Hypertension Nouf Aloudah, M.S Clinical Pharmacy Lecturer King Saud University
Hypertension Why to treat hypertension … 150/95 mmHg ?!!! 150/95 mmHg ?!!! 200/100 mmHg ?!!! 200/100 mmHg ?!!! So what? So what?
Terri before and 15 years after stroke and now she is dead And many other sad stories ….. And many other sad stories …..
Hypertension Hypertension means Hypertension means “ many organs in the body are under attack ”
Hypertension Diagnosis a late stage when target-organ damage has already started target-organ damage has already started + the optimum time to start treatment remains "under discussion."
Hypertension complications premature cardiovascular disease premature cardiovascular disease increases the risk of heart failure at all ages increases the risk of heart failure at all ages Left ventricular hypertrophy is a common problem in patients with hypertension Left ventricular hypertrophy is a common problem in patients with hypertension Hypertension is the most common and most important risk factor for stroke Hypertension is the most common and most important risk factor for stroke Hypertension is the most important risk factor for the development of intracerebral hemorrhage Hypertension is the most important risk factor for the development of intracerebral hemorrhage Hypertension is a risk factor for chronic renal insufficiency and end-stage renal disease Hypertension is a risk factor for chronic renal insufficiency and end-stage renal disease Marked elevations in blood pressure can cause an acute, life-threatening emergency Marked elevations in blood pressure can cause an acute, life-threatening emergency
Hypertension USA # 1.5 billion estimated to be hypertensive by billion estimated to be hypertensive by 2025 Risk is 90% for individuals in developing country Risk is 90% for individuals in developing country
Hypertension USA # NHANES NHANES III NHANES III NHANES II Awarenes s Treatment Control*
Hypertension Saudi # 9.1% and 8.7% ≥160/95 mmHg 9.1% and 8.7% ≥160/95 mmHg 20.4% 25.9% ≥ 140/90 mmHg 20.4% 25.9% ≥ 140/90 mmHg Arterial hypertension in Saudi Arabia Arterial hypertension in Saudi Arabia Volume 4, Issue 2, 1998, Page 382 Volume 4, Issue 2, 1998, Page 382 M.M. Al-Nozha, M.S. Ali and A.K. Osman M.M. Al-Nozha, M.S. Ali and A.K. Osman one fourth of Riyadh city people are unaware of their high blood pressure, and also we can note that those with higher social class are prone to hypertension. one fourth of Riyadh city people are unaware of their high blood pressure, and also we can note that those with higher social class are prone to hypertension. Wahid Saeed AA, 1996 Wahid Saeed AA, 1996
Hypertension USA and Saudi # Lots of effective treatment Lots of effective treatment Overwhelming evidence Overwhelming evidence No control ??? Compliance!!!! Compliance!!!! Pharmacist plays a big rule! Pharmacist plays a big rule! Lancet, augest Lancet, augest
Hypertension The Role of Pharmacists The Role of Pharmacists in the Detection, Management, and Control of Hypertension: A National Call To Action The Role of Pharmacists in the Detection, Management, and Control of Hypertension: A National Call To Action Pharmacotherapy 20(2): , 2000 Community Pharmacies most accessible once a month most accessible once a month Knows all the medications, cost of drugs important link between the physician and patient. work together to achieve goals developie optimal, cost-effective strategies that use the principles and guidelines from the JNC-VI. developie optimal, cost-effective strategies that use the principles and guidelines from the JNC-VI.
Hypertension The Role of Pharmacists The Role of Pharmacists in the Detection, Management, and Control of Hypertension: A National Call To Action The Role of Pharmacists in the Detection, Management, and Control of Hypertension: A National Call To Action Pharmacotherapy 20(2): , 2000 Integrated Health Systems pt Blindly evaluate 2 clinical pharmacist and 3 physicians pharmacists significantly higher for the selection of the most appropriate drug therapy compared with physicians. the pharmacist-managed group (97%) had controlled blood pressure compared with the physician-managed group (78%)!
Hypertension Diuretics Mechanism of action Increase renal execration of sodium and water Increase renal execration of sodium and water Decrease fluid volume within the intravascular compartment Decrease fluid volume within the intravascular compartment
Hypertension Diuretics Potassium wasting Chlorthalidone (hygroton), Hydrochlorothiazide (hydrodiuril, esidrix), Indapamide (lozol), Metalazone (zaroxolyn) Chlorthalidone (hygroton), Hydrochlorothiazide (hydrodiuril, esidrix), Indapamide (lozol), Metalazone (zaroxolyn) ↑ cholesterol and TG ↑ glucose and uric acid Hypokalemia ↑ calcium conc ↑
Hypertension Diuretics Loops Frusamide (lasix), ethacrynic acid (edecrin), bumetanide (bumex), torsemide (demadex) Frusamide (lasix), ethacrynic acid (edecrin), bumetanide (bumex), torsemide (demadex) Short duration of action Short duration of action No hypercalcemia No hypercalcemia
Hypertension Diuretics Potassium sparing Potassium sparing Amiloride (midamor), spironolactone (aldactone), triameterene (dyrenium) Amiloride (midamor), spironolactone (aldactone), triameterene (dyrenium) Hyperkalemia, gynacomastia with spironolactone Hyperkalemia, gynacomastia with spironolactone
Hypertension sympatholytic drugs Beta adrenergic blockers Beta adrenergic blockers Alpha and beta blockers Alpha and beta blockersLabetalol Alpha blocker Alpha blocker Prazosin, doxazosin, terazosin Presynaptic adrenergic inhibitors Presynaptic adrenergic inhibitors Guandrel, guanethidin, reserpine Centrally acting agents Centrally acting agents Clonidine, guanabenz, guanfacine, and methyldopa Ganglionic blockers Ganglionic blockers
Hypertension Beta-Blockers Mechanism of action: ↓ heart rate and force of contraction ↓ heart rate and force of contraction ↓ cardiac output ↓ cardiac output Other mechanism postulated Other mechanism postulated
Hypertension Beta-Blockers Acebutolol (sectral) Acebutolol (sectral) Atenolol (tenormin) Atenolol (tenormin) Betaxolol (kerion) Betaxolol (kerion) Bisprolol (zebeta) Bisprolol (zebeta) Carteolol (cartrol) Carteolol (cartrol) Carvedilol (coreg) Carvedilol (coreg) Metoprolol (lopressor, toprol XL) Metoprolol (lopressor, toprol XL) Nadolol (corgard) Nadolol (corgard) Penbutolol (levatol) Penbutolol (levatol) Pindolol (visken) Pindolol (visken) Propranolol (inderal) Propranolol (inderal) Timolol (blocadren Timolol (blocadren Bronchospasm Bradycardia Heart failure Mask hypoglycemia and delay recovery Impaired peripheral circulation ↓Exercise tolerance
Hypertension vasodilators Hydralazine (apresoline) Hydralazine (apresoline) Injectable for emergency Onset of action: I.V.: 5-20 minutes Minoxidil (loniten) Minoxidil (loniten) For renal failure patient who are resistant to everything Hair growth, fluid accumulation
Hypertension calcium antagonists Mechanism of action Block calcium entry into vascular smooth muscle Block calcium entry into vascular smooth muscle vasodilatation vasodilatation ↓ peripheral resistance ↓ peripheral resistance ↓ heart rate ↓ heart rate ↓ Myocardial contractile force ↓ Myocardial contractile force
Hypertension calcium antagonists Nondihydropyridines Diltiazim (cardizem) Diltiazim (cardizem) Verapamil (isoptin) Verapamil (isoptin)Dihydropyridines Amlodipine (norvasc) Amlodipine (norvasc) Felodipine (plendil) Felodipine (plendil) Isradaoine (dynacirc) Isradaoine (dynacirc) Nifedipine (procardia, adalat) Nifedipine (procardia, adalat) Nisoldipne (sular) Nisoldipne (sular) Nondihydropyridines Conduction defects Worsening systolic dysfunction Gingival hyperplasia Constipation (verapamil) Dihydropyridines Ankle edema Flushing Headache Gingival hyperplasia
Hypertension Renin Angiotensin Aldosterone Inhibitors Angiotensin converting enzyme inhibitors (ACEI) Angiotensin converting enzyme inhibitors (ACEI) Block conversion of angiotensin I to angiotensin II Block conversion of angiotensin I to angiotensin II (angiotensin II cause vasoconstriction) (angiotensin II cause vasoconstriction) Angiotensin II receptor blockers (ARBs) Angiotensin II receptor blockers (ARBs) Block the angiotensin II receptor on the cells Block the angiotensin II receptor on the cells
Hypertension ACEI Benzopril (lotensin) Benzopril (lotensin) Captopril (capoten) Captopril (capoten) Enalapril (vasotec) Enalapril (vasotec) Fosinopril (monopril) Fosinopril (monopril) Lisinopril (zestril) Lisinopril (zestril) Moexipril (univasc) Moexipril (univasc) Perindopril (aceon) Perindopril (aceon) Quinapril (accupril) Quinapril (accupril) Ramipril (altace) Ramipril (altace) Trandolapril (mavik) Trandolapril (mavik) Cough Angioedema Hyperkalemia Rash Loss of taste Leukopenia Pregnancy category C and D
Hypertension ARBs Candesartan (atacand) Candesartan (atacand) Eprosartan (tevetan) Eprosartan (tevetan) Irbesartan (avapro) Irbesartan (avapro) Losartan (cozaar) Losartan (cozaar) Olmesartan (benicar) Olmesartan (benicar) Telmisartan (micardis) Telmisartan (micardis) Valsartan (diovan) Valsartan (diovan) Hyperkalemia Very rare angioedema Pregnancy category C and D
Monotherapy versus combination
Compelling indications for specific pharmacotherapy
Large outcome trials for HTN