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RELIEVING THE PRESSURE

RELIEVING THE PRESSURE. Medications for Treating Hypertension Jeannie Collins Beaudin, RPh Keswick Pharmacy. WIDESPREAD PROBLEM. CANADIAN STATISTICS: More than 1 in 5 adults have hypertension (22%) 46% of Canadians age 55-65 42% - No diagnosis Only 16% are controlled

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RELIEVING THE PRESSURE

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  1. RELIEVING THE PRESSURE Medications for Treating Hypertension Jeannie Collins Beaudin, RPh Keswick Pharmacy

  2. WIDESPREAD PROBLEM... CANADIAN STATISTICS: • More than 1 in 5 adults have hypertension (22%) • 46% of Canadians age 55-65 • 42% - No diagnosis • Only 16% are controlled • 9% of those with diabetes (more stringent targets)

  3. IMPORTANCE OF NURSES’ ROLE • Nurses have: • Frequent patient contact • Patient trust • Favourable financial model • Educational role

  4. ...PART OF THE PICTURE • METABOLIC SYNDROME: • Hypertension • Insulin resistance • Hypercholesterolemia • Abdominal weight gain • Prothrombic state • Pro-Inflammatory state • All are risk factors for cardiovascular disease • #1 cause of death

  5. CAUSES OF METABOLIC SYNDROME • Obesity • Inactivity • Poor diet • Unknown genetic factors • Stress? • Cortisol • Increases BP, heart rate, lipids, blood glucose • Weight gain around waist

  6. KEY CHEP MESSAGES... • Need to assess overall CVD risk • Combination of drug therapy and lifestyle changes are most effective • Monitor regularly when above target • Regular screening for all adults • Focus on adherence

  7. ADHERENCE • Assess regularly • Encourage patients to bring bottles • Check date filled and amount remaining • Fit to daily schedule • Strive for once daily dosing • Long-acting formulas • Fixed-dose combinations • Fewer pills per day • Often more expensive, not covered • Use unit-of-dose packaging • Improve patient education • Encourage patient involvement in monitoring

  8. TYPES OF HYPERTENSION MEDICATIONS • Those that affect hormone systems • Beta-blockers • ACE Inhibitors (angiotensin converting enzyme inhibitors) • ARBs (angiotensin receptor blockers • Those that affect electrolytes • Fluid balance • Diuretics • Vasodilation • Calcium channel blockers

  9. ABCs OF HYPERTENSION MEDS • Angiotensin Converting Enzyme Inhibitors (ACE-I), Angiotensin Receptor Blockers (ARB) • Beta-Blockers • Calcium channel blockers (CCBs) • Diuretics • “Everything else”... Alpha-Blockers

  10. ACE-Inhibitors • End with “-pril” • Block the enzyme that converts Angiotensin I to Angiotensin II • Also reduce morbidity/mortality of • HF, angina, stroke, DM neuropathy • Generally well tolerated • 25% can develop dry cough • ACE enzyme also block breakdown of bradykinin (xs causes cough) • Teratogenic – caution in pre-menopausal women

  11. ANGIOTENSIN RECEPTOR BLOCKERS (ARBs) • End with “-sartan” • Block the effect of Angiotensin II instead of blocking production • Actions similar to ACE-I • But does not affect bradykinin • No cough side effect • Better tolerated • More expensive • Also teratogenic

  12. BETA-BLOCKERS • End with “-olol” • “Beta adrenergic receptor blockade” • Block beta receptors for adrenalin • Beta-1, Beta-2 receptors • Beta-1 - heart, blood vessels • Beta-1 selective BB’s (e.g. Atenolol, Metoprolol) • Beta-2 - lungs, brain • Non-selective BB’s (e.g. Propranolol, Nadolol)

  13. BETA-BLOCKERS BETA-2: • Lungs • Bronchodilation • Site of action of Salbutamol (beta-agonist) • Brain • Dreaming • Migraine • Beta-blockers can decrease frequency

  14. BETA-BLOCKERS • Block action of adrenalin and beta(adrenalin) agonists on lungs: • Can worsen bronchospasm, asthma • Block action of inhaled Salbutamol • Can be useful for blocking essential tremor

  15. BETA-BLOCKERS • Disadvantages: • Slow heart rate, lower blood pressure (fatigue) • Reduce blood flow to extremities (cold hands, feet, impotence) • Less heart-selective can increase dreaming • Increase risk of diabetes (especially with diuretics) • Not recommended over 65 years • Advantages: • Reduce mortality post-MI • Also useful for HF, angina • Non-cardio selective can prevent migraine • Inexpensive

  16. CALCIUM CHANNEL BLOCKERS • Calcium is necessary for smooth muscle contraction • Calcium enters cells via tiny channels • Blocking calcium channel inhibit muscle contraction • Vasodilation • Reduced force of heart muscle contraction • Affect heart, blood vessels – not skeletal muscle

  17. CALCIUM CHANNEL BLOCKERS Three types: • Dihydropyridines (DRPs) - end with “-dipine” • Amlodipine, Felodipine, Nifedipine • Phenylalkylamines • Verapamil • Benzothiazepines • Diltiazem • Last 2 have similar characteristics • Often referred to as “non-dihydropyridines” (non-DRPs) • Essentially 2 classes now: DRPs and non-DRPs

  18. CALCIUM CHANNEL BLOCKERS DIFFERENT SITES OF ACTION: • DRPs (-dipines) act mainly on blood vessels “vasodilating” • Excess relaxation -> peripheral edema • Adversely affect renal function in diabetes • Non-DRPs (verapamil, diltiazem) also act on heart “modulating” • Verapamil has the strongest effect on heart • Diltiazem is “middle of the road” • Both slow conduction of impulse through AV node • Caution with 2nd and 3rd degree heart block • Avoid in heart failure • Renal protective • Preferable if risk of diabetes or kidney damage

  19. CALCIUM CHANNEL BLOCKERS • No effect on: • Insulin secretion or action • Blood glucose • Plasma protein levels • Potassium balance • Magnesium balance • Grapefruit interaction • Amlodipine, felodipine

  20. CALCIUM CHANNEL BLOCKERS • Short-acting nifedipine • Spike in norepinephrine, transient rise in plasma renin • Reflex tachycardia, BP rise • No longer used for emergency hypertension

  21. DIURETICS • End with “-ide” • Hydrochlorothiazide, indapamide, furosemide • Act on kidney to increase fluid excretion • Reduced blood volume -> reduced pressure • Thiazides – act on tubules • Furosemide - “Loop” diuretic, more potent • Most cause loss of potassium • Increased risk of electrolyte imbalances • Exceptions “potassium sparing”: • Spironolactone (Aldactone) • Amiloride (in Moduret, Apo-Amilzide), • Triamterene (in Dyazide, Apo-Triazide, Nov0-Triamzide )

  22. DIURETICS • Many side effects: • Lethargy, reduced exercise tolerance, polyuria • Hypokalemia • Skeletal muscle weakness, GI hypomotility (ileus, constipation) • Leg cramps, arrhythmia • Can precipitate gouty arthritis (increased uric acid) • Adverse effect on glucose and lipids (especially with B-Blockers) • Poorer compliance noted than with other classes • Very inexpensive, effective

  23. “EVERYTHING ELSE” ALPHA BLOCKERS • End with “-azosin” • Prazosin, terazosin • Also used for enlarged prostate • Block alpha adrenalin receptors • Strong rapid blood pressure reduction • Dose must be started low and raised slowly • Side effect: • Postural hypotension (may be severe)

  24. CONCLUSION... • HTN is most important cause of stroke, angina and renal and heart failure • Most important key for successful treatment is patient education • Important to focus on multiple CV risk factors: • 10%  in BP + 10%  in TC = 45%  in CVD!

  25. QUESTIONS? THANK YOU!

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