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-HypertensivesClass Mechanism of
ActionExamples 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?