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Antihypertensive Medications ANTIHYPERTENSIVE MEDICATIONS Dana Bartlett, RN, BSN, MSN, MA, CSPI Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Rocky Mountain Poison Control Center. ABSTRACT The use of antihypertensive medications is a well accepted treatment for heart disease and stroke, poor function of the kidney and peripheral vascular systems. The medications help to lower blood pressure and to enhance patient health outcomes by slowing cardiovascular disease outcomes. The classes of drugs used to treat hypertension and cardiovascular disease, and specifically the effectiveness of antihypertensive medication in certain medical conditions and populations, and in the setting of certain lifestyle practices, is discussed. 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 2.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content is 2.5 hours. Statement of Learning Need Antihypertensive medications are abundant, often are used in combination treatment, and health clinicians have a wide variety of medications to currently select from when treating a cardiovascular and hypertensive condition. The newer and older antihypertensive medications differ slightly in chemical structure but produce nearly identical effects. Clinicians are better able to individualize patient use of a drug to better control elevated blood pressure, and to avoid medication side effects. In addition, treatment of co- occurring conditions is possible, such as hypertension and congestive heart failure. 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Course Purpose To inform health clinicians of the indications, uses, contraindications and potential side effects of antihypertensive medication. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Dana Bartlett, RN, BSN, MSN, MA, CSPI, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – All have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. Which of the following act as competitive antagonists that reduce the release of norepinephrine and lower blood pressure? a. Alpha1 blockers b. Vasodilators c. Alpha2 agonists d. Non-steroidal anti-inflammatory drugs (NSAIDs) 2. Benign prostatic hyperplasia may be treated with the following medication(s): a. Prazosin b. Metolazone c. Doxazosin, terazosin d. Guanfacine, methyldopa 3. For doxazosin, the 24-hour maximum dose is ___ mg. a. 10 b. 8 c. 25 d. 16 4. The maximum dose of prazosin is 20 mg a day in divided doses, although some patients may need and tolerate up to ___ mg a day. a. 40 b. 50 c. 25 d. 30 5. Terazosin should begin with ___ mg a day, given at bedtime. a. 8 b. 4 c. 7 d. 1 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction Antihypertensive medications are used to treat heart disease and stroke, as well as comorbid conditions of the kidneys and peripheral vascular system. The use of an antihypertensive medication lowers blood pressure and improves health outcomes of patients by slowing disease outcomes caused by cardiovascular morbidity. The classes of drugs used to treat hypertension and cardiovascular disease is discussed in the following sections. Additionally, the effectiveness of antihypertensive medication in certain medical conditions and populations, and in the setting of certain lifestyle practices, is discussed. Alpha1-adrenergic Blocking Medication Alpha1‐adrenergic‐blocking drugs help to reduce blood pressure. When combined with most drug classes, they not only lower the blood pressure but also improve plasma lipid profiles. They are also used for other conditions as well, such as anxiety disorders and benign prostatic hypertrophy. There are significant side effects and patients prescribed an alpha1-adrenergic blocking (alpha1 blocker, for short) should be closely monitored. Category ● Alpha1 blocker ● Antihypertensive Uses ● Benign prostatic hyperplasia (Doxazosin, terazosin) ● Hypertension (Doxazosin, prazosin, terazosin) 5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Mechanism of Action The alpha1 blockers act as competitive antagonists at postsynaptic alpha1 adrenergic receptors, reducing the release of norepinephrine. This decreases systemic vascular resistance (SVR) and lowers blood pressure. Available Forms ● Doxazosin: 1 mg, 2 mg, 4, and 8 mg tablets, generic and brand name Cardura. Extended release 24-hour tablet: Cardura XL, 4 mg and 8 mg ● Prazosin: 1 mg, 2 mg, and 5 mg capsules, generic and brand name Minipress. ● Terazosin: Generic capsules, 1 mg, 2 mg, 5 mg, and 10 mg. Dosing Doxazosin: Begin with 1 mg a day, titrate by doubling the daily dose; the 24-hour maximum dose is 16 mg. For Cardura XL, the starting dose is 4 mg. If needed after 3-4 weeks the dose can be increased to a maximum of 8 mg.1 Prazosin: The initial dose should be 1 mg two-three times a day. The dosage can be gradually increased to a maximum of 20 mg a day in divided doses, although some patients may need and can tolerate 40 mg a day. Some patients only require twice a day dosing.2 Terazosin: Begin with 1 mg a day, given at bedtime. Slowly increase the dose until the desired blood pressure level has been reached; the maximum 24-hour dose 6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com is 20 mg. If the patient’s blood pressure is significantly decreased two to four hours after a dose, the total daily amount can be divided into two doses.3 Dosing Adjustments: Geriatric Patients Doxazosin: There are no recommendations about specific doses of doxazosin that should be used to treat geriatric patients. However, the prescribing information does note that for extended release Cardura the incidence of hypotension (a common adverse effect of the drug) appears to be related to age and is more prevalent in people aged 70 and older.1 Prazosin: Use the adult dosing recommendations for geriatric patients. Terazosin: There are no recommendations about specific doses of terazosin that should be used to treat geriatric patients. However, the prescribing information states that terazosin was listed in the 2015 Beers Criteria as a medication that could be potentially harmful in patients 65 years and older because of the risk for orthostatic hypotension.3 The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, commonly called the Beers Criteria, is a list produced by the American Geriatrics Society. The Beers Criteria (named after one of its founders, Dr. Mark Beers) identifies medications that should be avoided in older adults or used with caution and close monitoring because of the risk of harmful adverse effects.4 7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Orthostatic hypotension is defined as an abnormal decrease in blood pressure after moving from a lying to a standing position. After five minutes of being supine blood pressure is measured after the patient has been standing quietly for two to five minutes. At that point orthostatic hypotension is present if the systolic blood pressure has decreased ≥ 20 mmHg, the diastolic blood pressure has decrease ≥10 mm Hg, or both.5 Elderly patients are more likely to have orthostatic hypotension, probably because of decreased baroreceptor sensitivity.5 Dosing Adjustments: Hepatic Impairment Doxazosin: The prescribing information for Cardura states that as the drug is extensively metabolized by the liver, Cardura could be problematic for patients who have hepatic impairment; Cardura should not be used for patients who have severe hepatic impairment (Child-Pugh class C), and Cardura should be used cautiously for patients who have mild or moderate hepatic impairment (Child-Pugh call A or B) and these patients should have their blood pressure monitored. The Child-Pugh classification system measures albumin, bilirubin, and prothrombin time and assesses the severity of ascites and hepatic encephalopathy, assigns a point score to each, and the total
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