4/3/2014 OBJECTIVES BLOOD PRESSURE BASICS. Discuss the new blood pressure guidelines (JNC 8) and recognize the changes from JNC 7

Transcription

1 1 OBJECTIVES Discuss the new blood pressure guidelines (JNC 8) and recognize the changes from JNC 7 Review mechanisms for the main drug classes used to treat hypertension Describe the dosing strategies for antihypertensives 2 BLOOD PRESSURE BASICS Size of your fist Beats 100,000 times per day Pumps out 2,000 gallons of blood Supplies vital organs through circulatory system 60,000 miles of vasculature - 2x around the earth Reacts to fluctuations Involved in fight or flight Involved in many other important processes Homeostasis, ph balance, transport nutrients, gases and hormones Random knowledge Egyptians were cardiocentric 3 1

2 JNC 8 Background JNC 8=Eighth Joint National Committee Guidelines came out in December 2013 JNC7 was released in 2003 Highly anticipated Focus on blood pressure Goal was to help simplify care 4 JNC 8 Things that changed? Who to treat Disease state Age Race Evidence Consensus RCT Lifestyle modifications Medication preferences Specific groups Why do we care about this? Mortality!!! $$$ How you can be proactive? 5 GOALS Thiazide: Thiazide Diuretic ACE-I: Angiotensin Converting Enzyme Inhibitor ARB: Angiotensin Receptor Blocker CCB: Calcium Channel Blocker CKD: Chronic Kidney Disease 6 2

3 ANGIOTENSIN-CONVERTING-ENZYME INHIBITORS History Studying an enzyme since 1898? 1965 found an enzyme in a Brazilian snake 1977 first ACE inhibitor was developed, Captopril 7 ANGIOTENSIN-CONVERTING-ENZYME INHIBITORS MECHANISM 8 SINGLE AGENTS Benazepril Captopril Enalapril Enalaprilat Fosinopril Lisinopril Moexipril Perindopril Quinapril Ramipril Trandolapril Zestril, Brand Name Lotensin Capoten Vasotec Vasotec Monopril Univasc Aceon Accupril Altace Mavik Prinivil Dosage Forms Injection Caps Strengths Available 5mg, 10mg, 20mg, 40mg 12.5mg, 25mg, 50mg, 100mg 2.5mg, 5mg, 1.25mg/ 10mg, ml 20mg 10mg, 20mg, 40mg 2.5mg, 5mg, 10mg, 7.5mg, 20mg, 15mg 30mg, 40mg 2mg, 4mg, 8mg 5mg, 10mg, 20 mg, 40 mg 1.25m g 2.5mg, 5mg, 10mg 1mg, 2mg, 4mg Generic Availability Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 9 3

4 SINGLE AGENTS Benazepril Captopril Enalapril Enalaprilat Fosinopril Lisinopril Moexipril Perindopril Quinapril Ramipril Trandolapril Brand Name Lotensin Capoten Vasotec Vasotec Monopril Zestril, Prinivil Univasc Aceon Accupril Altace Mavik 25 mg 2-3 Initial Dose 10mg times/day 5 mg mg IV every 6 hours 10 mg 10 mg 7.5 mg 4 mg 10 mg 2.5 mg 1 mg mg mg/day mg/day mg/day 4-8 mg mg Usual Dose in mg in 2 divided in 1-2 mg in 1-2 mg mg doses/day doses doses doses 10 Pricing $0.07 $0.06 $0.10 $1.50 $0.10 $0.01 $1.30 $0.40 $0.15 $0.08 $0.40 COMBINATION PRODUCTS Generic Name Benazepril/HCTZ Benazepril/Amlodipine Captopril/ HCTZ Enalapril/ / HCTZ Fosinopril/ / HCTZ Lisinopril/ / HCTZ Moxepril/ / HCTZ Trandolapril/ Verapamil Brand Name Lotensin HCT Lotrel Capozide Vaseretic Monopril HCT Prinizide, Zestoretic Uniretic Tarka Dosage Forms Capsule 2.5 mg/10 mg, 5 mg/6.25 mg, 5 mg/10 mg, 25 mg/15 mg, 180 mg/2 mg, 10 mg/12.5 mg, 7.5 mg/12.5 mg, Strengths 10 mg/12.5 mg, 5 mg/ 20 mg, 25 mg/25 mg, 5 mg/12.5 mg, 10 mg/ 12.5 mg, 240 mg/1 mg, 20 mg/12.5 mg, 15mg/12.5 mg, Available 20 mg/12.5 mg, 5 mg/ 40mg 50 mg/15 mg, 10 mg/25 mg 20mg/ 12.5 mg 240 mg/2 mg, 20 mg/25 mg 15 mg/25 mg 20 mg/25 mg 10 mg/20 mg, 50 mg/25 mg 240 mg/4 mg 10 mg/ 40mg Generic Yes Yes Yes Yes Yes Yes Yes Yes Availability 11 Price $2.30 $1.10 $0.50 $0.70 $1.30 $0.60 $0.60 $4.00 SIDE EFFECTS Bradykinin cough (dry raspy cough) High potassium Dizziness Minor worsening of renal function at first Headache Angioedema in African Americans (RARE) 12 4

5 FYI No individual agent has been demonstrated to be superior to another ACEI Mortality benefit in several disease states such as chronic heart failure and post heart attack Should NOT be given in women of childbearing age May elevate serum potassium levels Some salt substitutes contain high levels of potassium 13 ANGIOTENSIN II RECEPTOR BLOCKER History Discovered in 1986 by a bunch of inexperienced scientists for their first assignments after completing Ph.Ds Found a key piece of information in an old chemistry book in a bargain bin of a Manhattan Barnes & Noble Colleague screwed up to find out the selectivity DuPont skeptical on pursuing it Beat out a big drug company in a drug race If you have an idea, pursue it, says Duncia. Don t dismiss any far fetched ideas, because you never know, they might be useful. 14 ANGIOTENSIN II RECEPTOR BLOCKER Mechanism Lets review!!!! 15 5

6 SINGLE AGENTS Azilsartan Candesartan Eprosartan Irbesartan Losartan Olmeseartan Telmisartan Valsartan Brand Name Edarbi Atacand Teveten Avapro Cozaar Benicar Micardi s Diovan Dosage Forms Strengths Available 40 mg, 80 mg 4 mg, 8 mg, 16 mg, 32 mg 400 mg, 600 mg 75 mg, 150 mg, 300 mg 25 mg, 50 mg, 100 mg 5 mg, 20 mg, 40 mg 40 mg, 20 mg, 80 mg, 40 mg, 160 mg, 80 mg 320 mg Generic Availability No Yes Yes Yes Yes No Yes 16 No SINGLE AGENTS Azilsartan Candesartan Eprosartan Irbesartan Losartan Olmeseartan Telmisartan Valsartan Brand Name Edarbi Atacand Teveten Avapro Cozaar Benicar Micardis Diovan Initial Dose 80 mg 16 mg 600 mg 150 mg 50 mg 20 mg 40 mg mg Usual Dose mg in 1-2 doses in 1-2 doses Up to 300 mg mg mg mg mg 17 Price $3.10 $2.35 $2.60 $0.23 $0.04 $4.50 $3.60 $4.30 COMBINATION PRODUCTS Azilsartan/ Chlorthalidone Candesartan/ HCTZ Eprosartan/ HCTZ Irbesartan/ HCTZ Losartan/ HCTZ Olmesartan/ HCTZ Brand Name Edarbyclor Atacand HCT Teveten HCT Avalide Hyzaar Benicar HCT Dosage Forms Strengths Available 40 mg/12.5 mg, 40 mg/ 25 mg 16 mg/12.5 mg, 32 mg/12.5 mg, 32 mg/25 mg 600 mg/12.5 mg, 600 mg/25 mg 150 mg/12.5 mg, 300 mg/12.5 mg, 300 mg/25 mg 50 mg/12.5 mg, 20 mg/12.5 mg, 100 mg/12.5 mg, 40mg /12.5 mg, 100 mg/25 mg 40 mg/25 mg Generic availability No Yes No Yes Yes No 18 Price $3.00 $3.10 $ 5.40 $4.50 $0.12 $5.10 6

7 COMBINATION PRODUCTS Olmesartan/ amlodipine Olmesartan/amlodipine /HCTZ Telmisartan/amlodipine Brand Name Azor Tribenzor Twynsta Telmisartan/ HCTZ Micardis HCT Valsartan/amlodpine Valsartan/amlodipine/ HCTZ Valsartan/ HCTZ Exforge Exforge HCT Diovan HCT Dosage Forms Strengths Availble 160/5/12.5 mg, 80 mg/12.5 mg, 20 mg/5 mg, 20/5/12.5 mg, 40 mg/5 mg, 160 mg/5 mg, 40 mg/12.5 mg, 160/10/12.5 mg, 160 mg/12.5 mg, 40 mg/5 mg, 40/5/25 mg, 40 mg/10 mg, 160 mg/10 mg, 80 mg/12.5 mg, 160/5/25 mg, 160 mg/25 mg, 20 mg/10 mg, 40/10/12.5 mg, 80 mg/5 mg, 320 mg/5 mg, 80 mg/25 mg 160/10/25 mg, 320mg/12.5 mg, 40 mg/10 mg 40/10/25 mg 80 mg/10 mg 320 mg/10 mg 320/10/25 mg 320/25 mg Generic No No Yes No No No Yes availability 19 Price $5.30 $6.40 $5.00 $3.60 $6.00 $ 5.00 $ 3.50 SIDE EFFECTS Very similar to ACE-I Dizziness High potassium Low blood pressure Orthostatic hypotension Maybe a cough? 20 FYI Never use an ACE-I and an ARB together Not really sure what the AT-2 receptor does completely Full effects are not typically demonstrated until 4 weeks ACE-I s and ARB s have renal protective effects 21 7

8 QUIZ TIME What is the goal blood pressure for a 55 year old Caucasian male without diabetes or chronic kidney disease? 1. <140/90 2. <130/80 3. <150/90 4. <140/80 22 QUIZ TIME! Vasereticcontains contains which combination of medications? 1. HCTZ and felodipine 2. HCTZ and lisinopril 3. HCTZ and enalapril 4. Amlodipine and enalapril 23 QUIZ TIME! Which drug class will you see a dry cough with? 1. Thiazides 2. ACE inhibitors 3. ARB s 4. Loop diuretics 24 8

9 CCB History: Discovered by Albrecht Fleckenstein who was a German pharmacologist in The original agent: Verapamil also was known as iproveratril Realized that Verapamil had the same inhibitory effect as withdrawing calcium from the Ringer s solution. MOA: Inhibits calcium ions from moving across the cell membrane, depresses the contraction and pace of the heart 25 CALCIUM CHANNEL BLOCKERS Amlodipine Clevidipine Diltiazem Felodipine Isradipine Nicardipine Nifedipine Verapamil Brand Name Norvasc Cleviprex Cardizem Plendil DynaCirc Cardene Procardia, Calan, Isoptin, Nifedical Verelan Dosage Forms, Capsule, IV ER & & Capsule, & Capsule, Capsule, & ER, Capsule ER Capsule, IV & ER form IV Strengths Available 2.5 mg, 5 mg, 10 mg IV 0.5mg/mL 30 mg, 60 mg, 90 mg, 120 mg, 180 mg, 240 mg 2.5 mg, 5 mg, 10 mg 2.5 mg, 5 mg, 10 mg 20 mg, 30 mg, 2.5 mg/ml 10 mg, 20 mg, 30 mg, 60 mg, 90 mg 40 mg, 80 mg, 100 mg, 120 mg, 180 mg, 240 mg Generic Availability 26 Yes No Yes Yes Yes Yes Yes Yes CALCIUM CHANNEL BLOCKERS Generic Name Amlodipine Clevidipine Diltiazem Felodipine Isradipine Nicardipine Nifedipine Verapamil Brand Name Norvasc Cleviprex Cardizem Plendil DynaCirc Cardene Procardia Calan, Verelan Initial Dose 5 mg 1-2 mg/hr mg mg 2.5 mg twice 30 mg twice 180 mg mg (SR) (ER) Usual Dose mg once 120- Only Inpatient 540mg/day ER mg mg in 2 60 mg twice divided doses (SR) mg mg once (ER) 27 Price $0.07 $0.41 $0.42 $0.84 $0.70 $0.85 $0.75 9

10 SIDE EFFECTS & OTHER USES Side effects: Bradycardia Hypotension/Dizziness Edema Angioedema Flushing Palpitations Other Uses: Angina Atrial arrhythmias 28 FYI **2 types of Calcium Channel Blocker: Non-dihydropyridine: Work on the periphery and heart Verapamil, Diltiazem Dihydropyridine: Work on the periphery All others 29 THIAZIDE DIURETICS History: Until 1957 the medical field used IV or IM mercurial agents Originated from carbonic anhydrase inhibitors which possess some diuretic effect from the sulfonamide group Developed chlorothiazide which was both a sulfonamide and carbonic anhydrase inhibitor profound diuretic In the 1950 s when it was being researched it was used in heart failure patients MOA: Increase urinary excretion of sodium and chloride by inhibiting reabsorption in the cortical thick ascending limb of the loop of Henle and the early distal tubules (Inhibits carbonic anhydrase as well but has little overall effect) 30 10

11 THIAZIDES Brand Name Dosage Forms Strengths Available Hydrochlorothiazide Microzide Hydrodiuril & Capsule 12.5 mg, 25 mg, 50 mg Chlorthalidone Thalitone Hygroton Hylidone Indapamide Lozol Metolazone Zaroxolyn, Mykrox 25mg, 50 mg, 100 mg 1.25 mg, 2.5 mg 2.5 mg, 5 mg, 10 mg Chlorothiazide Diuril IV, & Suspension 500 mg IV, 250/5 mg/ml, 250 mg, 500 mg Methyclothiazide Aquatensen Enduron 5 mg 31 Generic Availability Yes Yes Yes Yes Yes Yes THIAZIDES Hydrochlorothiazide Chlorthalidone Indapamide Metolazone Chlorothiazide Methyclothiazide Brand Name Microzide Hydrodiuril Thalitone, Hygroton, Hylidone Lozol Zaroxolyn, Mykrox Diuril Aquatensen Enduron Initial Dose 12.5mg 12.5 mg 1.25 mg 2.5 mg mg 2.5 mg mg Usual Dose mg mg mg mg mg in 1-2 doses 32 Price $0.05 $0.37 $0.09 $0.49 $0.26 $1.53 Side effects: THIAZIDE DIURETICS Sensitivity to light May increase blood glucose, uric acid, and calcium Increase frequency of urination Caution: As kidney function decreases this class becomes ineffective Exception: Metolazone, Indapamide Do not use if patient has gout, lupus, hypercalcemia Other Uses: Edema 33 11

12 QUIZ TIME Calcium channel blockers overall have these effects: 1) in heart rate 2) contractility 3) conductivity in the heart 4) All of the above 34 QUIZ TIME True or False: Thiazide diuretics work in the distal tubule and also block carbonic anhydrase. True 35 STRATEGIES TO DOSING ANTIHYPERTENSIVES 1) Begin with 1 drug, titrate to a maximum dose If not controlled begin a second medication 2) Begin with 1 medication, start a 2 nd medication before maximum dose reached Then titrate the two medications to their maximum recommended doses. If not at goal after two medications begin a third medication. 3) Begin with 2 medications Either 2 separate medications or one combination 36 12

13 DON T FORGET THE LIFESTYLE CHANGES Exercise 3-4 times/week of 40 minute sessions (moderate to vigorous activity) 30 minute sessions most days of the week Moderate activity in 10 minute intervals can be beneficial 1 hour = 4% of our day Maintaining a healthy weight Smoking cessation 37 HEALTHY EATING Not a diet! Lifestyle changes! Eating Healthy: No Diet Reduce Sodium Increase Fruits, Veggies, and Lean Meats Can Decrease Blood Pressure by 6/3 mmhg 38 BLOOD PRESSURE MONITORING Patient s should sit and relax for at least 5 minutes Both feet on the floor and an empty bladder Arm should be at heart height Two reading separated by a few minutes and an average is beneficial Check blood pressure s sitting, standing, and lying down 39 13

14 HOW CAN YOU HELP? Assist patients with taking their blood pressure. Recognize what medications the patients are taking. Medication reconciliations in the hospital. Assisting patients with refills and new prescriptions in the community. The more you know the more errors you can help find! 40 CONCLUSIONS The target/goal blood pressures are: <60 years old: <140/90 >60 years old: <150/90 unless patient has diabetes or chronic kidney disease The main drug classes to treat hypertension include: 1. Angiotensin Converting Enzyme Inhibitors 2. Angiotensin Receptor Blockers 3. Thiazide Diuretics 4. Calcium Channel Blockers Healthy eating and exercise are important! 41 QUESTIONS 42 14