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Manar & Samah1 Supervised by: Dr. Seema King Faisal Specialist Hospital and Research Center (2007-1428) Presented by: Manar Lashkar Samah Al-shehri Pharm.D.

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Presentation on theme: "Manar & Samah1 Supervised by: Dr. Seema King Faisal Specialist Hospital and Research Center (2007-1428) Presented by: Manar Lashkar Samah Al-shehri Pharm.D."— Presentation transcript:

1 Manar & Samah1 Supervised by: Dr. Seema King Faisal Specialist Hospital and Research Center ( ) Presented by: Manar Lashkar Samah Al-shehri Pharm.D candidates

2 Manar & Samah2

3 3 Outline Hypertension JNC VII Guidelines Resistant hypertension Pheochromocytoma Case Scenario Points of Discussion

4 Manar & Samah4 Hypertension affects more than 20% of the adult Saudi population with expected increasing prevalence It is an important modifiable risk factor for cardiovascular diseases Despite overwhelming evidence that lowering BP reduces morbidity and mortality, its management remains frequently sub-optimal

5 Manar & Samah5 Hypertension It is defined as persistent elevation of systolic blood pressure SBP 140 mm Hg and/or diastolic blood pressure DBP 90 mm Hg in adults not on anti- hypertensive medications It can be classified as either essential (primary) or secondary Essential hypertension indicates that no specific medical cause can be found to explain a patient's condition Secondary hypertension indicates that the high blood pressure is a result of (i.e. secondary to) another condition

6 Manar & Samah6 Hyperkalemia, cough, hypotension, angioedema, loss of taste, renal failure, neutropenia, cholestasis, rash, blood dyscrasias. Renal failure, pregnancy, renal artery stenosi Similar to ACEI but do not cause cough Headache, flushing, hypotension, dizziness, palpitation, rash Dihydropyridines (edema, tachycardia) Diltiazem (Lupus-like rash) Verapamil (Constipitation, bradycardia, AV block) Congestive heart failure, heart block Headache, dizzines, sodium and fluid retention, positive antinuclear antibody, lupus-like syndrome, hepatitis, nasal congestion, GI disturbance.

7 Manar & Samah7 Fatigue, insomnia, nightmare, depression, sexual dysfunction, dyslipidemia, rash, withdrawal rebound coronary heart disease, bradycardia, GI upset, mask symptoms of hyperglycemia Asthma, COPD, Decompensated CHF, heart block, DM, peripheral vascular disease. Less bradycardia and dyslipidemia, drug-induced Lupus Erythematosus Orthostatic hypotension, hepatotoxiciy No dyslipidemia Syncope after first dose or dose increase, orthostatic hypotension, headache, dizziness, drowsiness, tachycardia, sodium and fluid retention. Advanced age, first dose Sedation, dry mouth, sexual dysfunction, withdrawal rebound hypertension, impaired mental concentration Methyldopa (hepatitis, Coombs- positive hemolytic anemia, colitis, drug-induced lupus erythematosus) Depression, taper dosage when discontinue to avoid rebound.

8 Manar & Samah8 Triamterene urinary sediment, nephrolithiasis Renal dysfunction, Diabetes, ACEI Gynecomastia, impotence, hirsutism, menstrual irregularities, GI symptoms.

9 Manar & Samah9 Identifiable Causes of Hypertension Chronic kidney disease Coarctation of the aorta Cushings syndrome and other glucocorticoid excess states including chronic steroid therapy Drug induced or drug related Obstructive uropathy Pheochromocytoma Primary aldosteronism and other mineralocorticoid excess states Renovascular hypertension Sleep apnea Thyroid or parathyroid disease

10 Manar & Samah10 Blood Pressure Classification SBP mm HgDBP mm HG Normal< 120and < 80 Prehypertension or Stage 1 Hypertension or Stage 2 Hypertension > 160or > 100 Classification of Blood Pressure for Adults

11 Manar & Samah11 Resistant hypertension is defined as the failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic Resistant Hypertension

12 Manar & Samah12 Nonadherence Inadequate doses Inappropriate combinations Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2 inhibitors Cocaine, amphetamines, other illicit drugs Sympathomimetics (decongestants, anorectics) Oral contraceptive hormones Adrenal steroid hormones Cyclosporine and tacrolimus Erythropoietin Licorice (including some chewing tobacco) Selected over-the-counter dietary supplements and medicines (e.g., ephedra, bitter orange) Causes of Resistant Hypertension Excess sodium intake Volume retention from kidney disease Inadequate diuretic therapy Volume overload Drug-induced or other causes Obesity Excess alcohol intake Associated conditions

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16 Manar & Samah16 ClassDrug Usual Dose Range (mg/d) Daily Frequency Thiazide Diuretics Hydrochlorothiazide Indapamide Metolazone OD Loop Diuretics Furosemide20-80BID Potassium Sparing Diuretics Amiloride Triamterene OD/BID Aldosterone receptor blocker Spironolactone25-50OD/BID Adverse EffectsSpecial Precautions hyperurecimia, glucose intolerance, dyslipidemia, sexual dysfunction, dehydration, increase Ca, decrease (K, Na, Mg), skin rash and photosensitivity Gout, renal failure, digoxin, lithium Adverse EffectsSpecial Precautions Loop diuretics Similar to thiazide diuretics except hypocalcemia Effect in patients with renal insufficiency ClassAdverse EffectsSpecial Precautions Potassium Sparing Diuretics Triamterene urinary sediment, nephrolithiasis Renal dysfunction, Diabetes, ACEI Aldosterone receptor blocker Gynecomastia, impotence, hirsutism, menstrual irregularities, GI symptoms. Diuretics

17 Manar & Samah17 ClassDrug Usual Dose Range (mg/d) Daily Frequency -Blockers Atenolol Bisoprolol Metoprolol Propranolol /100 40/160 OD OD/BID BID -Blockers with ISA Acebutolol BID Combined / Blocker carvedilol Labetalol BID 1 Blocker Doxazocin Prazocin OD BID/TID Central 2 agonist Clonidine Methyldopa Reserpine BID OD Adverse EffectsSpecial Precautions Fatigue, insomnia, nightmare, depression, sexual dysfunction, dyslipidemia, rash, withdrawal rebound coronary heart disease, bradycardia, GI upset, mask symptoms of hyperglycemia Asthma, COPD, Decompensated CHF, heart block, DM, peripheral vascular disease. Less bradycardia and dyslipidemia, drug-induced Lupus Erythematosus Orthostatic hypotension, hepatotoxiciyNo dyslipidemia ClassAdverse EffectsSpecial Precautions Blocker Syncope after first dose or dose increase, orthostatic hypotension, headache, dizziness, drowsiness, tachycardia, sodium and fluid retention. Advanced age, first dose Central 2 agonist Sedation, dry mouth, sexual dysfunction, withdrawal rebound hypertension, impaired mental concentration Methyldopa (hepatitis, Coombs- positive hemolytic anemia, colitis, drug-induced lupus erythematosus) Depression, taper dosage when discontinue to avoid rebound. Adrenergic Blockers

18 Manar & Samah18 ClassDrug Usual Dose Range (mg/d) Daily Frequency Angiotensin Converting Enzyme Inhibitor Captopril Enalapril BID OD/BID Angiotensin II Antagonist Candesartan Irbesartan Losartan Valsartan OD OD/BID Calcium Channel Blocker Amlodipine Nifedipine LA Verapamil LA Diltiazem LA OD OD/BID OD Direct VasodilatorHydralazine25-100BID Adverse EffectsSpecial Precautions Hyperkalemia, cough, hypotension, angioedema, loss of taste, renal failure, neutropenia, cholestasis, rash, blood dyscrasias. Renal failure, pregnancy, renal artery stenosis Similar to ACEI but do not cause cough Class Adverse EffectsSpecial Precautions Calcium Channel Blocker Headache, flushing, hypotension, dizziness, palpitation, rash Dihydropyridines (edema, tachycardia) Diltiazem (Lupus-like rash) Verapamil (Constipitation, bradycardia, AV block) Congestive heart failure, heart block Direct Vasodilator Headache, dizzines, sodium and fluid retention, positive antinuclear antibody, lupus-like syndrome, hepatitis, nasal congestion, GI disturbance. ACE-I, ARBs, CCB, and Direct Vasodilator

19 Manar & Samah19 After age 50, high systolic blood pressure (> 140 mm Hg) is much more important than high diastolic pressure as a risk factor for cardiovascular events People who are normotensive at age 55 still have a 90% lifetime risk for developing hypertension. People with a systolic blood pressure of 120 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg should be considered prehypertensive and should undertake health promoting lifestyle modifications to prevent cardiovascular disease. Thiazide-type diuretics should be used to treat most patients with uncomplicated hypertension, either alone or combined with drugs from other classes, but certain high risk conditions constitute compelling indications for the initial use of other types of antihypertensive drugs Most patients with hypertension need two or more antihypertensive medications to achieve their goal pressure (< 140/90 mm Hg or < 130/80 mm Hg for patients with diabetes or chronic kidney disease). If blood pressure is more than 20/10 mm Hg above goal, one should consider starting therapy with two agents, one of which usually should be a thiazide-type diuretic

20 Manar & Samah20 Pheochrmocytoma Pheochromocytoma is a rare catecholamine- secreting tumor derived from chromaffin cells (medulla) Because of excessive catecholamine secretion, pheochromocytomas may precipitate life-threatening hypertension or cardiac arrhythmias

21 Manar & Samah21 Pathophysiology The clinical manifestations of a pheochromocytoma result from excessive catecholamine secretion by the tumor. Catecholamines typically secreted, either intermittently or continuously, include norepinephrine and epinephrine and rarely dopamine Stimulation of alpha-adrenergic receptors Elevated blood pressure Increased cardiac contractility Glycogenolysis Gluconeogenesis Intestinal relaxation Increase in heart rate Increase cardiac contractility -adrenergic receptors

22 Manar & Samah22 Symptoms and Signs Symptoms Headache Diaphoresis Palpitations Tremor Nausea Weakness Anxiety Clinical signs Hypertension (50% paroxysmal) Postural hypotension Hypertensive retinopathy Pallor Fever Tachyarrhythmias Pulmonary edema

23 Manar & Samah23 Symptoms and Signs Symptoms Headache Diaphoresis Palpitations Tremor Nausea Weakness Anxiety Epigastric pain Flank pain Constipation Weight loss Clinical signs Hypertension (50% paroxysmal) Postural hypotension Hypertensive retinopathy Pallor Fever Tachyarrhythmias Pulmonary edema Cardiomyopathy Ileus Café au lait spots Patches of cutaneous pigmentation, which vary from 1-10 mm and occur any place on the body. Characteristic locations include the axillae and groin. They vary from light to dark brown

24 Manar & Samah24 Risk Factors Precipitants of a hypertensive crisis –Anesthesia induction –Opiates –Dopamine antagonists –Cold medications –Radiographic contrast media –Drugs that inhibit catecholamine reuptake, such as tricyclic antidepressants and cocaine –Childbirth

25 Manar & Samah25 Diagnosis Plasma metaphrine testing Sensitivity (96%) Specificity (85%) 24-hour urinary metanephrine and normetanephrine Sensitivity (87%) Specificity (99%)

26 Manar & Samah26 Medical Care Surgical resection of the tumor is the treatment of choice and usually results in cure of the hypertension Careful treatment with alpha- and -blockers is required preoperatively to control blood pressure and prevent intraoperative hypertensive crises Start alpha blockade with phenoxybenzamine 7-10 days preoperatively The patient should undergo volume expansion with isotonic sodium chloride solution. Encourage liberal salt intake Initiate a -blocker only after adequate alpha blockade If -blockade is started prematurely, unopposed alpha stimulation could precipitate a hypertensive crisis Administer the last doses of oral alpha- and - blockers on the morning of surgery

27 Manar & Samah27 Either surgical option requires prior treatment with the non-specific and irreversible alpha adrenoceptor blocker Phenoxybenzamine. Doing so permits the surgery to proceed while minimizing the likelihood of severe intraoperative hypertension (as might occur when the tumor is manipulated). Some authorities would recommend that a combined alpha/beta blocker such as labetalol also be given in order to slow the heart rate. Regardless, a 'pure' beta blocker such as atenolol must never be used in the presence of a pheochromocytoma due to the risk of such treatment leading to unopposed alpha agonism and, thus, severe and potentially refractory hypertension.Phenoxybenzaminelabetalolatenolol The patient with pheochromocytoma is invariably volume depleted. In other words, the chronically elevated adrenergic state charactersitic of an untreated pheochromocytoma leads to near-total inhibition of renin- angiotensin activity. Volume depletion results. Hence, once the pheochromocytoma has been resected, thereby removing the major source of circulating catecholamines, a situation arises where there is both very low sympathetic activity and volume depletion. This can result in profound hypotension. Therefore, it is usually advised to "salt load" pheochromocytoma patients before their surgery. This may consist of simple interventions such as consumption of high salt food pre-operatively, direct salt replacement (perhaps in the form of bouillon cubes such as Oxo), or through the administration of intravenous saline solution.adrenergicrenin angiotensincatecholamines hypotensionOxo

28 Manar & Samah28

29 Manar & Samah29 Interventions: CAD CABG (2002, KFMH) PCI LCX (5/2006) PCI RCA (12/2006) Labs: ( 7/2007) Ejection Fraction= 40-45% Negative Thallium A 75-year-old female with a history of: Past Medical History: Hypertension Left Bundle Branch Block Diabetes Mellitus Chronic renal impairment (Serum Cr = 127umol/L) Bronchial Asthma Osteoporosis Social History: Quit smoking 3 years ago

30 Manar & Samah30 Past Medication History Aspirin 81 mg PO OD Clopidogrel 75 mg PO OD Carvedilol 12.5 mg PO BID Atorvastatin 40 mg PO OD Amlodipine 10 mg PO OD Irbesartan 300 mg PO OD Furosemide 60 mg PO BID Isosorbide dinitrate retard 40 mg PO OD

31 Manar & Samah31 On 10/12/2007 Came to arrhythmia clinic complaining of recurrence syncope and blood pressure of 206/100 mm Hg Admitted to N2 (cardiology ward)

32 Manar & Samah32 During whole admission period she was on Aspirin 81 mg PO OD Gabapentin 400 mg PO BID Clopidogrel 75 mg PO OD Atorvastatin 40 mg PO OD Insulin regular SC (Sliding Scale) Q6h < none units units units units units > notify MD and do STAT blood sugar, urine ketone

33 Manar & Samah33 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 Hypertension Asthma Others 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 Surgery for single chamber pacemaker implantation Recurrence Syncope She started to have tremor

34 Manar & Samah34 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 Hypertension Asthma Others 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12

35 Manar & Samah35 Hypertension COPD/ Asthma Others 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 Irbesartan 300 mg PO OD Isosorbide dinitrate retard 20 mg PO BID Amlodipine PO OD carvedilol 12.5 mg PO BID Furosemide 40 mg IV 40 mg PO OD 10 mg5 mg 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 SrCr 160 umol/L

36 Manar & Samah36 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 Hypertension Asthma Others 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 11\1218\12 17\1216\12 15\12 14\12 13\12 12\12 Irbesartan 300 mg PO OD Isosorbide dinitrate retard 20 mg PO BID Amlodipine PO OD carvedilol 12.5 mg PO BID Furosemide 40 mg IV 40 mg PO OD 10 mg 5 mg Fluticasone/salmeterol 250/25 mcg/ puff BID Budesonide nebulizer 500 mcg TID Ipratropium nebulizer 500 mcg TID Asthma Attack

37 Manar & Samah37 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 Asthma / COPD Others Hypertension 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1

38 Manar & Samah38 Irbesartan 300 mg PO OD Isosorbide dinitrate retard PO BID Amlodipine 10 mg PO OD Nifedipine LA 60 mg PO STAT Captopril 6.25 mg PO TID carvedilol 12.5 mg PO BID Metoprolol 12.5 mg PO BID Clonidine 100 mcg PO OD Furosemide IV BID 20 mg PO 40 mg PO Hypertension 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 20 mg 40 mg 60 mg 40 mg 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 SrCr 107 umol/L ?

39 Manar & Samah39 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 Methylprednisolone 60 mg IV OD Prednisolone PO OD Magnesium Sulphate 2 g IV Different inh/neb 60 mg 50 mg 15 mg 30 mg 20 mg 10 mg5 mg 40 mg 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 Ca polystyrene Sulphonate 30 g PO OD Heparin Sodium 5000 U S.C BID Asthma Others Hypertension 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 K 5.3 mmol/L K 5.4 mmol/L K 5.5 mmol/L COPD

40 Manar & Samah40 Patient was distress, tachypnic, wheezing, complaining of shortness of breath, orthopnea, bilateral chest crepitation

41 Manar & Samah41 Transferred to ICU

42 Manar & Samah42 Hypertension COPD/ Asthma Others 5\1 10\1 9\1 8\1 7\1 6\1 5\1 10\1 9\1 8\1 7\1 6\1 5\1 10\1 9\1 8\1 7\1 6\1

43 Manar & Samah43 Hypertension Irbesartan 300 mg PO OD Amlodipine 10 mg PO OD Nitroglycerin 5 mg SL stat 200 mcg/ml INF Clonidine 100 mcg PO OD Enalapril 5 mg PO OD Furosemide IV BID 5\1 10\1 9\1 8\1 7\1 6\1 60 mg 40 mg 80 mg 5\1 10\1 9\1 8\1 7\1 6\1

44 Manar & Samah44 Others 5\1 10\1 9\1 8\1 7\1 6\1 5\1 10\1 9\1 8\1 7\1 6\1 Hydrocortisone IV stat IV TID Different Neb/Inh Aminophylline IV 250 mg stat 80 mg 40 mg 20 mEq 40 mEq Piperacillin/Tazobactam 2.25 mg IV Q6h Potassium Chloride IV over 2h 40 mEq PO Heparin (PROTECT study) 5\1 10\1 9\1 8\1 7\1 6\1 Hypertension Irbesartan 300 mg PO OD Amlodipine 10 mg PO OD Nitroglycerin 5 mg SL stat 200 mcg/ml INF Clonidine 100 mcg PO OD Enalapril 5 mg PO OD Furosemide IV BID 60 mg 40 mg 80 mg K 3.5 mmol/L K 2.9 mmol/L Hospital Acquired Pneumonia COPD

45 Manar & Samah45 Returned to Cardiology Ward

46 Manar & Samah46 11/1 12/1 14/115/116/117/118/119/120/121/122/113/1 Irbesartan 300 mg PO OD Amlodipine 10 mg PO OD Nifedipine LA 60 mg PO OD Nitroglycerin 200 mcg/ml INF Isosorbide dinitrate 40 mg PO BID Spironolactone 25 mg PO OD Hydralazine 25 mg PO BID Enalapril PO Furosemide 40 mg IV BID 40 mg PO OD 10 mg BID10 mg QD Hypertension 11/1 12/1 14/115/116/117/118/119/120/121/122/113/1

47 Manar & Samah47 Hypertension COPD Others 11/1 12/1 14/115/116/117/118/119/120/121/122/113/1 Prednisolone PO QD Different Neb/Inh 20 mg10mg 5 mg Heparin Sodium 5000 U S.C BID Potassium Chloride 40 mEq IV 40 mEa PO OD K 2.8 mmol/L K 3.2 mmol/L 11/1 12/1 14/115/116/117/118/119/120/121/122/113/1 10 mg BID 10 mg QD Irbesartan 300 mg PO OD Isosorbide dinitrate 40 mg PO BID Amlodipine 10 mg PO OD Nifedipine LA 60 mg PO OD Spironolactone 25 mg PO OD Hydralazine 25 mg PO BID Enalapril PO Nitroglycerin 200 mcg/ml INF Furosemide 40 mg IV BID 40 mg PO OD 11/1 12/1 14/115/116/117/118/119/120/121/122/113/1 Hypertension

48 Manar & Samah48 Discharge Medications vs Past Medication History Aspirin 81 mg PO OD Clopidogrel 75 mg PO OD Isosorbide dinitrate retard 40 mg PO OD carvedilol 12.5 mg PO BID Atorvastatin 40 mg PO OD Amlodipine 10 mg PO OD Irbesartan 300 mg PO OD Furosemide 60 mg PO BID

49 Manar & Samah49 Hypertension/ CV Problems COPD Daibetes/ Complications Osteoporosis was on Insulin NPH SC 32 Units BID Gabapentin 400 mg PO BID Same Medications was on Was not managed before Alfacalcidol 0.5 mcg PO OD Calcium carbonate 500 mg PO BID Problems List/ Medications carvedilol 12.5 mg PO BID Spironolactone 25 mg PO OD Irbesartan 300 mg PO OD Furosemide 40 mg PO BID Nifedipine LA 60 mg PO BID Enalapril 10 mg PO BID Hydralazine 25 mg PO BID Isosorbide dinitrate retard 20 mg PO BID Aspirin 81 mg PO OD Clopidogrel 75 mg PO OD Atorvastatin 40 mg PO OD carvedilol 12.5 mg PO BID Irbesartan 300 mg PO OD Furosemide 60 mg PO BID Isosorbide dinitrate retard 40 mg PO OD Aspirin 81 mg PO OD Clopidogrel 75 mg PO OD Atorvastatin 40 mg PO OD Amlodipine 10 mg PO OD Was not managed before Prednisolone 5 mg PO OD (for 15 days) Fluticasone/ Salmetrol inhaler 2 puffs TID Albuterol 2 puffs inhaler PRN Discharge Medications

50 Manar & Samah50 Points of Discussion

51 Manar & Samah51 I) ACEI Induced Cough ACE inhibitor cough is an apparent class effect that may occur with all ACE inhibitors

52 Manar & Samah52 The cough is described as being a troublesome dry cough, without wheezing, typically starting from 1-7 days after the onset of therapy to as late as several weeks after the initiation of treatment Clinical Presentation The cough usually subsides within 4-7 days after cessation of treatment, but may continue for as long as 3-4 weeks The symptoms are apparently common to all ACE inhibitors, including those primarily tissue-bound such as quinapril and others that are found predominantly in the serum such as lisinopril Chest x-ray and ENT examinations are normal

53 Manar & Samah53 Diagnosis At times, the diagnosis of ACE inhibitor induced cough may be difficult to establish, particularly if the patients have asthma, COPD, allergic rhinitis, or congestive heart failure since coughing is frequently a symptom which complicates these disorders

54 Manar & Samah54 Diagnosis Rather than having the patient undergo expensive testing, the simplest manoeuvre would be Restart the ACE inhibitor Stop the ACE inhibitor for one week If the cough continues Treat the cause If the cough resolves If the cough stops Stop the ACE inhibitor Try another class of medication

55 Manar & Samah55 An alternative treatment of ACE inhibitors is angiotensen II receptor blockers Angiotensin II receptor blockers do not lead to cough and do not decrease the degradation of bradykinin as does the ACE inhibitor However, the beneficial effects of angiotensin II receptor blockers on myocardium, diabetic nephropathy or congestive heart failure have not yet been established Alternative Treatment

56 Manar & Samah56 Patients with congestive heart failure, diabetic nephropathy, acute myocardial infarction, or diabetes may have the medical need to continue ACE inhibitor therapy despite the cough Drugs, such as sodium cromoglycate, theophylline, and baclofen, may be prescribed to alleviate the cough

57 Manar & Samah57 Sodium cromoglycate: given by inhalation at 20 mg four times a day Theophylline: at a dosage of 8.5 mg/kg orally once a day while providing no bronchodilation resulted in a beneficial effect with reduction in cough Baclofen: starting with 5 mg three times a day and ending with 10 mg three times a day Larger trials are necessary to establish definitive conclusions

58 Manar & Samah58 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 Methylprednisolone 60 mg IV OD Prednisolone PO OD Magnesium Sulphate 2 g IV Different inh/neb 60 mg 50 mg 15 mg 30 mg 20 mg 10 mg5 mg 40 mg 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 Ca polystyrene Sulphonate 30 g PO OD Heparin Sodium 5000 U S.C BID Guaifenesin/ Dextromethorphan 10 ml PO BID Others Hypertension 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 COPD After single day use of captopril the patient developed cough that relieved by using Guaifenesin/ Dextromethorphan and captopril discontinuation

59 Manar & Samah59 Others 5\1 10\1 9\1 8\1 7\1 6\1 5\1 10\1 9\1 8\1 7\1 6\1 Hydrocortisone IV stat IV TID Different Neb/Inh Aminophylline IV 250 mg stat 80 mg 40 mg 20 mEq 40 mEq Piperacillin/Tazobactam 2.25 mg IV Q6h Potassium Chloride IV over 2h 40 mEq PO Heparin (PROTECT study) 5\1 10\1 9\1 8\1 7\1 6\1 Hypertension Irbesartan 300 mg PO OD Amlodipine 10 mg PO OD Nitroglycerin 5 mg SL stat 200 mcg/ml INF Clonidine 100 mcg PO OD Enalapril 5 mg PO OD Furosemide IV BID 60 mg 40 mg 80 mg Hospital Acquired Pneumonia COPD After treatment of hospital acquired pneumonia by the antibiotics the ACE-I was restarted with enalapril

60 Manar & Samah60 I) Prednisolone Side Effect and Tapering

61 Manar & Samah61 Corticosteroids Side Effects Prolonged therapy can lead to suppression of pituitary- adrenal function Too rapid withdrawal of long-term therapy can cause acute adrenal insufficiency (e.g. fever, myalgia, arthralgia and malaise) Adverse reactions: Dose and duration related side effects include fluid and electrolyte disturbance (e.g. hypokalemia with possible edema and hypertension), hyperglycemia, peptic ulcer disease, osteoporosis, euphoria, psychosis, myopathy, and infections In our case the patient suffered from: Myopathy Uncontrolled hypertension Hypokalemia Hospital acquired pneumonia The patient is predisposed to osteoporosis

62 Manar & Samah62 Corticosteroids Tapering Off There are many regimens for tapering off corticosteroids. Example of prednisone tapering schedule: Dosage (mg)Duration (wks) alternating with alternating with alternating with alternating with alternating with alternating with alternating with alternating with 04 However, corticosteroids can be rapidly tapered and discontinued abruptly if used for less than 2 to 3 weeks

63 Manar & Samah63 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 Methylprednisolone 60 mg IV OD Prednisolone PO OD Magnesium Sulphate 2 g IV Different inh/neb 60 mg 50 mg 15 mg 30 mg 20 mg 10 mg5 mg 40 mg 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 Ca polystyrene Sulphonate 30 g PO OD Heparin Sodium 5000 U S.C BID Guaifenesin/ Dextromethorphan 10 ml PO BID Asthma Others Hypertension 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 myopathy COPD This is not a prednisolone tapering off. The goal of decreasing the dose was to seek for the lowest effective and tolerated dose that can manage her COPD with minimum myopathy and fluid retention

64 Manar & Samah64 II) -Blocker Withdrawal

65 Manar & Samah65 -Blocker Withdrawal Withdrawing -blockers may produce -adrenergic supersensitivity. Both abrupt cessation and gradual withdrawal over 4 to 8 days have caused overshoot hypertension and cardiovascular complications within within 48 to 72 hours after the last b-blocker dose To prevent -adrenergic supersensitivity, the -blocker dosage should be reduced over 7 to 10 days to the equivalent of 30 mg/day of propranolol and then maintained at this low dosage for 2 additional weeks -blocker Withdrawal in patient who are free of CHD resulted in fourfold increase in onset of CHD

66 Manar & Samah66 Irbesartan 300 mg PO OD Isosorbide dinitrate retard PO BID Amlodipine 10 mg PO OD Nifedipine LA 60 mg PO STAT Captopril 6.25 mg PO TID carvedilol 12.5 mg PO BID Metoprolol 12.5 mg PO BID Clonidine 100 mcg PO OD Furosemide IV BID 20 mg PO 40 mg PO Hypertension 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 20 mg 40 mg 60 mg 40 mg 19/12 20/12 31/1222/1223/1224/1225/1226/1227/1228/1229/1230/1221/12 1/14/1 2/1 3/1 Titration of the cavedilol 12.5 mg to metoprolol 12.5 mg Then D/C -blocker after 8 days

67 Manar & Samah67

68 Manar & Samah68 References Chobanian AV, Bakris GL, Black HR, et al and the National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 report. JAMA 2003; 289:2560–2572. Vidit D, Borazanian R. Treat high blood pressure sooner: Tougher, simpler JNC 7 guidelines. Cleveland Clinic Journal of Medicine 2003; 70(8): Saudi Hypertension Management Society. Saudi hypertension guidelines. 2007; 1-46 Helms R, Quan D, Herfindal E eds. Textbook of therapeutics. Drug and disease management. Eighth Edition. Philadelphia, PA. Lippincott Williams & Wilkins; 2006: Herfindal E and Gourley D. Textbook of therapeutics. Drug and disease management. Seventh Edition. Philadelphia, PA. Lippincott Williams & Wilkins; 2000:


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