Antihypertensives choice

Tamsulosin is a good choice for patients who cannot tolerate hypotension have severe coronary artery disease, volume depletion, cardiac arrhythmias, severe orthostasis, or liver failure or are taking multiple antihypertensives. Tamsulosin is also suitable for patients who want to avoid the delay of dose titration. 

Antihypertensive therapy. Diuretics have long been used as drugs of first choice for lowering elevated blood pressure (p. 312). Even at low dosage, they decrease peripheral resistance (without significantly reducing EEV) and thereby normalize blood pressure. 

In comparison with more modem antihypertensives reserpine causes unpleasant side-effects, such as sedation, depression and various effects reflecting a dominant parasympathetic system (nasal congestion, diarrhea and exacerbation of peptic ulcers). Reserpine should be considered as an antihypertensive of second choice, although in certain countries it is still used because of its low price. 

In summary, a-methyl-DOPA may be considered as a second choice antihypertensive. In spite of this it is still used on a moderately large scale in certain countries because of its low cost. Its documented safety in pregnant women explains why it is sometimes used by obstetricians in such patients. 

Mahmnd A, Feely J. Choice of first antihypertensive simple as ABCD Am J Hypertens 2007 20(8) 923-7. 

There is general agreement on the principles governing the use of antihypertensive drugs to lower BP, independent of the choice of particular drugs. (Table 5). These principles (WHO-ISH 1999) include ... 

Their antihypertensive efficacy is comparable to that of (3-adrenergic blockers and angiotensin-converting enzyme (ACE) inhibitors. The choice of a calcium channel blocker, especially for combination therapy, is largely influenced by the effect of the drug on cardiac pacemakers and contractility and coexisting diseases, such as angina, asthma, and peripheral vascular disease. 

When diuretic therapy is indicated for the treatment of primary hypertension, the thiazide-type compounds (e.g., chlorothiazide, hydrochlorothiazide) are generally the drugs of choice. They can be used alone or in combination with other antihypertensive agents Approximately 30% of patients with mild hypertension may be treated effectively with thiazide therapy alone. 

As noted earlier, lithium is contraindicated in patients with unstable congestive heart failure or the sick sinus node syndrome ( 307, 328). In older patients or those with prior cardiac histories, a pretreatment ECG should be obtained. Except for the potential adverse interactions with diuretics, the concomitant use of other cardiac drugs is generally safe. Because verapamil may lower serum levels of lithium, however, more careful monitoring may be required to assure continued therapeutic effects (329). Some data also indicate that verapamil may predispose to lithium neurotoxicity. Conversely, increased lithium levels leading to toxicity has occurred with methyidopa and enalapril. When antihypertensive therapy is necessary, b-blockers are a reasonable choice when lithium is coadministered. 

Renal insufficiency is a late complication of hypertension (354). This is why the choice of the antihypertensive drug selected as the firs (dine treatment of a condition that will persist for many years is so important. From this viewpoint, the fall in blood pressure induced by ACE inhibitors might have beneficial renal effects, in addition to those induced by any decrease in perfusion pressure of the kidneys, especially in diabetic patients (222, 355-358). It is unknown if, independendy of the hemodynamic effect, at an early stage of hypertension and before the initiation of a progressive decrease in renal function, a local decrease in angiotensin II (or increase in bradykinin) explains or direcdy participates in a so-called renoprotective effect (359). 

It should be remembered that hypertension in patients with renal dysfunction can be particularly difficult to treat, and many patients require more than one antihypertensive agent in order to control their blood pressure. There is some guidance provided by the Renal Association in their Clinical Guidelines document as to choice of therapeutic agent ... 

The drugs of first choice in antihypertensive therapy are those that have been unambiguously shown in clinical studies to reduce mortality of hypertension—diuretics, ACE inhibitors and AT, antagonist, p-blockers, and calcium antagonists. 

Q5 Yes. Thiazide diuretic drugs are one of the treatments of choice for hypertension in elderly patients. Bendroflumethiazide, 2.5 mg daily, is commonly prescribed for hypertension in the United Kingdom. Although the thiazides have been in use for many years, their mechanism of action is not completely understood. They reduce renal reabsorption of sodium and water and so initially decrease blood volume they also dilate blood vessels and BP falls. However, blood volume may return to normal while the vasodilation and antihypertensive action remains. 

Every formulary is replete with combinations of antitussives, expectorants, mucolytics, broncho-dilators and sedatives. Although choice is not critical, a knowledge of the active ingredients is important, for some contain sedative anti-muscarinic antihistamines or phen)rpropanolamines (which may antagonise antihypertensives). Use of... 

The effects of antihypertensive agents have been evaluated in patients taking ciclosporin. Collectively, dihydropyridine calcium channel blockers that do not affect ciclosporin blood concentrations substantially or at all (felodipine, isradipine, and nifedipine) are usually considered to be the drugs of choice. However, the risk of gingival hyperplasia with nifedipine, which ciclosporin also causes, should be borne in mind. Combination therapy with angiotensin-converting enzyme inhibitors or beta-blockers, or the use of other calcium channel blockers (verapamil or diltiazem) should also be considered, but careful monitoring of ciclosporin blood concentrations is recommended with the latter because they inhibit ciclosporin metabolism. 

P-adrenergic receptor antagonists may also provide less benefit than other classes of antihypertensive drugs (45). Nevertheless, P-adrenergic receptor antagonists remain a widely accepted choice for the first-line treatment of hypertension. 

Examples include, choice of antihypertensive agent to he used while on cyclosporine or tacrolimus, timing medication ingestion around meal times. After identifying medications that are detrimental to the bone marrow, offer options for treatment that have no effect or minimal effect on the bone marrow. 

Most patients with hypertension and CKD require drug regimens that include three or more antihypertensive agents to achieve target blood pressure. Blood pressure reductions can be achieved with agents in all antihypertensive classes, and choice should be guided by the individual patient s concomitant disease states. 

Initial therapy choices for hypertension in diabetes mellitus usually include angiotensin-converting enzyme inhibitors or an angiotensin receptor blocker due to their well documented renoprotective effects. Currently, angiotensin receptor blockers have less robust data to support cardiovascular reduction compared to other therapeutic choices, yet the data that exists appears to be positive in patients with type 2 DM. Also, diuretics have shown superior results to an ACE inhibitor in the ALLHAT trial. The ADA currently recommends the use of any class (ACE inhibitors, angiotensin receptor blockers, /3-blockers, diuretics, or calcium channel blockers) of antihypertensive medication that has shown benefit in prevention of poor cardiovascular outcomes. Choice of monotherapy may not be important, as an average of two to three antihypertensive medications are needed to reach blood pressure goals. 

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