Shared Flashcard Set

Details

CKD HTN
Cardone again
19
Pharmacology
Graduate
01/30/2010

Additional Pharmacology Flashcards

 


 

Cards

Term
What are the causes of HTN?
Definition

Primary - Essential HTN

Secondary - CKD, Coarctation of the aorta

Term
What are some contributing factors to HTN in CKD?
Definition

- Sodium and Volume

- Increased vasoconstrictor activity

- Decreased vasodilator activity

- EPO use

- PTH and Ca

- Structure changes in arteries

- Primary HTN

- Renovascular Dz

- Others......

Term
What causes resistant HTN?
Definition

- Improper measurement of BP

- Fluid overload due to non-adherence of fluid restriction or dialysis regimen

- Medication-related (sub therapeutic, wrong-med, side effect)

- Obesity and excess EtOH intake

Term
What medications could be held responsible for inducing HTN?
Definition

- NSAIDS

- Corticosteroids

- Calcineurin inhibitors - transplant medications (cyclosporin)

- Sympathomimetics

- ESA's

- Oral Contraceptives

- Ilicit drugs like cocaine or amphetamines (maybe crystal meth?)

- Certain herbal/supplements

Term
What are the JNC7 Guidelines?
Definition

- PreHTN, Stage I, Stage II

- Goal BP is <140/90 or <130/80

- Treatment 1st line, compelling indications

Term
What are the compelling indications and corresponding drug classes for JNC7?
Definition

 

Compelling Indication

Preferred 1st Line Agents

 Heart failure

THIAZ, BB, ACEI, ARB, ALDO ANT

Post myocardial infarction

BB, ACEI, ALDO ANT

High CVD risk

THIAZ, BB, ACEI, CCB

Diabetes

THIAZ, BB, ACEI, ARB, CCB

Chronic kidney disease

ACEI, ARB

Recurrent stroke prevention

THIAZ, ACEI

Term
To quickly review.....what are the BP goals and first line agents in a CKD patient?
Definition

BP Goal < 130/80mmHg

First line:  ACEi or ARB

Term
In stages 1-5 of CKD, what are the guidelines of treatment as set forth by JNC7?
Definition

 Goals of Tx:  Dec. BP, Prevent Progression of CKD, Prevent CV events

BP Goals - 130/80 mmHg

Non-pharmacological interventions

First line:  ACEi or ARB if DM or proteinuria plus a diuretic in most

Term
What are the treatment goals at stage 5D of CKD?
Definition

BP Goal:  Go as low as you can go before patient becomes hypotensive

Dialysis:  PreHD 140/90

Post HD 130/80

Non-Pharmacological:  Fluid management, sodium restriction

First line agents:  ACEi/ARBs despite little/no kidney to preserve, still have CV protective effects, cardiac remodeling, regression of LVH

Term
What is the 2009 approach to CKD HTN?
Definition

 

¨Stage I HTN
1.Lifestyle
2.Add 1 drug (ACEi, ARB, CCB, Diuretic)
3.Add 2nd drug (ACEi, ARB, BB, CCB, Diuretic)
4.Add 3rd drug (Adherence; Optimize doses)
¨Stage II HTN
1.Lifestyle + 2 Drugs
2.3rd drug, (Adherence, optimize)
3.4th drug (Address EtOH and salt)
4.Look for 2ndary causes
For one more additional compelling indication, give a BB, or CCB for angina pectoris
Term
What is important regarding thiazide diuretics?
Definition

- Offer CV protection

- Used if GFR >30ml/min

- May be used to enhance fluid removal with loop diuretics

- Dose in the AM

- exacerbate gout, hyperglycemia/DM

 

Loops:  Furosemide, Bumetanide, Torsemide; primarily used for fluid management, high doses usually in later stages of CKD, used as adjunctive agents or in treatment of hyperkalemia

Term
What are some things to consider in Dialysis?
Definition

- Removal of drugs

- Intradialytic Hypotension

- EDW

- "Non-dipping"

- Timing of medications around dialysis

Term
What are some considerations in the Dialysis removal of drugs?
Definition

- Molecular weight/size

- Protein binding

- VD

- Water Solubility

- Plasma Clearance

- Dialysis membrane

- Blood and Dialysate flow rates

- Several BP medications can be removed by HD

 

Term
What's the deal with intradialytic hypotension?
Definition

Non-pharmacological

- Adherence with fluid restriction, Sodium/UF profiling, Extended dialysis sessions

 

Pharmacologic Approaches

- Midodrine, Carnitine, Sertaline

Term
What is non-dipping in Dialysis?
Definition
Non-dipping - Typically patients will have a lower blood pressure at night.  CKD patients do not do this and it is a major risk for Cardiovascular events.
Term
How do we time medications around Dialysis?
Definition

- Evening preferred for most antihypertensives

- If hypotensive during HD:  Hold meds prior, more info to come (Dr. Mason in next lecture or so?)

- If on Diuretics dose in AM if possible

- Very confusing scheduling

Term
What is special about Transplant patients?
Definition

- Usually on corticosteroids with Calcineurin inhibitors, will raise BP

- Goal BP is 130/80

- KDOQI recommended agents:  CCB, Diuretic, ACEi, ARB, BB

- In terms of Graft loss and transplant kidney function, CCB's were best when treating HTN.

- More studies are needed

- ACE/ARB used in proteinuria

- Other agents could be necessary to control BP

 

Term
What are the key points to remember in CKD patients with HTN?
Definition

 

Hypertension…

¨Is common among those with CKD
¨Increases risk of CV events

¨ACE/ARB Inhibitors are cornerstone therapies for patients with CKD (esp DM / proteinuria)
¨Fluid/Sodium management is imperative in patients with CKD.
¨Methods to improve adherence should be implemented by all clinicians.
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