Drug in hypertension

1. Antihypertensive Drugs &
Approach to the patients of HTN.
By Dr. Mahbub Tamim
Intern Doctor

2. 1.ACE inhibitors:
Use at night
Drug of choice in Type 2 DM
(a)Ramipril ***
(b) captopril
(c) Enalapril
S/E:
Dry cough
1st dose hypotension
Conta: pregnancy ( renal fetal Shut down ) ,bilateral renal artery stenosis

3. 2. Angiotensin Receptor Blocker (ARBs)
Use At night
Drug of choice in Type 2 DM & diabetic nephropathy
a.Telmisartan *
b.#Olmesartan*****.
C.Losartan ***
(Angilock 25/50/100)
D.valsartan*
S/E:
1st dose hypotension
Conta: pregnancy ( renal fetal Shut down ) ,bilateral renal artery stenosis

4. 3. calcium channel blocker (CCB)
Use at morning
↓↓bp very well
a.. #Amlodipine *** (amdocal
b.. Lecidipine
c.. #Cilnidipine ***
d..nifedipine (low cost).
e..verapamil (rate limiting)
f... Diltiazem (rate limiting)
Alternative of beta blocker in asthma : rate limiting CCB
Used in Isolated systolic HTN
Never use rate limiting CCB with beta blocker → Bradycardia
S/E: ankle edema, constipation
Contra: complete heart block

5. 4. Beta blocker
★Should not stop abruptly
★Don‘t use in B. Asthma patient
a.Bisoprolo*****
b. Atenolol**
c.metoprolol** (betaloc)
d. Labetolol
e.Propranolol*
f. Nevivolol (Nebicard)
g.Carvedilol Carvista
Indication:
HTN with angina / MI / HF
Contr: Asthma(non selective), Complete Heart block

6. 5. Diuretics
a.Hydrochlorothiazide ****
(Used in Isolated systolic HTN,
S/E:Hyperurecemia, atypical gout- like elbow)
b.indapamide****
c.Cholorthalidone

7. 6. Alpha blocker
a.prazosin (prazpreas/ alphapress)
Use: BPH, uncontrolled HTN in ckd
S/E:1st dose hypotesion/ postural hypotension
Contra: Urinary incontinence
7. Central alpha-2 agonist.
a.Alpha methyledopa(pregnancy)
Sardopa
8.. Direct vassodilator
hydralazine. (Malignant htn)

8. 9. vasodilators drugs
• 👉hydralazine - reflex tachycardia করে
• 👉minoxidil -combination এ use হয়
• 👉nitroprusside -HTN crisis এ use হয়
• 🚫🚫centrally acting sympatholytics
• 💊💊clonidine 👉decrease sympathetic outflow
• 💊💊alpha methyldopa 👉HTN in pregnancy

9. Combination CCC+ARB:
Amlodipine+Olmesartan
Bizoran/Duopres 5/20 or 5/40
Amlodipine+Telmisartan
Telmidip
Amlodipine+valsartan

10. CCC+ BB:
• Amlodipine+atenolol
Fixocard
• Amlodipine+bisolol
ARB+TLD:
Losartan+ Hydrochlorothiazide
Angilock plus
Olmesartan+Hydrochlorothiazide
Olmecar plus
Telmisartan+Hydrochlorothiazide

11. Commonly used combination Trade name
Angilok plus / osartil plus 50 (12tk)
Bizoran 5/20 (12tk)
Amdocal plus 5/50 or Fixocard (Very effective) (6 tk)

12. For low socio-economic patients
Tenolock (0.8tk)
Enaril/ anapril (2tk)
Cardizem 30 (3tk)
Metoprol /betaloc(1.5-3tk)
Nifr*Nifin 10 (mg) 1+1+1Nidipine/Nifecap SR (20mg)1+0+1 (0.7tk)

14. STEP 1
★HTN+DM= ACEi /ARB
★HTN without DM
Age < 55y = ACEi /ARB
Age >55y = CCB
Step 2
ACEi/ARB+ CCB
(Bizoran/Duopres 5+20 or 5+40)
Step 3
ACEi/ARB+CCB+ thiazide like diuretics
(Olmecar plus at night amdocal 5mg at morning)
Steps 4
+ beta blocker /spironolactone/alpha blocker
(Do a serum Potassium level)
If potassium <4.5= spironolactone
If potassium >4.5= beta Blocker/ alpha bocker
If still not controlled → refer

15. Target BP
Age <80years
140/90 mmHg
Age >80years
150/90 mmHg

17. Special conditions :
1.HTN with heart failure:
ARB + diuretics e.g.
Tab. Olmecar plus (Hydrochlorothiazide+Omlesartan)
1+0+1- to be continued
2. HTN with angina:
Beta blocker, calcium channel blocker
3.HTN with DM: ACE inhibitor e.g.___
Tab. Angilock (Losartan) 25 mg/50mg
1+0+0-To be continued

18. 4. HTN with CKD: (check s.creatinine & s. Potassium)
(S. Creatinine <2.5mg =ACEi/ARB, >2.5mg =CCB)
ACE inhibitor e.g.
Tab. Angilock (Losartan) 25 mg/50mg
1+0+0-To be continued
(In severe/uncontrolled case
Alphapress 1mg 1+1+1+1 or
Prazopress ER 2.5mg
5. HTN with BPH:
Tab. Alphapress (Prazosin) 1 mg/2mg
1+0+1- to be continues
6. HTN with asthma: Avoid beta blocker.
Ca channel blocker, diuretics can be given.
E.g. Tab. Amdocal (amlodipine) 5mg/10mg
1+0+0-To be continued

19. Pregnancy + HTN
Alpha methyl Nifedipindopa
Sardopa 250 or 500 mg
Labetalol
Nifedipine

20. Approach to HTN patients
Symptoms:
Headache,neck pain, dizziness, Blurry vision
Clinical sign(must):
Anaemia
Pulse (AF, pulsus alternas)
Edema
Basal creps
Heart sound(Third Heart sound?)

21. Investigations
Urine R/E
Serum Fasting lipid profile
S. Creatinine
S. TSH, S. FT4
(Hypothyroidism=diastolic hypertension
Thyrotoxicosis = ↑ systolic B)
ECG, Echo
Chest Xray
Serum electrolyte (in conn's syndrome- hypokalemic alkalosis)
*Resistance HTN:pheochromocytoma, conn's syndrome

22. HYPERTENSIVE URGENCIES
Hypertensive urgencies: BP >180/120 mm of Hg without any signs of end organ
damage.
RX,
1. Immediate hospitalization
2. Bed rest of 30 mins
3. Target: 25% reduction of BP in 24 hours but not lower than 160/90 mm of Hg
4. Drug:
Tab. Captopril 25mg
1 Tab stat and 2 hourly if necessary
Or,
Tab. Labetolal 200mg/400mg
1 tab stat and 4 hourly if necessary

23. HYPERTENSIVE EMERGENCIES
Hypertensive emergencies: BP>180/120 mm of Hg + evidence of impending or
progressive target organ damage such as
1.Hypertensive encephalopathy
2. Sovere shortness of breath
3.Prolonged chest pain
4. Acure MI
5. ALVF with pulmonary oedema
Rx,
1. Immediate hospitalization in ICU
2. In 1st hour:Inj. Labetolol 5mg/1ml
10ml slow IV over 1 minute stat and repeated after every 5 mins until reduction of
mean arterial pressure 25%
3. In next 2-6 hours:
Inj. Labetolol 5mg/1ml
10ml slow IV over 1 minute stat and repeated after every 5 mins until BP is
160/110 mm of Hg.