Prescribing for Hypertension Case 2B Brillantes – del Rosario

Prescribing for Prescribing for Hypertension Hypertension Case 2BCase 2BBrillantes – del Rosario

GUIDE to GOOD GUIDE to GOOD Prescribing Prescribing Define the Patient’s ProblemSpecify the Therapeutic ObjectiveChoose an appropriate

TreatmentWrite a Prescription and/or Start

treatmentGive Information, Instructions

And WarningsMonitor the Patient

Defining the Patient’s Defining the Patient’s ProblemProblem

General Data & Chief General Data & Chief ComplaintComplaintMr. Paprika, 40/MLiving in ManilaReferred for “high blood”

Defining Patient’s Problem

History of Present IllnessHistory of Present Illness

Good functional capacity until...

1 mo. PTC – At private preemployment consult, BP was 180/90 mmHg. Prescribed unrecalled meds, did not take.

1 day PTC – BP at local clinic was 170/90 mmHg.


Review of SystemsReview of Systems

(-) fever, weight loss, nausea(-) headaches, dizziness, syncope,

seizure(-) BOV, PND(-) exertional dyspnea, orthopnea,

cough(-) palpitations, chest heaviness(-) abdominal pains, vomiting(-) oliguria, dysuria(-) edema, paresis, paresthesias


Past Medical HistoryPast Medical HistoryType 2 diabetes mellitus –

diagnosed July 2008, on metformin 500 mg BID

No Hx of PTB, asthma, allergies, thyroid disorders, gout


Family Medical HistoryFamily Medical HistoryFather – hypertension, suffered

MI at 45 years old, still alive?


Personal & Social HistoryPersonal & Social HistorySales managerMarried, with 2 childrenDenies smoking, alcohol

consumption, illicit drug useNo food preferences


Physical ExaminationPhysical Examination

General | conscious, coherent, not in distress

Vital Signs | BP 180/90, HR 76/min, RR 12/min, T 37.1°C

HEENT| anicteric sclerae, pink conjunctivae, (-) CLAD, JVP = 4 cm at 30 deg, (-) carotid bruits

Chest & Lungs |equal chest expansion, no rales or wheezes

Heart | good S1, AB-PMI at 6th ICS L MCL, normal & regular HR and rhythm, (-) S3 or murmurs


Physical ExaminationPhysical Examination

Abdomen | round, soft, normoactive bowel sounds, (-) tenderness or organomegaly

Extremities | full, equal pulses w/ pink nail beds, no edema

Neurologic|20/20 vision by Snellen chart; on fundoscopy – normal AV ratio, no AV nicking or hemorrhages


Laboratory and Imaging Laboratory and Imaging StudiesStudiesCBC & chemistries | all w/in normal

limitsUrinalysis | USG = 1.020, pH = 6.0, (-)

sugar, +1 proteins, WBC 0-1, RBC 0-1, (-) casts/crystals

EKG | sinus rhythm, normal axis, LVH

CXR PA & Lateral | cardiomegaly, LVH form


Problem ListProblem ListType 2 diabetes mellitusEssential hypertension, grade 3 –

very high added risk


Specify the Therapeutic Specify the Therapeutic ObjectiveObjective

Therapeutic ObjectivesTherapeutic Objectives

1. Control the hypertension. Target BP <130/80 mmHg.

2. Control blood sugar. Target FBS <7.0 mmol/L.

3. Minimize existing target organ damage and prevent development in other organs.

4. Avoid unhealthy lifestyle choices.

Specifying Treatment Objectives

Choose an Appropriate Choose an Appropriate TreatmentTreatment

Antihypertensive DrugsAntihypertensive DrugsACE inhibitorAlpha BlockersARBsBeta bl0ckersCCBsThiazide Diuretics

Choosing the Right Treatment

Mechanisms of ActionsMechanisms of ActionsACE inhibitors

◦Block the conversion of angiotensin I to angiotensin II by inhibiting angiotensin converting enzyme (ACE)

Alpha-blockers◦Lower by by reducing the peripheral

resistanceAngiotensin II antagonists

◦Block type I angiotensin II receptors


Mechanism of ActionMechanism of ActionBeta-blockers

◦Competitive antagonists of the effects of catecholamines at beta-adrenergic receptor sites

Thiazide Diuretics◦Blocks renal tubular reabsorption of

Na leading to urinary Na loss


Mechanism of ActionMechanism of ActionCalcium Antagonists

◦Inhibit the cellular influx of Ca which is responsible for maintenance of the plateau phase of the action potential

◦The cells they affect are typically the vascular smooth muscle, myocardial cells and cells within the SA and AV nodes

◦They dilate coronary and peripheral arteries with little or no effect on venous tone, have a-ve inotropic action, reduce HR and slow AV conduction


Drugs Efficacy Safety Suitability Cost (Php per day)

ACE inhibitors 4 3 4 1-30

Alpha blocker 2 (not enough

studies)

2 (postural

hypotnsn)

3 (increasing dose)

ARBs 4 4 4 10-50

Beta blockers 3 2 (diabetogenic)

0(contraindicated in

DM)

16-20

CCB: 3 2 (diabetogenic)

0(interaction w/

metformin)

15-25

Thiazide Diuretics 3 2 (diabetogenic)


DM)

4-8




studies)

2 (postural

hypotnsn)

3 (increasing dose)

ARBs 4 4 4 10-50



DM)

16-20


0(interaction w/

metformin)

15-25



DM)

4-8




studies)

2 (postural

hypotnsn)

3 (increasing dose)

ARBs 4 4 4 10-50



DM)

16-20


0(interaction w/

metformin)

15-25



DM)

4-8




studies)

2 (postural

hypotnsn)

3 (increasing dose)

ARBs 4 4 4 10-50



DM)

16-20


0(interaction w/

metformin)

15-25



DM)

4-8




studies)

2 (postural

hypotnsn)

3 (increasing dose)

ARBs 4 4 4 10-50



DM)

16-20


0(interaction w/

metformin)

15-25



DM)

4-8

P-DrugP-DrugACE INHIBITORSARBs


ACE InhibitorsACE InhibitorsCaptoprilEnalaprilLisonopril


Drug Efficacy Safety Suitability Cost (per day)

Captopril 4 3 2 (BID and patient is

noncompliant)

1-2

Enalapril 4 3 4 10-30

Lisonopril 4 3 4 30



noncompliant)

1-2


Lisonopril 4 3 4 30



noncompliant)

1-2


Lisonopril 4 3 4 30

Angiotensin Receptor Angiotensin Receptor BlockersBlockersLosartanTelnisartanValsartan


Drug Efficacy Safety Suitability Cost

Losartan 4 4 4 8-20

Telnisartan 4 4 4 40

Valsartan 4 4 4 40


Losartan 4 4 4 8-20


Valsartan 4 4 4 40


Losartan 4 4 4 8-20


Valsartan 4 4 4 40


Losartan 4 4 4 8-20


Valsartan 4 4 4 40

Write a PrescriptionWrite a PrescriptionStart TreatmentStart Treatment

PrescriptionPrescriptionPrescription and Starting Treatment

Giving of Information, Giving of Information, Instructions and WarningsInstructions and Warnings

Effects of the drug:◦Why the drug is needed: “Mr. Paprika,

you have to take these drugs because these will control your high blood pressure.”

◦Which symptoms will disappear and which will not: “BP will be lowered and should last for about 24 hours.”

◦What will happen if the drug is taken incorrectly or not at all: “ The hypertension will persist and can result to further organ damage and other complications.”

Infos, Instructions, Warnings

Side effects:◦Which side effects may occur:

“Captopril may cause persistent dry cough, dizziness, fatigue, headache, abdominal pain, and skin reactions. Losartan may cause dizziness, runny nose, sore throat and back pain.”

◦What action to take: “Inform the doctor/me.”


Instructions◦How the drug should be taken; when it

should be taken; how long the treatment should continue– “For Captopril, you have to take ½ tablet orally twice a day. It should be taken on an empty stomach 1 hour before or 2 hours after meals: breakfast and dinner. For Losartan, you have to take 1 tablet orally once a day with or without food. Continue the treatment for 2 weeks”.

◦How the drug should be stored: “Store the drugs at room temperature”

◦What to do with left-over drugs: “Finish all the drugs and none should be left”


Warnings:◦When the drug should not be taken:

“As much as possible, do not drink any alcoholic drink as this may interact with the drugs.”

◦Why the drug should be taken regularly: “You have to take the drugs correctly and regularly for it to have an effect on your BP and prevent further serious complications.”


Future Consultations:◦When to come back (or not): “You have to

come back after two weeks for evaluation.”◦In what circumstances to come earlier: “

You can come back earlier if you experience side effects of the drugs or other new symptoms.”

◦What information the doctor will need at the next appointment: “Please have your BP taken regularly (at least twice a day), record it in a logbook and when you come back, bring the log of your BP from the start of treatment.”


Everything clear?◦Ask the patient whether everything

is understood◦Ask the patient to repeat the most

important information◦Ask whether the patient has any

more questions


Non-Pharmacologic Non-Pharmacologic Treatment StrategiesTreatment Strategies1. Lifestyle Measures

a) Smoking/Alcohol/Illicit Drugs• Positive reinforcement• Passive smoking

b) Diet• Sodium Restriction• Glycaemic Control• Other Dietary Changes

c) Physical Exercise2. Family Education


Monitoring of TreatmentMonitoring of Treatment

MonitoringMonitoring

Passive Monitoring◦Encourage Mr. Paprika to invest in a

good BP apparatus and educate his family members or neighbors on proper usage.

◦Inform patient that his his BP should be monitored regularly In the morning and afternoon

Monitoring

MonitoringMonitoring

Active Monitoring◦Advise Mr. Paprika to return for consult

after 2 weeks If a control in BP is evident at the 2 week

checkup continue the treatment If BP control is not evident at the 2 week

checkup adjust the treatment If any of the side effects (ACEi-induced cough)

is bothering the patient adjust treatment accordingly

Monitoring

Documents

Prescribing for Hypertension Case 2B Brillantes – del Rosario