE (Catapres)

9.1.1.1. alpha 2 selective

9.1.1.2. for anxiety, panic, withdrawl, substance abuse +HTN

9.1.1.3. START: .1mg BID

9.1.1.3.1. rebound HTN

9.1.1.3.2. increase by .1mg/day qwk

9.1.1.3.3. MAX: 2.4mg/day

9.1.1.3.4. taper over 2-4 days to D/C

9.1.1.4. CI: abrupt withdrawal, elderly, renal impairment, CV dx, hypotension, MI, CAD, dehydration, depression, etoh, BETA BLOCKERS, -GILINE,

9.1.1.5. AE: hypotension, syncope, bradycardia, AV block, HA, fatigue, nightmares, URI, irritability, otalgia, sexual dysfunction

9.1.1.6. MONITOR: Cr, VS, HR, BP

9.2. SECOND LINE

9.2.1. METHYLDOPA (Aldomet)

9.2.1.1. HTN control in pregnancy

9.2.1.2. START: 250mg PO BID-TID

9.2.1.2.1. adjust q2 days

9.2.1.2.2. MAX: 3g/day

9.2.1.3. CI: Hepatitis, cirrhosis, elderly, renal impairment, -zines, -giline,

9.2.1.4. AE: Myocarditis, leukopenia, bradycardia, sedation, HA, weakness, CHF, angina, V/D/C, hyperprolactinemia,

9.2.1.5. MONITOR: CBC, HR, LFT

10. RENIN INHIBITOR

10.1. ALISKIREN

10.1.1. new - $$$

10.1.2. Start: 150 mg PO qd

10.1.2.1. MAX: 300mg/day

10.1.3. decreases AGT I & II

10.1.4. OK with HCTZ

10.1.5. CI: ACE/ARB, PREGNANCY, renal dx, volume depletion, hyponatremia, CHF, post MI,

10.1.6. AE: angioedema, hypotension, renal failure, diarrhea, hyperkalemia, BUN/Cr elevation

11. VASODILATORS

11.1. ARTERIOLAR

11.1.1. HYDRALAZINE (Apresoline)

11.1.1.1. relaxes smooth muscle = vasodilation

11.1.1.2. used with nitrates in CHF/HTN

11.1.1.3. Start 10mg PO qid x 2-4days, then 25mg PO qid x 1 week

11.1.1.3.1. MAX: 300mg/day PO

11.1.1.3.2. OR 10-40mg IM/IV q4-6hrs

11.1.1.4. CI: CAD, rheumatic heart disease, hypotension, renal impairment, thioridazine,

11.1.1.5. AE: MI, hypotension, neutropenia, SLE, HA, tachycardia, angina, palpitations, N/V/D

11.1.1.6. Monitor Cr & BP, ANA,

11.1.2. MINOXIDIL (Loniten)

11.1.2.1. more potent

11.1.2.2. START: 5mg PO qd

11.1.2.2.1. increase dose q3 days

11.1.2.2.2. MAX: 100mg/day

11.1.2.3. AE: tachycardia, palpitations, hair growth, edema, CHF, SJS, HA, parasthesia

11.1.2.4. CI: pheo, renal failure, post MI, CHF, tachycardia, -azoles, -dones, -ils,

11.2. ARTERIOLAR AND VENULE

11.2.1. SODIUM NITROPRUSSIDE

11.2.1.1. HTN emergency

11.2.1.1.1. START: .25-.3mcg/kg/hr IV

11.2.1.2. BLACK BOX: hypotension, must dilute, cyanide tox

11.2.1.3. CI: aortic coarctation, CHF, renal impairment, anemia, hypothyroidism, hypovolemia, B12 deficiency, avanafil, riociguat

11.2.1.4. AE: hypotension, nausea, dizziness, HA, diaphoresis, acidosis, bradycardia, cyanide tox, flushing, rash

11.2.1.5. MONITOR Cr, BP, ABG, thiocyanate

12. POSTASSIUM SPARING DIURETICS

12.1. TRIAMTERENE/HYDROCHL. (Maxzide)

12.1.1. add on for loop diuretics

12.1.2. 37.5mg/25mg PO qd

12.1.2.1. MAX: 75mg/50mg/day

12.1.3. CI: hyperkalemia, PREGNANCY, anuria, renal impairment, hepatic impairment, arrhythmias, gout, SLE, amiloride, dofetilide, other K sparings,

12.1.4. AE: Electrolyte disorders, jaundice, cramps, N/V, rash, impotence, blurred vision, HA, anorexia

12.2. ALDOSTERONE ANTAGONISTS

12.2.1. CHF > HTN use

12.2.1.1. SPIRONOLACTONE

12.2.1.1.1. Hyperaldosteroneism

12.2.1.1.2. Hirsuitism

12.2.1.2. EPLERENONE