HYPERTENSION. Dr. Ahmed A. Elberry, MBBCH, MSc, MD Assistant Professor of Clinical Pharmacy Faculty of pharmacy, KAU. Hypertension

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HYPERTENSION Dr. Ahmed A. Elberry, MBBCH, MSc, MD Assistant Professor of Clinical Pharmacy Faculty of pharmacy, KAU 1 Hypertension It is a sustained of arterial bl. pr. 140/90 Causes: 1. 2.

1 HYPERTENSION Dr. Ahmed A. Elberry, MBBCH, MSc, MD Assistant Professor of Clinical Pharmacy Faculty of pharmacy, KAU 1 Hypertension It is a sustained of arterial bl. pr. 140/90 Causes: ry: Essential or Idiopathic : 90-95% of cases 2ry: about 5% of cases Disease: Renal or renovascular disease Coarctation of the aorta Endocrine disease: eg: Phaeochomocytoma Cushing syndrome Acromegaly Drugs (Iatrogenic) 2 1

Drug-Induced HT: 1- Hormones: 3- CNS: Steroids Anxiolytic: Buspirone Estrogens & OC Anesthetic: Ketamine Desflurane Erythropoietin 2- Autonomic: Phenylpropanolamines Clonidine withdrawal Ergotamine

2 Drug-Induced HT: 1- Hormones: 3- CNS: Steroids Anxiolytic: Buspirone Estrogens & OC Anesthetic: Ketamine Desflurane Erythropoietin 2- Autonomic: Phenylpropanolamines Clonidine withdrawal Ergotamine Sibutramine Antiparkinsonian: Bromocryptine Antiepileptic: Carbamazepine Antiemetic: Metoclopramide Antidepressants: Venlafaxine 4- Antiinflammatory: NSAIDs Methylphenidate 5- Immunosuppressive: cyclosporine/tacrolimus Risk factors for 1ry HT Controllable Risk Factors Uncontrollable Risk Factors 1- Salt intake 2- Alcohol 3- Stress 4- Weight (Obesity) 1- Heredity 2- Age 5- exercise 3- Race :More in - Men: Women: after menopause African Americans 2

JNC 7 Classification of BP: The 7th report of the Joint National Committee on Detection, Evaluation & Treatment of High Bl Pr (JNC 7) classifies adult BP as

(mmhg) <120 120 139 140 159 160 (mmhg) <80 80 89 90 99 100 NB.: If systolic & diastolic lie in different stages, the highest is considered Diastolic bl.pr.

3 JNC 7 Classification of BP: The 7th report of the Joint National Committee on Detection, Evaluation & Treatment of High Bl Pr (JNC 7) classifies adult BP as shown Classification rmal Prehypertension Stage 1 hypertension Stage 2 hypertension Systolic BP Diastolic BP. (mmhg) < (mmhg) < NB.: If systolic & diastolic lie in different stages, the highest is considered Diastolic bl.pr. is generally more reliable, while, systolic is more important in elderly 5 Manifestations Usually NO SYMPTOMS! The Silent Killer May have: Headache Blurry vision Chest Pain Frequent urination at night 6 3

4 Complications of HT 7 Treatment of HT npharmacological Pharmacological 8 4

n pharmacological therapy Include: Approximate SBP Reduction 1- Adopt DASH eating plan 8-14 mmhg 2- Dietary sodium 2-8 mmhg 3- Alcohol consumption 2-4 mmhg 4- Weight 5-20 mmhg/ 10 kg weight loss 5-

5 n pharmacological therapy Include: Approximate SBP Reduction 1- Adopt DASH eating plan 8-14 mmhg 2- Dietary sodium 2-8 mmhg 3- Alcohol consumption 2-4 mmhg 4- Weight 5-20 mmhg/ 10 kg weight loss 5- Physical activity 4-9 mmhg Indication: patients with prehypertension. Patients diagnosed with stage 1 or 2 hypertension should be placed on lifestyle modifications & drug therapy concurrently. 9 DASH Eating Plan 1. saturated fat, cholesterol & total fat 2. red meat 3. sweets & sugar containing beverages 4. fruits, vegetables & fiber 5. low fat diary products & plant protein 6. magnesium, potassium & calcium DASH Can reduce BP in 2 weeks (SBP, 8-14 mmhg) 5

6 Pharmacological treatment 1st line 1ry options: (ABCD) Diuretics, ACE inhibitors (or ARBs)*, CCBs & β-blockers** Alternatives: Sympatholytics: central α2-agonists, α1-blockers, peripheral adrenergic neurone antagonists (guanithidine, reserpine, α-methyldopa) direct renin inhibitors (Aliskiren) Direct arterial vasodilators: (hydralazine, minoxidil, diazoxide) *ACE inhibitors (or ARBs) are contraindicated in pregnancy **BBs are not indicated as first line therapy for elderly (age 60 and above) 11 The A B C D classes (1st line) D A Diuretics ACEI, ARB Ca channelblockers DIURETICS βblockers ACEI and ARB D A Fourth Choice, Useful First Good and third Best Choice Choice Second Best Choice B C Can be combined combined with D, AC Can be be combined with A, D Can Can be combined with with D, B,A, CB, B C β-blockers Ca-Blockers 12 6

7 GOAL OF THERAPY -PLUSHypertension With Framingham risk factor 10% 1-Framingham risk factor 10% 2- DM 3- Renal Disease 4- CAD < 140/90 mmhg < 130/80 mmhg -PLUSHF < 120/80 mmhg Stage 1: monotherapy Stage 2: combination therapy

Algorithm for Treatment of HT Lifestyle Modifications t at Goal Blood Initial Drug Choices Without Compelling Indications Stage 1 HTN Thiazide diuretics for most.

8 Algorithm for Treatment of HT Lifestyle Modifications t at Goal Blood Initial Drug Choices Without Compelling Indications Stage 1 HTN Thiazide diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. With Compelling Indications Stage 2 HTN 2-drug combination for most (usually thiazide diuretic and ACEI, or ARB, or BB, or CCB) Drug(s) for the compelling indications t at Goal Blood Pressure Optimize dosages or add additional drugs Compelling Indications Compelling Indication Initial Therapy Options Sequential therapy Diabetes ACEI (or ARB) THIAZ, BB, CCB Chronic kidney disease (CKD) ACEI (or ARB) CAD BB + ACEI (or ARB) Recurrent stroke prevention ACEI (or ARB) + THIAZ HF BB + THIAZ + ACEI (or ARB) - THIAZ for BP control - CCB fro ischemia control - Aldosterone antagonist for severe HF - Hydralazine or nitrates for black patients 8

9 Diuretics 1. Thiazides: As hydrochlorthiazide (HCTZ) or chlorthalidone 2. Loop Diuretics: Furosemide (lasix) twice daily Torsemide once daily 3. Potassium-Sparing Diuretics: n-aldosterone antagonists: Triamterene & Amiloride. Aldosterone antagonists (more potent) : Spironolactone & Eplerenone Thiazide Diuretics Indication: of choice for treating HT (it has both diuretic & direct VD effect) all are equally effective. Dosage: Starting dose of HCTZ (Esidrex) or chlorthalidone of 12.5 mg once daily. Maintenance dose of 25 mg once daily effectively lower BP with low incidence of SE. SE: Hpokalemia, Hyponatremia, Hypomagnesemia, Hypochloremic alkolosis Hyper uricemia, Hyper glycemia, Hyper lipidemia, Hyper sensitivity Hypercalcemia Ca

2- Loop diuretics Indication: of choice for: severe CKD (GFR<30 ml/min./1.73 m2) Lt ventricular dysfunction, or severe edema (because potent diuresis is often needed in these patients).

: Loop diuretics have less effect on serum lipids & glucose 19 Hypokalemia K+ Manifestation: Muscle fatigue or cramps. Serious cardiac arrhythmias may occur, esp.

10 2- Loop diuretics Indication: of choice for: severe CKD (GFR<30 ml/min./1.73 m2) Lt ventricular dysfunction, or severe edema (because potent diuresis is often needed in these patients). SE: Hpokalemia, Hyponatremia, Hypomagnesemia, Hypochloremic alkolosis Hyper uricemia, Hyper glycemia, Hyper lipidemia, Hyper sensitivity Hypocalcemia, Deafness, Dehydration Ca++ NB.: Loop diuretics have less effect on serum lipids & glucose 19 Hypokalemia K+ Manifestation: Muscle fatigue or cramps. Serious cardiac arrhythmias may occur, esp. in patients: receiving digitalis, with LV hypertrophy, with IHD. Monitoring: Serum K+ should be measured at baseline & within 4 w of initiating therapy or after increasing diuretic doses. Management: Intermittent use of the least effective dose K+ rich food (bananas, potatoes, avocados) KCl supplement (20 40 meq/day) Add K+ sparing diuretic 20 10

SE: Hyperkalemia, especially in: chronic kidney disease DM, concurrent treatment with

11 3- K+-Sparing Diuretics Indication: Patients who develop hypokalemia while on a thiazide diuretic. SE: Hyperkalemia, especially in: chronic kidney disease DM, concurrent treatment with an ACE.I, ARB, NSAID, or K+ supplement. Gynecomastia with Spironolactone (in up to 10% of patients), but this effect occurs rarely with eplerenone. 21 ACEIs 11

Enalapril (renitec) - Perindopril - Benazepril Ramipril Trandolapril - Fosinopril NB.

12 ACEIs 1. S.H containing: Captopril (capoten): [Active drug, given 2-3 times daily, absorption is affected by food] 2. n-s.h containing: Active drug Lisinopril (zestril) & Enalaprilate (given IV in emergency hypertension) Prodrugs Enalapril (renitec) - Perindopril - Benazepril Ramipril Trandolapril - Fosinopril NB.: Enalaprilate (enalaprilic acid) is the active metabolite of Enalapril ACE.I is more effective in young white patients than in black or elderly 24 12

13 ACEIs Side effects: 1) Related to S.H: 1. Allergy 2. Taste (Dysgeusia) 3. Protinuria 4. Neutropenia 2) Related to ACE Cough due to bradykinin 1st dose Hypotension (esp. in elderly & heart failure). So tart with low dose with slow dose titration Hyperkalemia ARF esp. in bilateral renal art. stenosis 25 ACEIs Contraindications: Hypotension Pregnancy (They are fetopathic may cause oligohydramnios pulmonary hypoplasia growth retardation fetal death) Bilateral renal artery stenosis Drug interactions: Na+ depleting diuretics initial Hypotension K+ retaining diuretics hyperkalemia NSAID Hypotensive Effect Through Inhibition of Bradykinin & PGs Antacids absorption 26 13

AT-II Blockers (ARBs) Candesartan - Losartan (Cozar) - Olmesartan Valsartan Eprosartan -Irbesartan Telmisartan Actions & Uses As ACEI Side effects As

nisoldipine felodipine isradipine n-dihydropyridine: Verapamil (isoptin) Diltiazem (cardizem) Side effects: 1. Bl.V.: Headache flush Hypotension ankle oedema 2.

14 AT-II Blockers (ARBs) Candesartan - Losartan (Cozar) - Olmesartan Valsartan Eprosartan -Irbesartan Telmisartan Actions & Uses As ACEI Side effects As ACEI but with less cough 27 CCB Classification: Dihydropyridine: Short acting: Nifedipine (Adalat, Epilat) Long acting: Amlodipine (rvasc) nisoldipine felodipine isradipine n-dihydropyridine: Verapamil (isoptin) Diltiazem (cardizem) Side effects: 1. Bl.V.: Headache flush Hypotension ankle oedema 2. Heart: Bradycardia with Diltiazem & marked with verapamil Reflex Tachycardia with nifedipine 3. G.I.T.: Constipation is marked with verapamil

β-blockers Mechanism of antihypertensive effect: 1. 2. 3. 4. 5. 6. Block -1 of Heart COP. Block -1 of CNS Sympathetic outflow. Block -1 of Kidney Renin.

according to Selectivity according to Lipid solubility 29 Classification according to Selectivity ISA A.

15 β-blockers Mechanism of antihypertensive effect: Block -1 of Heart COP. Block -1 of CNS Sympathetic outflow. Block -1 of Kidney Renin. Block Pre-synaptic Release of r-adr. Resetting the sensitivity of Baro-receptors. Prostacyclin (VD) synthesis PGs Classification: according to Selectivity according to Lipid solubility 29 Classification according to Selectivity ISA A. n- selective: Pindolol Oxprenolol Propranolol (Inderal) Sotalol Nadolol Timolol B. Cardio-selective (B1) Acebutolol Atenolol (Tenormin) Bisoprolol (Concor) Betaxolol Metoprolol (Lopressor) Esmolol L.A tes Extensive hepatic 1st pass metabolism Eye drop in glaucoma. Ultrashort. I.V. Infusion

Absorption: 2. Passage across B.B.B.: - Well Absorbed. Pass BBB has CNS. effects. - Poorly absorbed. t pass BBB has little CNS effect 3. Metabolism: 4.

16 NB.: Vasodilator B- Blockers: 1. 2-Partial agonist: Celiprolol: (Selective 1 Block ISA LA) 2. Nitrogenic effect ( production of NO): Nebivolol 3. 1-blocking effect: Labetalol Bucindolol Carvedilol (dilatrend) - Medraxalol Classification of according to Lipid solubility Lipophilic Hydrophilic 1. G.I.T. Absorption: 2. Passage across B.B.B.: - Well Absorbed. Pass BBB has CNS. effects. - Poorly absorbed. t pass BBB has little CNS effect 3. Metabolism: 4. Duration of Action: 5. Examples: - Extensive hepatic. Short (4-6 Hours) Propranolol. Oxprenolol. Metoprolol. Timolol - Mainly Renal. Longer (12-24 Hs) Nadolol. Atenolol. Sotalol. Bisoprolol 32 16

SE & contraindications Side effects Contraindications - Sedation - depression - sleep disturbances (only in lipophilic B.B. crossing BBB) I. CNS: II. CVS: 1.Heart: 1.

Metabolism - Precipitate acute attack of B.A. in asthmatics 1. 2. 3. V.

withdrawal syndrome sympathetic over activity and precipitation of anginal attack even myocardial infarction Severe depression (use hydrophilic B.B.) H.F.

17 SE & contraindications Side effects Contraindications - Sedation - depression - sleep disturbances (only in lipophilic B.B. crossing BBB) I. CNS: II. CVS: 1.Heart: 1.Heart failure - Heart block - Bradycardia B.V. 2.Cold extremities, Raynaud's phenomenon, numbness, tingling 3.B.P. 3.Hypotension III. Respiration IV. Metabolism - Precipitate acute attack of B.A. in asthmatics V. Others Hypoglycemia (severe in patient receiving insulin or oral hypoglycemic [coma can occur without warning (silent death) ] Hyperkalemia Atherosclerosis ( HDL & Triglycerides) Sudden withdrawal withdrawal syndrome sympathetic over activity and precipitation of anginal attack even myocardial infarction Severe depression (use hydrophilic B.B.) H.F. - Hear block - severe bradycardia With Verapamil: H.F. & H. Block Variant angina. Raynaud's phenomenon & P.V.D & alone in pheochromocytoma Hypotension - Bronchial asthma (use selective B1) Hypoglycemia in insulin or oral hypoglycemic treatment. Never stop suddenly. 33 α1-receptor Blockers Prazosin (Minipress), terazosin, and doxazosin (Cardura) Side Effects: Initial Syncopal Attack (1st dose phenomenon). An αattack of severe postural hypotension. Start by small dose while patient is recumbent (At Bed Time), then increase the dose gradually Sexual dysfunction after long use in males & failure of ejaculation Salt & H2O retention as it C.O. R.B.F. So, Diuretic is added

Kidney: Release of Renin Side effects of centrally acting drugs Sudden Withdrawal Rebound severe hypertension Treat by Re-using Clonidine or by

18 Central α2-agonists Include: Clonidine, guanabenz, guanfacine, & methyldopa Mechanism: Selective α2 & Imidazoline I1 Agonist (15 : 1) Hypotension by: 1. Sympathetic outflow from C.N.S. 2. Presynaptic Release of N.A. 3. Kidney: Release of Renin Side effects of centrally acting drugs Sudden Withdrawal Rebound severe hypertension Treat by Re-using Clonidine or by -Blocker + -Blocker. 2. Sedation 3. Dry mouth (xerostomia) & Dry nasal mucosa Moxonidine (physiotens) & Rilmenidine (Hyperium): They are selective I1 agonist used in ttt of hypertension Less liable to cause sedation 36 18

Peripheral adrenergic neurone depressants Include Guanethidine Reserpine Methyldopa (act centrally also) 37 Guanethidine Reserpine *Kinetic - Incompletely absorbed - t pass B.

19 Peripheral adrenergic neurone depressants Include Guanethidine Reserpine Methyldopa (act centrally also) 37 Guanethidine Reserpine *Kinetic - Incompletely absorbed - t pass B.B.B - Slowly excreted in urine *Kinetic: - Well absorbed - Passes B.B.B - Slowly excreted in urine Mechanism ( Release) Mechanism: (Depletion) * Side effects: 1) Parasymp. Predominance: 1. Nasal congestion 2. Bradycardia 3. Postural hypotension 4. Diarrhea * Side effects: 1) Parasymp. Predominance: 1.Nasal congestion {Stuffiness} 2.Bradycardia 3.Hypotension 4.Diarrhea 2) Others: 2) Others: 1. Na & H2O retention 1. Parotid pain 2.Weight gain 2. Failure of ejaculation 3.Peptic ulcer 4.Endocrinal disturbance 5.Breast cancer. 6.Impotence 3) C.N.S: 1. Psychic depression 2. Nightmares 3. Parkinsonism -Methyldopa *Kinetic - Well absorbed - Passes B.B.B - Transformed to -methyl NA Mechanism ( synthesis & Central) * Side effects: 1) Parasymp. Predominance: 1.Nasal congestion 2.Bradycardia 3.Hypotension 4.Diarrhea 2) Other: 1.Na & H20 retention weight gain 2.Liver toxicity 3.Bone marrow Depression 3) C.N.S: 1. Psychic depression 2. Night mares 3. Parkinsonism 4. Sedation 38 19

Direct renin inhibitors (Aliskirin (Tecturna )) Inhibit directly the renin Similar to ACEIs & ARBs & contraindicated in pregnancy Used once orally as an alternative antihypertensive agent Direct

20 Direct renin inhibitors (Aliskirin (Tecturna )) Inhibit directly the renin Similar to ACEIs & ARBs & contraindicated in pregnancy Used once orally as an alternative antihypertensive agent Direct Arterial Vasodilators Include: Hydralazine - Minoxidil - Diazoxide Actions & effects : Direct Arterio-dilator Bl.Pr useful in Hypertension Bl.Pr symp & after load Co useful in H.F Disadvantages & general SE: 1. Bl.Pr sympathetic leading to: Tachycardia & Angina [Add - blockers] Rennin edema [Add diuretic] (So, they are not used alone, but used in combination with - blockers & diuretics) 2. V.D Headache congestion flush 40 20

(1)Hydralazine (2) Minoxidil (3) Diazoxide Side effects 1.

Hypertrichosis - Rash - Rheumatoid arthritis - Systemic lupus erythematosus like

Hyperuricemia (as it is related to Thiazide diuretic) Uses Orally& I.V 1.

Methyldopa is the drug of choice Alternatives: ΒB & CCBs.

Thiazides & CCBs are particularly effective.

21 (1)Hydralazine (2) Minoxidil (3) Diazoxide Side effects 1. Hypersensitivity in the form of:. Hypertrichosis - Rash - Rheumatoid arthritis - Systemic lupus erythematosus like syndrome 2. GIT upset 3. Peripheral neuritis 1. Hyperglycemia 2. Hyperuricemia (as it is related to Thiazide diuretic) Uses Orally& I.V 1. Hypertension & emergency 2. H.F Orally 1. Hypertension 2. H.F 3. Locally in alopecia I.V Emergency Hypertension 41 SPECIAL POPULATIONS Pregnancy: African Americans: Methyldopa is the drug of choice Alternatives: ΒB & CCBs. ACEI & ARBs are contraindicated (teratogens). Thiazides & CCBs are particularly effective. Response is significantly when either class is combined with a BB, ACEI, or ARB. Older People: Diuretics & ACEI can be used safely, but in smallerthan-usual initial doses, and titrations should occur over a longer period to minimize the risk of hypotension. Centrally acting agents & BB should be avoided or used with caution because they are associated with dizziness & postural hypotension. 21

22 HYPERTENSIVE CRISIS This image cannot currently be display ed. 180/110 & may be classified into: Hypertensive urgency: without target organ damage (TOD) (eg. Encephalopathy, unstable angina, renal failure & papilledema) ttt: adjusting maintenance therapy by adding a new antihypertensive and/or increasing the dose of a present drug. Hypertensive emergency: with TOD ttt: require immediate BP reduction to limit new or progressing target-organ damage. 43 Goal in treatment of hypertensive crisis The goal: not to lower BP to normal; as rapid drops in BP may cause end- organ ischemia or infarction. The initial target is MAP 25% within minutes to hours. If BP is then stable, it can be reduced to 160/ mm Hg within the next 2-6 hours. Additional gradual decrease toward the goal BP after hours

Treatment of hypertensive crises Hypertensive urgency: Acute administration of short-acting oral drugs (captopril or labetalol) followed by careful observation for several hours to ensure gradual BP

Hypertensive emergency: Nitroprusside is the drug of choice in most cases. Given as a IV infusion (0.25 to 10 mcg/kg/min.) Onset of action is immediate & disappears within 1-2 min of discontinuation.

23 Treatment of hypertensive crises Hypertensive urgency: Acute administration of short-acting oral drugs (captopril or labetalol) followed by careful observation for several hours to ensure gradual BP reduction. Captopril mg may be given at 1- to 2-hour intervals. The onset of action is min. Labetalol mg, followed by additional doses every 2-3 h. Hypertensive emergency: Nitroprusside is the drug of choice in most cases. Given as a IV infusion (0.25 to 10 mcg/kg/min.) Onset of action is immediate & disappears within 1-2 min of discontinuation. When infusion is continued 72 h., serum thiocyanate levels should be measured, & infusion should be stopped if the level 12 mg/dl. Other Parentral drugs used in emergency HT Nitroprusside Nitroglycerin Nicardipine Diazoxide Esmolol Enalaprilate Fenoldopam Hydralazine Labetalol 46 23

24 Causes of Resistant HT 1. Improper BP measurement 2. Identifiable causes of HTN 3. Excess sodium intake 4. Excess alcohol intake 5. Inadequate diuretic or medication therapy 6. Drug actions and interactions: NSAIDs, sympathomimetics, oral contraceptives, OTC drugs & herbal supplements 24

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Hypertension (JNC-8)

Hypertension (JNC-8) Southern California University of Health Sciences Physician Assistant Program Management and Treatment of Hypertension April 17, 2018, presented by Ezra Levy, Pharm.D.! The 8 th Joint