1. Antihypertensive drugs for primary care physician
Domina Petric, MD

2. 1.) Centrally acting antiadrenergic agents
Imidazole receptors selective agonists:
moxonidinum
guanfacine (for ADHD)

3. Moxonidinum 0,2 mg or 0,4 mg tbl.
For treatment of arterial hypertension.
Start dose is 0,2 mg per os a day.
Maximum dose is 0,6 mg per os a day divided in two doses.
It can be taken with or without food.
Contraindications are hypersensitivity, sick sinus syndrome, bradycardia (<50 bmp), AV block of II. and III. degree, heart insufficiency.
It is not recommended to use it with tricyclic antidepressants and benzodiazepines. It is not recommended during pregnancy and lactation.

4. 2.) Peripherally acting antiadrenergic agents
Alfa adrenergic receptors blocators:
doxazosinum
urapidilum

5. Doxazosinum 2 mg or 4 mg tbl.
Indicated for arterial hypertension as monotherapy or in combination with tiazide diuretics, beta-blockers, calcium antagonists or ACE-i.
It is also indicated for treatment of symptoms in benign prostatic hyperplasia.
Start dose for arterial hypertension treatment is 1 mg.
Maintenance dose is 2-4 mg per os a day.
Maximum daily dose is 16 mg.
Contraindicated in hypotension and lactation.

6. Urapidilum for iv. application hypertensive crisis
Ebrantil 25 mg/50 mg ampulla
Ebrantil 60 mg/90 mg tbl.
for iv. application
hypertensive crisis
refractory hypertension
10-50 mg iv. slowly
arterial blood pressure monitoring is obligatory
for treatment of arterial hypertension in adults
30 mg per os twice a day for slowly lowering blood pressure
60 mg per os twice a day for more rapidly lowering RR
mg per os a day is maintenance dose

7. Contraindicated in pregnancy and lactation.
Urapidilum
Contraindicated in pregnancy and lactation.
Not recommended (caution is mandatory) for children and patients with heart, kidney or liver failure.
Caution also with older patients and patients taking cimetidine.

8. DIURETICS
3.)

9. A) Low threshold diuretics, sulphonamides
chlortalidonum
indapamidum

10. Chlortalidonum (Hygroton 25 mg tbl.)
Indications are:
arterial hypertension (esential, nephrogenic, systolic)
chronic heart failure (NYHA II or III)
ascites (liver cyrosis in stable patients)
oedemas in nephrotic sydrome
diabetes insipidus

11. Chlortalidonum (Hygroton 25 mg tbl.)
For arterial hypertension daily dose is 25 mg per os.
Dose can be increased up to 50 mg per os a day.
For heart failure dose is mg per os a day, but the dose can be increased up to mg per os a day.
For diabetes insipidus start dose is 100 mg twice a day and then maintenance dose should be 50 mg a day.
Contraindications are hypersensitivity, anuria, severe kidney failure (ClCr <30 mL/min), hypokalemia, hyponatremia, hypercalcemia, gout, hypertension during pregnancy.

12. Indapamidum (1,5 mg tbl.)
Indicated for treatment of esential hypertension in adults.
Dose is 1,5 mg per os a day taken with glass of water in the morning.
Contraindications are hypersensitivity, severe kidney failure, hepatic encephalopathy or severe liver damage, hypokalemia.

13. B) High treshold diuretics, sulphonamides
torasemidum
furosemidum

14. Furosemidum (40 mg tbl. , 500 mg tbl. , 40 mg/4 mL ampulla for iv
Furosemidum (40 mg tbl., 500 mg tbl., 40 mg/4 mL ampulla for iv. application)
Indicated for treatment of oedemas caused with heart or liver failure, oedemas in kidney diseases and arterial hypertension.
Start dose is usually 40 mg and can be increased on 80 mg or even on 160 mg per os a day depending on the severity of the heart/liver/kidney failure.
Diuresis (with furosemid) should not be more than 1 kg a day.
High treshold diuretics better act when the daily dose is divided into two or three doses taken every 12 hours (or 8 hours if three doses, or 6 hours if four doses needed).
For arterial hypertension dose is 40 mg a day.

15. Furosemidum
Tablet should be taken on the empty stomach with lots of water.
Contraindications are hypersensitivity, kidney insufficiency with anuria not responding on this medication, hepatic coma, severe hypokalemia or hyponatremia, hypovolemia or dehydration, during lactation.

16. Furosemidum 500 mg tbl. (Edemid forte)
prevention of acute kidney insufficiency in patients with GF<20 mL/min
chronic kidney insufficiency before dialysis
patent with fluid retention and very high blood pressure
nephrotic syndrome (together with albumins infusion)
resistent congestive heart failure
Dose varies from 250 mg a day up to 2000 mg per os a day!

17. C) Potassium sparing diuretics, aldosterone antagonists
spironolactonum
eplerenonum

18. Spironolactonum 25 mg, 50 mg and 100 mg tbl.
Indications are primary hyperaldosteronism, oedemas and ascites in conditions with secondary hyperaldosteronism.
Dose is mg per os a day.
Contraindications are anuria, acute kidney failure, hyperkalemia, hyponatremia, pregnancy and lactation.

19. Eplerenonum 25 mg and 50 mg tbl.
Indication: chronic heart failure (LVEF≤40 %) for cardiovascular mortality and morbidity reduction.
Maximum dose is 50 mg per os a day.

20. Beta adrenergic receptors blockers
4.)

21. A) Non-selective beta adrenergic blocators
sotalolum
propranololum

22. Propranololum 40 mg tbl. after acute myocardial infarction
prophylaxis of stenocardic pain in patients with chronic stable angina pectoris
arterial hypertension (alone or in combination, usually with tiazide diuretics)
prevention of bleeding in portal hypertension
pheochromocytoma
esential tremor
migraine

23. For arterial hypertension start dose is 80 mg per os twice a day.
Propranololum 40 mg tbl.
For arterial hypertension start dose is 80 mg per os twice a day.
Overall daily dose can vary from 160 mg up to 320 mg.
Contraindications are hypersensitivity, bronchial spasm (asthma, COPD), severe sinus bradycardia (heart rate <50 bmp), Prinzmetal´s angina, cardiogenic shock, right heart failure caused with pulmonary hypertension, severe heart failure, severe hypotension, risk of hypoglicemia...

24. B) Selective beta adrenergic blockers
atenololum
metoprololum
bisoprololum
esmololum
nebivololum

25. Bisoprololum 2,5 mg, 5 mg, 10 mg tbl.
Treatment of arterial hypertension, angina pectoris, stable chronic heart failure with left ventricular systolic dysfunction.
Start dose for arterial hypertension is 5 mg per os a day.
Maintenance dose is 10 mg a day, maximum dose is 20 mg a day.
Dose in stable chronic heart failure should be titrated:
1,25 mg a day for a week
2,5 mg a day for a week
3,75 mg a day for a week
5 mg a day during next four weeks
7,5 mg a day during next four weeks
10 mg a day is maintenance dose

26. Contraindications: acute heart failure cardiogenic shock
AV block of II. and III. degree without pacemaker
sick sinus syndrome
symptomatic bradycardia, symptomatic hypotension
severe bronchial asthma or COPD
metabolic acidosis
All beta adrenergic blockers should be taken carefully if patient is diabetic!

27. Calcium inhibitors
V.)

28. Dihydropyridine derivatives
amplodipinum
lercanidipinum
nifedipinum
lacidipinum
felodipinum

29. Lercanidipinum 10 mg or 20 mg tbl.
Indication is mild to moderate esential arterial hypertension.
Daily dose is 10 mg per os 15 minutes before meal with glass of water.
Dose can be increased up to 20 mg.
Lercanidipinum causes less peripheral oedemas than other dihydropyridine derivatives.

30. Renin angiotensin system agents
VI.)

31. A) ACE-inhibitors
quinaprilum
lisinoprilum
ramiprilum
perindoprilum
cilazaprilum
trandolaprilum
...

32. Ramiprilum 1,25 mg, 2,5 mg, 5 mg, 10 mg tbl.
treatment of arterial hypertension
reduction of cardiovascular morbidity and mortality in patients with coronary artery disease, diabetes...
treatment of glomerular diabetic nephropathy

33. Contraindications:
hypersensitivity
angioedema in family anamnesis
bilateral renal artery stenosis
second and third trimester of pregnancy
severe hypotension
haemodinamic instability

34. B) Angiotensin II antagonists
irbesartan
candesartanum
losartanum
valsartanum
azilsartan medoximil
...

35. Literature:
Mediately
HALMED