RELIEVING THE PRESSURE

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RELIEVING THE PRESSURE

• Medications for Treating Hypertension
• Jeannie Collins Beaudin, RPh
• Keswick Pharmacy

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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)

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IMPORTANCE OF NURSES ROLE

• Nurses have
• Frequent patient contact
• Patient trust
• Favourable financial model
• Educational role

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...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

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CAUSES OF METABOLIC SYNDROME

• Obesity
• Inactivity
• Poor diet
• Unknown genetic factors
• Stress?
• Cortisol
• Increases BP, heart rate, lipids, blood glucose
• Weight gain around waist

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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

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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

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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

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ABCs OF HYPERTENSION MEDS

1. Angiotensin Converting Enzyme Inhibitors (ACE-I),
   Angiotensin Receptor Blockers (ARB)
2. Beta-Blockers
3. Calcium channel blockers (CCBs)
4. Diuretics
5. Everything else... Alpha-Blockers

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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

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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

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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 BBs (e.g. Atenolol, Metoprolol)
• Beta-2 - lungs, brain
• Non-selective BBs (e.g. Propranolol, Nadolol)

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BETA-BLOCKERS

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

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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

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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

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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

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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

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CALCIUM CHANNEL BLOCKERS

• DIFFERENT SITES OF ACTION
• DRPs (-dipines) act mainly on blood vessels
  vasodilating
• Excess relaxation -gt 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

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CALCIUM CHANNEL BLOCKERS

• No effect on
• Insulin secretion or action
• Blood glucose
• Plasma protein levels
• Potassium balance
• Magnesium balance
• Grapefruit interaction
• Amlodipine, felodipine

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CALCIUM CHANNEL BLOCKERS

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

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DIURETICS

• End with -ide
• Hydrochlorothiazide, indapamide, furosemide
• Act on kidney to increase fluid excretion
• Reduced blood volume -gt 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 )

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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

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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)

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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!

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QUESTIONS?

• THANK YOU!