Antihypertensive drugs for primary care physician DOMINA PETRIC

Antihypertensive drugs for primary care physician DOMINA PETRIC, MD

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

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.

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

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.

Urapidilum Ebrantil 25 mg/50 mg ampulla Ebrantil 60 mg/90 mg tbl. ▪ for iv. application ▪ for treatment of arterial hypertension in adults ▪ hypertensive crisis ▪ refractory hypertension ▪ 30 mg per os twice a day for slowly lowering blood pressure ▪ 10 -50 mg iv. slowly ▪ 60 mg per os twice a day for more rapidly lowering RR ▪ arterial blood pressure monitoring is obligatory ▪ 60 -180 mg per os a day is maintenance dose

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.

DIURETICS 3. )

A) Low threshold diuretics, sulphonamides chlortalidonum indapamidum

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

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 25 -50 mg per os a day, but the dose can be increased up to 100 -200 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 (Cl. Cr <30 m. L/min), hypokalemia, hyponatremia, hypercalcemia, gout, hypertension during pregnancy.

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.

B) High treshold diuretics, sulphonamides torasemidum furosemidum

Furosemidum (40 mg tbl. , 500 mg tbl. , 40 mg/4 m. L 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.

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.

Furosemidum 500 mg tbl. (Edemid forte) ▪ prevention of acute kidney insufficiency in patients with GF<20 m. L/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!

C) Potassium sparing diuretics, aldosterone antagonists spironolactonum eplerenonum

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

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.

Beta adrenergic receptors blockers 4. )

A) Non-selective beta adrenergic blocators sotalolum propranololum

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

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. . .

B) Selective beta adrenergic blockers ▪ atenololum ▪ metoprololum ▪ bisoprololum ▪ esmololum ▪ nebivololum

Bisoprololum 2, 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

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!

Calcium inhibitors V. )

Dihydropyridine derivatives ▪ amplodipinum ▪ lercanidipinum ▪ nifedipinum ▪ lacidipinum ▪ felodipinum

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.

Renin angiotensin system agents VI. )

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

Ramiprilum 1, 25 mg, 2, 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

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

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

Literature: Mediately HALMED