KORI LAWIE, PHARM. D CANDIDATESARAH DAOUD, PHARM. D

CANDIDATE PRECEPTOR: DR. THOMAS

ROBERTSON

Hypertension CasePresentation

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Objectives

Case Overview

Define hypertension

Discuss diagnostic criteria

Identify the pathophysiology of hypertension

Identify the pathophysiology of NIDDM

Discuss treatment strategies for hypertension

Evaluate and assess the patient’s current drug therapy

Discuss pharmacist’s care plan

Discuss counseling points

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Chief Complaint

“ I’m just here for my regular check-up”

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Past Medical History

NIDDM for past six years

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History of Present Illness

JB is a 46 year old AA man who presents to his local physician for routine check-ups. His only complaint is mild SOB when walking long distances or up a flight of stairs.

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Social History Family History

Smokes 8 cigarettes a day

No known drug or alcohol problems

Both parents had hypertension

NIDDM in one older sister, younger brother, two aunts (deceased), and mother

Mother has a CRI and had a CVA several yrs ago

Father died of MI at 54yrs old

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Medications

He was initially managed with Glipizide 10mg po BID Advil 2-3 tabs po PRN

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Current Presentation

General Patient is a WDWN AA man in no acute distress.

ROSNon-contributory

HEENTPERRLA: EOMI; mild arteriolar narrowing, with AV ration 1:3; no hemorrhages, exudates, or papilledema; TMs intact; oral mucosa clear

PulmClear to A&P

CVRRR, no murmurs, S3 gallop noted

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Abd+BS, NT/ND, no masses, no bruits

ExtNo CCE; pulses 2+ throughout

NeuroCranial nerves grossly intact; DTRs 2+; sensory and motor levels intact; toes downgoing

UANegative; no microalbuminuria present

EchocardiogramIncreased size of the left ventricle; ejection fraction 0.40

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Vital Signs

Pulse 84

RR 13

Temp 37.1 C

Ht 173 cm

Wt 95.5 kg

BP 146/101

Lab Values

Potassium 4.6 mEq/L

Chloride 109 mEq/L

CO2 Content 26 mEq/L

BUN 26 mg/dL

Serum Creatinine

1.2 mg/dL

Glucose (Fasting)

240 mg/dL

Sodium 142 mEq/L

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Definition: Hypertension

A medical condition in which the pressure in the arteries are elevated.

Hypertension is considered after the BP reaches 140/90 mm Hg or higher or when pt is on antihypertensive drug therapy.

Blood pressure is measured in two ways: Systolic Diastolic

Diagnosis

Periodic screening for all individuals older than 21 years

Patient seated quietly in chair for at least 5 minutes

Use appropriate cuff size (bladder length at least 80% the circumference of the arm).

Take BP at least 2 times, separated by at least 2 minutes.

The average BP on two separate visits is required to diagnose hypertension accurately.

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Pathophysiology: Hypertension

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Pathophysiology: NIDDM

Algorithm for Treatment

Classes of Anti-HypertensivesClass

Mechanism of Action

Examples Cost

Beta Blockers

Antagonize the beta-adrenergic receptors in the heart

Propanolol (Inderal®)Carvedilol (Coreg®)Metoprolol (Lopressor®)

$28-$40

Calcium Channel Blockers

Non-Dihydropyridines:Inhibits calcium ion from entering the “slow channels” or select voltage-sensitive areas of vascular smooth muscle and myocardium

Diltiazem (Cardizem®)Verapamil (Calan®)

$27-$45

Dihydropyridines:Inhibits calcium ion from entering the “slow channels” or select voltage-sensitive areas of vascular smooth muscle

Amlodipine (Norvasc®)Nifedipine (Procardia®)Felodipine (Plendil®)

$27-$45

Classes of Anti-Hypertensives

Class Mechanism of Action

Examples Cost

Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors)

Inhibits the activity of the enzyme ACE, which decreases the production of angiotensin II. As a result, the blood vessels enlarge or dilate, and blood pressure is reduced.

Prinivil (Lisinopril®) Benazepril (Lotensin®)Enalapril (Vasotec®)

$30-$90

Angiotensin Receptor Blockers (ARBs)

Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II

Olmesartan (Benicar®) Valsartan (Diovan®)Losartan (Cozaar®)

$50-$80

Classes of Anti-Hypertensives

Class Mechanism of Action

Examples Cost

Alpha Antagonists

Antagonize the alpha receptors exhibiting a peripheral-vasodilating effect

Hydralazine (Apresoline®)Clonidine (Catapres®)Methyldopa (Aldomet®)

$15-$29

Nitrates Improves the contractile state in smooth muscle by stimulating guanylate cyclase through formation of free radical nitric oxide thus causing vasodilation.

Nitrogylcerin (Nitrostat®)

$25-35

Classes of Anti-Hypertensives

Class Mechanism of Action

Examples Cost

Diuretics

Loop Diuretics:Inhibits the Na+/K+/2Cl- co-transporter in the thick ascending loop of Henle in the kidneys.

Furosemide (Lasix®)Torsemide (Demadex®)Bumetanide (Bumex®)

$10-$30

Thiazide Diuretics:Decrease active re-absorption of sodium and chloride ions by inhibiting the sodium/chloride co-transporter in the distal convoluted tubule

Hydrochlorothiazide (Microzide®)Methylclothiazide (Enduron®)

$10-$30

Classes of Anti-Hypertensives

Class Mechanism of Action

Examples Cost

Diuretics

Thiazide-Like Diuretics:Sulfonamide-derived diuretic that inhibits sodium and chloride reabsorption in the cortical-diluting segment of the ascending loop of Henle

Chlorthalidone (Thalitone®)Indapamide (Lozol®)

$10-$35

Osmotic Diuretics:Promotes diuresis by increasing osmolarity and therefore blocking the tubular reabsorption of water

Mannitol(Osmitrol®)

$7-$32

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DRUG THERAPY ASSESSMENT

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Drug Therapy Assessment

Type of Problem Assessment

Correlation between Drug Therapy and Medical Problems

No therapy for hypertension and hyperlipidemia in place

Appropriate Drug Selection Glipizide alone not effective for NIDDM

Drug Regimen Regimen for Glipizide inappropriate

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PHARMACIST CARE PLAN

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Pharmacist Care plan

Health Care Problem

Priority

Therapeutic goals

Recommendation of therapy

Monitoring Parameters and endpoints

Heart Failure

1 • Correct blood pressure

• Increase urine output

• Blood pressure medication

• Use of diuretic

• EF >40%• BP < 130

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Pharmacist Care plan

Health Care Problem

Priority

Therapeutic goals

Recommendation of therapy

Monitoring Parameters and endpoints

NIDDM 2 • Slow the disease process

• Insulin• Diet • Exercise• Take

medications properly

• Daily blood glucose readings

• A1C• Symptoms

of Hyper or Hypoglycemia

• Blood Glucose levels

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Pharmacist Care plan

Health Care Problem

Priority Therapeutic goals

Recommendation of therapy

Monitoring Parameters and endpoints

Hypertension

3 • Blood pressure at

or below 140/80

• Lisinopril 10mg PO

• Indapamide 1.25mg PO

• DASH diet

• Supervised exercise regimen

• Smoking cessation

• Blood pressure

• BMI

• Weight

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Pharmacist Care plan

Health Care Problem

Priority

Therapeutic goals

Recommendation of therapy

Monitoring Parameters and endpoints

Hyperlipidemia

4 • Decrease LDL’s

• Total Cholesterol

• Pravastatin 20mg

• Smoking cessation

• AST• ALT• Creatinine

Kinase

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Counseling Tips

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Counseling Tips Cont.

Monitor hyper- and hypoglycemiaClean injection site (abdomen preferred)Weight Gain Insulin at BedtimeTake ACE inhibitor, Statin, and diuretic in the morning

with full glass of H20.Reduce sodium intake to less than 1.5gms per day. Incorporate fruit and vegetables into dietPhotosensitivityS/E of PravacholSmoking is a major risk factor

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References

1. DiPiro, Joseph T., Robert L. Talbert, et al. “Pharmacotherapy, A Pathophysiologic Approach (Chapter : Hypertension)”. 7th. 7. New York: McGraw-Hill, 2008. 185-217. Print.

2. Feher, Michael D., et al. Hypertension in non-insulin dependent diabetes mellitus and its management. Postgrad Med J (1990) 67, 938-946

3. Galloway, John A., et al. Treatment of NIDDM with insulin agonists or substitutes. Diabetes Care, Vol. 13. No. 12, December 1990.

4. Disertori M, Latini R, Barlera S, et al. Valsartan for prevention of recurrent atrial fibrillation. N Engl J Med. 2009;360(16):1606-17.

5. Sacks FM, Campos H. Dietary therapy in hypertension. N Engl J Med. 2010;362(22):2102-12.

6. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report.2003 May 21; 289(19) :2560-71 

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QUESTIONS?