CCB in Management of Hypertension in Older Persons Presented by Mona Ahmed sherif Marwa Shaaban Shimaa Adel Ahmed Salma Sadek Alia khalid

Antihypertensive therapy has been shown to reduce morbidity and mortality in older patients with elevated systolic or diastolic blood pressures. Systolic blood pressure is the most important predictor of cardiovascular disease. Low-dose thiazide diuretics remain first-line therapy for older patients. BB, ACEI, ARB and CCB are second-line medications that should be selected based on comorbidities and risk factors.

calcium channel blockers o As a group, CCB have compelling indications for use in patients at high risk for coronary disease and those with diabetes mellitus. o CCB prevent calcium from entering the cells of the arterial vasculature and cause dilation in the coronary arteries and periphery. o There are two classes of CCB, both are effective treatments for hypertension in older patients. o Nondihydropyridines (e.g., diltiazem, verapamil) exhibit negative inotropic and chronotropic effects, making them beneficial in atrial fibrillation and supraventricular tachyarrythmias. o Dihydropyridines (i.e., amlodipine,felodipine ) are safe for use in patients with heart failure, hypertension, or chronic stable angina. o Short-acting agents are not recommended in clinical practice.

CCB Vs other Anti-hypertensive drugs o In comparison with other anti-hypertensives, systematic reviews generally have found CCB to be equivalent or inferior to other agents. o CCB have been found to be effective in salt sensitive hypertensive patients, such as blacks and older persons. o 4 recent trials have evaluated the effects of different antihypertensive regimens (i.e., ACEI,ARBs, BB, CCB alone and in combination) on the treatment of hypertension in older persons. There were no overall differences in total mortality.

CCB- Drugs inteactions Calcium-channel blockers + Azole Itraconazole raise the serum levels of felodipine, which increases its adverse effects, in particular ankle and leg oedema. A few case reports suggest that nifedipine can interact similarly with itraconazole Mechanism Ankle swelling due to precapillary vasodilatation is a relatively common adverse effect of the dihydropyridine, and this effect appears to be dose-related. CCB are metabolised in the gut wall and liver by the cytochrome P450 CYP3A, which are inhibited by itraconazole, ketoconazole and to a lesser extent by fluconazole, so that in the presence of these antifungals the levels of the CCB are raised and the adverse effects increased. Caution is warranted with all calcium-channel blockers when azole antifungals, particularly itraconazole and ketoconazole, are used.

Calcium-channel blockers+Phenobarbital Limited evidence suggests that phenobarbital greatly reduces the serum levels and/or increases the clearance of felodipine, nifedipine, nimodipine, and verapamil. Mechanism Phenobarbital is an enzyme inducer which can increase the metabolism of the calcium-channel blockers by the cytochrome P450 isoenzyme CYP3A4 in the liver, resulting in lower serum levels. Importance and management Phenobarbital markedly reduces felodipine, nifedipine and verapamil levels. A considerable increase in the dosage of these calcium-channel blockers will probably be needed in patients taking phenobarbital. Nimodipine effects are also markedly reduced by phenobarbital and the manufacturer contraindicates concurrent use.

Calcium-channel blockers + Nitrates Enhanced hypotensive effects may occur when CCB are given with nitrates. Increased hypotensive effects and faintness due to additive vasodilating effects have been noted when diltiazem given with nitrate. The manufacturers of amlodipine say that long-acting nitrates and sublingual glyceryl trinitrate have been given safely with amlodipine. In patients treated with CCB, the dosage of concurrent nitrate derivatives should be increased gradually.

CCB + CCB Plasma levels of both nifedipine and diltiazem are increased and blood pressure is reduced accordingly by concurrent use. Verapamil is predicted to interact similarly. There are isolated reports of intestinal occlusion attributed to the concurrent use of nifedipine and diltiazem. The excessive relaxation of the intestine was attributed to elevated nifedipine plasma levels, which were said to be caused by diltiazem. Note that if nimodipine is used with another CCB, monitoring, with possible dose reduction or discontinuation of the other CCB is recommended.