Medications for Hypertension |
| * Remember to emphasize lifestyle
modification (e.g., low-salt diet, regular physical activity, weight control,
off smoking, etc.) and medication
adherence. |
Diuretics
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Hydrochlorothiazide/Esidrix 12.5, 25, 50 mg tab/day
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Maxzide-25 (HCTZ 25 mg/ triamterene 37.5 mg) once/day
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Dyazide (HCTX 25 mg/ triamterene 50 mg) once/day
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Triamterene/Dyrenium 25-100 mg
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Ethacrynic acid (Edecrin)- Initial dose: 25 mg/day PO; range: 25–100
mg/day PO; 0.5-1 mg/kg IV (max 50 mg IV) for edema.
Only non–sulfa-based diuretic, an alternate diuretic in renal
insufficiency or sulfa-based diuretic allergy
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Aldactone (Spironolactone) 25, 50, 100 mg tab 2-3x/day; Potassium sparing,
watch for hyperkalemia, gynecomastia.
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Modurectic (amiloride 5 mg/ HCTZ 50 mg) once/day
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Amiloride HCl/Midamor 5-10 mg
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Lasix (Furosemide) 20, 40, 80 mg tab 1-2x/day PO or
IV
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Bumex (Bumetanide) 0.5, 1, 2 mg tablets; 0.5-2 mg once/day PO; IV
or IM 0.5- 1 mg initially (max=10 mg/d) ; 2-10 ml vials(0.25 mg/ml)
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Zaroxolyn (metolazone) 1.25-2.5-5 mg 1x/d
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Lozol (Indapamide) 1.25 - 2.5 mg tablet 1x/d
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ACE INHIBITORS - Angiotensin Converting Enzyme
Inhibitor
Indications: Patients with Hypertension, CHF, Kidney disease, Diabetes,
Cardiovascular disease, Heart Attack, Diabetes prevention, ? stroke.
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Lisinopril (Zestril/Prinivil) 5, 10,
20, 40 mg tablets Start 10 mg/d; usual dose 10-40 mg/d once daily
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Prinzide (Lisinopril/HCTZ) 10-12.5, 10-25,
20-12.5, 20-25 tab - 1-2 tab daily.
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Captopril (Capoten) 12.5, 25, 50, 100
mg tab 12.5-50 mg 2-3x/day; Max:100-150 mg 2-3x/d
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Benazepril (Lotensin) 5, 10, 20, 40 mg
tablets Start 10 mg/d; usual dose 20-40 mg/d once daily
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Cilazapril ( Inhibase) 1, 2.5, 5 mg tab
Initial dose 1.25-2.5 mg PO qd, usual dose 2.5-5 mg qd, Max 10 mg qd
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Enalapril (Vasotec) 2.5, 5, 10, 20 mg
tablets 2.5-20 mg/d once daily.
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Fosinopril (Monopril) 10 mg tablet Start
10 mg once/d; usual 20-40 mg/d once daily
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Moexipril (Univasc) 7.5,
15 mg tab. Start 7.5 mg qd PO, usual dose 7.5 - 30 mg/day (max 30
mg/d)
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Perindopril erbumine (Acceon) 4-8 mg
once daily
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Quinapril (Accupril) 5,10, 20, 40 mg
tab - Start 10 mg qd, usually 20-80 mg qd or in divided bid dose.
Max 80 mg/d
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Ramipril (Altace) 1.25, 2.5, 5, 10 mg
cap - Start with 2.5 mg once daily up to 20 mg/d (once or in 10 mg bid)
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Trandolapril (Mavik) 1, 2, 4 mg
table once daily.
ARB - Angiotensin II Receptor Blockers
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BETA
BLOCKERS
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Blocadren (Timolol) 5 10 20 mg tab usual dose 10 20 mg bid; max: 60
mg/d
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Brevibloc (Esmolol) 80 mg bolus over 30 sec, then 12 mg/min IV infusion
(150 ug/kg/min) for perioperative stress related tachycardia or hypertension.
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Coreg (Carvedilol) 3.125, 6.25, 12.5, 25 mg PO bid
for CHF or HTN.
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Corgard (Nadolol) 20 40 80 120 160 mg tab Start 40 mg once daily,
usual dose 40-80 mg/d upto 160-240 mg/d
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Inderal (Propanolol) 10 20 40 60 80 mg tab, 60 80 120 160 mg
LA cap 20 80 mg 2 3x/d
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Lopressor (Metoprolol) 50 100
mg tab; 5 ml (=5 mg) amp Initial dose 100 mg/d once or in divided doses;
Max<450 mg/d In early MI Rx, may give 5 mg IV bolus x3, then PO 50 mg
q6h x2d, then 100 mg bid PO as tolerated.
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Toprol XL (Metoprolol) 50 100 200 mg tab Initial dose: 50 100 mg/d;
max:<400 mg/d
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Normodyne (Labetalol) 100, 200, 300 mg tab. Start 100 mg bid,
usual dose 200-400 mg bid PO.
IV bolus 20 mg slowlyu over 2 min, additional 40 or 80 mg can be given at
10 min interval until desired BP achieved. Max. effect usually occurs
within 5 min of each injection. Max. dose 300 mg total IV. Half
life is 5-8 hours.
IV infusion 200 mg in 200 mL fluid at the rate of 2 mg=2mL/min, rate to be
adjusted to control BP, then stop IV infusion, & change to PO Labetalol
200-1200 mg bid
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Sectral (Acebutolol) 200 400 mg cap Start with 200 mg bid; optimal
PVC response 600 1200 mg/d. Use in elderly: doses >800 mg/d should be
avoided.
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Tenormin (Atenolol) 25 50 100
mg tablets . 50- 100 mg once/d
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Visken (Pindolol) 5, 10 mg tab. Start 5 mg bid, max. 60 mg/day
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Ziac (Bisoprolol) 2.5, 5, 10 mg with HCTZ 6.25 mg once
daily for BP
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| CA- BLOCKERS
Nondihydropytidines:
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Calan/Isoptin (verapamil) 80-120 mg tablets usual dose 80-120 mg tid
Calan SR/Isoptin SR (verapamil) 120-180-240 mg tablets usual dose 120-360
mg daily
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Cardizem (diltiazem) 30-60-90-120 mg tablets tid PO or
Injectable IV bolus for control of heart rate in atrial fibrillation or flutter.
Start with 0.25 mg/kg (ave=20 mg), may repeat in 15 min with 0.35 mg/kg (ave=25
mg), then infusion 5-15 mg/hr up to 24 hr. Onset: 3 min Duration
1-3 hr.
(*** Not to be used in WPW or short PR syndrome. Caution should be used in
CHF pts.)
Cardizem CD (diltiazem) 180- 240- 300 mg cap 1 cap daily
Cardizem SR (diltiazem) 60- 90- 120 mg cap
Dilacor XR (diltiazem) 180- 240 mg cap
1 cap daily
Tiazac (Diltiazem) 120, 180, 240, 300, 360 mg extended release cap for BP
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Posicor/mibefradil (T-channel Ca antagonist) 50-100 mg
Dihydropyridines:
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Cardene (nicardipine) 20 -30 mg capsules 20- 30 mg tid
Cardene SR (nicardipine) 30- 45- 60 mg capsules 30- 45 -60 mg 1 cap bid
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DynaCirc (isradipine) 2.5- 5 mg capsules 2.5 5 mg bid
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Nimotop (nimodipine) 30 mg cap 60 mg q4h PO for 21 days, preferably >1h
before or 2h after meal.
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Norvasc (Amlodipine) 2.5, 5,
10 mg tab. Usually 5-10 mg/day
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Plendil (felodipine) 5- 10 mg tablets
Start 5 mg/d once a day; usual dose 5 10 mg/d; max 20 mg/d
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Procardia (nifidipine) 10 -20 mg cap 10 -20 mg tid, up to 20- 30 mg 3 4x/d.
Procardia XL (nifidipine) 30- 60- 90 mg tablets. usual dose
30- 90 mg once daily
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Sular (Nisoldipine) 10, 20, 30, 40 mg tab once/day.
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ALPHA ADRENERGIC BLOCKERS
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Cardura (Doxazosin mesylate) 1 2 4 8 mg tab Start with 1 mg, dose:1
16 ng once daily
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Hytrin (Terazosin) 1-
2- 5 mg tab Start 1 mg/d, usual dose 1- 5 mg once a day; max: 20 mg/d
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Minipress (Prazosin) 1- 2- 5 mg cap Start 1 mg 2- 3x/d, usual dose
up to 20 mg/d in divided doses.
Combined
alpha- & Beta-blockers:
Central
alpha-agonist
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Clonidine/Catapres 0.2-1.2 mg/day; or
Catapres-TTS-1, -2, -3 patch weekly
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Methyldoma/Aldomet 500-3,000 mg/day
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Guanabenz/Wytensin 8-32 mg/day
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Guanfacine/Tenex 1-3 mg/day
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Direct
Vasodilators
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Hydralazine/Apresoline 50-300 mg/day
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Minoxidil/Loniten 5 - 100 mg/day
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Nitroglycerin 2.5, 6.5, 9 mg cap bid
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Peripheral agents
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Reserpine/Serpasil 0.1,0.25,1.0 mg tab. Usual dose 0.1-0.5 1-2x/d;
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Hydropress-25 (reserpine 0.125 mg + Hctz 25 mg );
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Guanadrel/Hylorel 10-75 mg/day
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Guanethidine/Ismelin 10-150 mg/day
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| Hypertension
Crisis
Definition
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Severe elevation in blood pressure, with diastolic blood pressure (DBP) >
120-130 mmHg.
-
Hypertensive Emergency is defined as
a clinical setting where BP must be reduced effectively within minutes to
<1hour, such as
accelerated & malignant hypertension, hypertensive encephalopathy, &
severe diastolic hypertension (120-160 mmHg) that is associated with
acute pulmonary edema, ischemic chest pain, dissecting aortic aneurysm, or
intracerebral hemorrhage, papilledema (+/ ), evidence of renal function
deterioration, or evidence of neurologic dysfunction, etc.
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Hypertensive Urgency is defined as a clinical setting
of severe hypertension with minimal
or no symptoms, where severe elevation of BP are not causing
immediate end-organ damage but should be effectively lowered within 24 hours
to reduce potential risk to the patient.
Symptoms as:
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Headache, Visual Changes, Papilledema
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Chest Pain (MI), Pain to Back (Dissection)
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Abdominal Pain - abdominal aneurysmal dissection
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Flank Pain - renal disease
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Mental Status Changes - stroke, leukoencephalopathy
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| ACP PIER 2006
Approach to Hypertensive
Emergency/Crisis
Distinguish between a hypertensive emergency and a pseudocrisis in patients
with markedly elevated BP.
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Do not use parenteral or sublingual drugs to treat markedly elevated BP
(>180/110 mm Hg to 220/120 mm Hg) in the absence of symptoms or progressive
target organ damage.
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Use the following treatment approaches:
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Administer one or more rapid-onset oral antihypertensive
drugs (e.g., furosemide, propranolol, captopril, clonidine, or
nicardipine);
once BP is less than 180/110 mm Hg, administer a longer-acting
formulation and recheck the BP within 48 hours.
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Administer a longer-acting oral formulation from the start and recheck BP
in 48 hours.
Identify when a hypertensive BP reading may constitute an emergency.
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Measure BP repeatedly and assess the possibility of ongoing or imminent target
organ damage.
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Consider hospitalizing a patient with hypertensive emergency for parenteral
antihypertensive medication when BP is sufficiently
elevated to cause target organ damage (imminent) or is judged to have caused
or played a role in present (ongoing) target organ damage.
Specifically, considering hospitalizing hypertensive patients
with:
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Coronary disease and crescendo angina
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Heart failure with increasing shortness of breath
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Abrupt worsening of renal function
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Headache, blurred vision, and increasing disorientation or confusion
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Past hypertensive end-organ damage
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Recent vascular surgery
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Organ transplantation
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Known aortic aneurysm or a tearing sensation between the scapulae
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A child with previously normal BP may have a hypertensive emergency at a
BP not considered particularly worrisome in an adult. Use clinical judgment
to determine need for hospitalization.
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A pregnant woman with previously normal or low BP may have a hypertensive
emergency at a BP not considered particularly worrisome in a nonpregnant
adult. Use clinical judgment to determine need for hospitalization.
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Measure the BP more than once or twice and carefully track it before declaring
an “emergency.” The duration of this tracking will vary according
to clinical presentation.
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Monitor the BP in a setting where intravenous antihypertensive drugs can
be given rapidly.
Quick Exam in Severe Hypertension Yes or No
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Are pressures equal in the arms?
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Are femoral pulses present?
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Is grade III or IV retinopathy present?
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Is the patient oriented?
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Are pupils equally dilated?
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Is the neck stiff?
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Are rales or an S3 present?
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Are abdominal bruits present?
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Are there overt neurologic deficits?
Quick History in Severe Hypertension Yes or No
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Was antihypertensive therapy recently interrupted?
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Are neurologic symptoms present?
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Were they sudden in onset: i.e., over minutes to hours?
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Did they occur gradually over days?
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Is severe headache present?
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Have visual disturbances occurred?
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Has nausea or vomiting occurred?
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Is severe dyspnea present?
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Is the patient pregnant?
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Does the patient have worsening angina?
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Is the patient post- vascular surgery (including CABG)?
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Has the patient taken sympathomimetics or cocaine?
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Is the patient taking a MAOI antidepressant ?
Situations In Which Severe Hypertension Constitutes
a Crisis
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Heart/Vascular
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Left ventricular failure
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MI
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Unstable angina
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After vascular surgery or CABG
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Aortic dissection
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Brain
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Hypertensive encephalopathy
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Subarachnoid hemorrhage
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Intracranial hemorrhage
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Thrombotic stroke with severe hypertension
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Miscellaneous
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Severe catecholamine excess:
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Pheochromocytoma
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Clonidine withdrawal
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Tyramine/MAOI interaction
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LSD/cocaine/phencyclidine/phenylpropanolamine use
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Eclampsia in pregnancy
Antihypertensive Agents That Are Useful in Hypertensive Crises to guide
treatment of patients with:
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Markedly elevated BP and high intracranial pressure
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Progressive azotemia
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Coronary ischemia
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Acute left ventricular failure
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Eclampsia
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Suspected aortic dissection
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Catecholamine excess
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Suspected aortic dissection, and in the perioperative setting
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EMERGENCY TREATMENT
OF HYPERTENSIVE CRISIS
Antihypertensive Agents That Are Useful in Hypertensive Crises
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Nitroprusside (Nipride) IV
Initial dose 0.3 µg/kg/min (Max dose 10µg/kg/min) Onset of action
<1 minute, duration <2 minutes
Best use for Encephalopathy, left ventricular failure, aortic dissection
(with ?-blocker)
Major side effects: Cyanide/thiocyanate toxicity (thiocyanate level>10
mg/dl is toxic; >20 mg/dl may be fatal) ; hypotension, N&V, apprehension,
convulsion, twitching, psychosis, dizziness, etc. It
has decreased efficacy in renal failure
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Nitroglycerin IV
Initial dose 5 µg/min (Max dose 100 µg/min) Onset of action <5
minutes, duration <5 minutes
For use for Unstable angina, MI. Excellent for titrating blood pressure
in setting of coronary ischemia
Major side effect: headache, tachycardia, vomiting, methemoglobinemia
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Labetalol (Trandate) IV
Mixed alpha/beta blocker, excellent for most
hypertensive emergencies.
First or second line for eclampsia; excellent
in catecholamine surges
Initial dose :20 mg IV bolus over 2 minutes, then 20- 80 mg q10 min
prn, or Continuous infusion at 0.5-2.0 mg/min (Max dose 300 mg),
Onset of action <5 minutes, duration 1-4 hours, but variable
Best use for Stroke, intracranial hemorrhage
Side effects: Nausea Fatigue, dizziness, scalp tingling
Contraindication: Asthma or bronchospasm, overt cardiac failure,
>first-degree heart block, severe bradycardia
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Diazoxide (Hyperstat) IV
Initial dose: 1-3 mg/kg (up to 150 mg) IV bolus q5-15 min over 5 minutes
until BP is controlled (Max dose 600 mg),
Onset of action <2 minutes, duration 6-12 hours
Side effects: — Profound hypotension Elevated heart rate, elevated glucose,
sodium retention
Contraindication: Thiazide allergy
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Nicardipine (Cardene) IV
Initial dose: 5 mg/h (Max dose 15 mg/h), Onset of action <1 hour, duration
<1 hour
Best use for Vascular surgery, subarachnoid hemorrhage
Side effects: Headache ,Elevated heart rate
Contraindication: Severe aortic stenosis
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Enalapril (Vasotec) IV
Highly variable response; precipitous BP drop in high-renin states, rarely
angioedema, hyperkalemia, or acute renal failure.
Initial dose: 1.25 -5mg IV over 5 min q6h if needed, duration 6 hours
Best use for Left ventricular failure
Contraindication: Angioedema
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Diltiazem (Cardizem) IV
Initial dose 0.25 mg/kg over 2 min, followed by infusion of 0.35 mg/kg at
an initial rate of 10 mg/hour
Onset: 3-30 min
Adverse effects: excessive hypotension, flushing
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Trimethaphan
Initial dose: 1 mg/min (Max dose 4 mg/min), Onset of action <5 minutes,
duration <10 minutes
Best use for Aortic dissection (with ?-blocker)
Side effect: Orthostatic hypotension
Contraindication: Severe volume depletion
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Hydralazine (Apresoline) IV
Indicated primarily for eclampsia
Dose is 10-50 mg IV or IM titrate to effect (onset <20 minutes, duration
3-8 hours)
Can be given IM as well, 10-50mg (onset 20-30 minutes)
Onset: 10- 20 min ; Duration: 3 -8 h
Adverse effects: tachycardia, flushing, contraindicated in angina or aortic
dissection
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Phentolamine
Mainly for catecholamine surges as in
pheochromocytoma hypertension (pure
alpha-adrenergic blockade)
Dose is 5-15mg IV; onset 1-2 minutes; duration 3-10 minutes
Side effects: Tachycardia, flushing and headache may occur
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Esmololol (Breviblock®)
Mainly for acute aortic dissection, perioperatively, acute coronary
ischemia
May be used with caution in acute MI with depressed LV to modulate heart
rate
Very short half life (2-4 minutes) non-selective ß-blockade
Dose is 250-500µg/kg/min for 1 minute, then 50-100µg/kg for 4
minutes
Sequence may be repeated, and continuous drip may be maintained
Onset of action is 1-2 minutes; 10-20 minute duration
Very close monitoring is required, and fluid load is large with this agent
Oral Medications for Hypertensive
Urgency:
-
Clonidine (Catapres)
0.2 mg PO, followed by 0.1 mg/hr to total of 0.8 mg until the diastolic
BP is <110 mmHg, or reduction in diastolic BP of 20 mmHg or more.
Onset 30-120 min; Duration 8-12 h
Adverse effects: sedation, dry mouth, dizziness, orthostasis, bradycardia
Contraindicated in pts with sinus bradycardia, sick sinus synd., or heart
block.
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Labetalol (Trandate)
200-300 mg PO, followed by 100-200 mg q8h
Onset 1-2h; Duration 12-24 h
Adverse effects: bradycardia
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Furosemide (Lasix)
20-40 mg PO or IV
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Nicardipine (Cardene)
20-40 mg PO tid (Max 120 mg/day) or IV 5 mg/h, increase by 2.5 mg/h q5-15
min to max 15 mg/h.
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Captopril (Capoten)
12.5-25 mg PO ,may repeat at intervals of = or > 30-60 min (Typical dose
<150mg/d; Max 450 mg/d)
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Distinguish between a hypertensive emergency and a pseudocrisis in patients
with markedly elevated BP.
-
Do not use parenteral or sublingual drugs to treat markedly elevated BP
(>180/110 mm Hg to 220/120 mm Hg) in the absence of symptoms or progressive
target organ damage.
-
Use the following treatment approaches:
-
Administer one or more rapid-onset oral antihypertensive
drugs (e.g., furosemide, propranolol, captopril, clonidine, or
nicardipine);
once BP is less than 180/110 mm Hg, administer a longer-acting
formulation and recheck the BP within 48 hours.
-
Administer a longer-acting oral formulation from the start and recheck BP
in 48 hours.
In less than hypertensive crises, but in
hypertension urgency:
one or more rapid-onset oral antihypertensive drugs, as:
-
Furosemide (Lasix) 20-40 mg PO or IV
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Clonidine 01.-0.2 mg PO
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Nicardipine (Cardene) 20-40 mg PO tid (Max 120 mg/day) or IV 5 mg/h, increase
by 2.5 mg/h q5-15 min to max 15 mg/h.
-
Captopril 12.5-25 mg PO ,may repeat at intervals of = or > 30-60 min (Typical
dose <150mg/d; Max 450 mg/d)
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Causes of
Hypertensive Crisis
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Chronic hypertension with acute exacerbation (most
common)
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Renovascular hypertension
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Parenchymal Renal Disease
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Acute glomerulonephritis
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Renal Infarction
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Vasculitis
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Scleroderma Renal Crisis
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Drug Ingestion
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Tricyclic anti-depressants
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Monoamine Oxidase (MAO) Inhibitors
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Cocaine
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Amphetamines
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Anti-hypertensive drug withdrawal or failed
compliance
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Centrally acting anti-hypertensives (eg. clonidine)
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Peripheral alpha blockers (eg. prazosin)
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Beta-Blocker acute withdrawal
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Pre-eclampsia and Eclampsia
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Autonomic hyperactivity
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Guillain-Barre Syndrome
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Spinal Cord Injury
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Pheochromocytoma
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