Diltiazem Diuretics

Patients having high plasma renin activity (PRA) (>8 ng/(mLh)) respond best to an ACE inhibitor or a -adrenoceptor blocker those having low PRA (<1 ng/(mLh)) usually elderly and black, respond best to a calcium channel blocker or a diuretic (184). -Adrenoceptor blockers should not be used in patients who have diabetes, asthma, bradycardia, or peripheral vascular diseases. The thiazide-type diuretics (qv) should be used with caution in patients having diabetes. Likewise, -adrenoceptor blockers should not be combined with verapamil or diltiazem because these dmgs slow the atrioventricular nodal conduction in the heart. Calcium channel blockers are preferred in patients having coronary insufficiency diseases because of the cardioprotective effects of these dmgs. 

Abciximab, aminophylline, amiodarone, amrinone, aspirin, carbamazepine, chlorpromazine, danazol, diltiazem, eptifi-batide, heparin, histamine2-receptor antagonists, low molecular weight heparins, methyldopa, milrinone, procainamide, quinidine, quinine, NSAIDs, thiazide diuretics, ticlopidine, tirofiban, and valproic acid... 

Blockers (without ISA) are first-line therapy in chronic stable angina and have the ability to reduce BP, improve myocardial consumption, and decrease demand. Long-acting CCBs are either alternatives (the nondihy-dropyridines verapamil and diltiazem) or add-on therapy (dihydropy-ridines) to /1-blockers in chronic stable angina. Once ischemic symptoms are controlled with /1-blocker and/or CCB therapy, other antihypertensive drugs (e.g., ACE inhibitor, ARB) can be added to provide additional CV risk reduction. Thiazide diuretics may be added thereafter to provide additional BP lowering and further reduce CV risk. 

Cyclosporine has significant nephrotoxicity, and its toxicity can be increased by drug interactions with diltiazem, potassium-sparing diuretics, and other drugs inhibiting CYP3A. Serum creatinine should be closely monitored. Other toxicities include hypertension, hyperkalemia, hepatotoxicity, gingival hyperplasia, and hirsutism. 

CALCIUM CHANNEL BLOCKERS POTASSIUM-SPARING DIURETICS t serum concentrations of eplerenone when given with diltiazem and verapamil Calcium channel blockers inhibit CYP3A4-mediated metabolism of eplerenone Restrict dose of eplerenone to 25 mg/day. Monitor serum potassium concentrations closely watch for hyperkalaemia... 

PORFIMER I. ACE INHIBITORS -enalapril 2. ANALGESICS -celecoxib, ibuprofen, ketoprofen, naproxen 3. ANTIARRHYTHMICS — amiodarone 4. ANTIBIOTICS -ciprofloxacin, dapsone, sulphonamides, tetracyclines 5. ANTICANCER AND IMMUNOMODULATING DRUGS -fluorouracil (topical and oral) 6. ANTIDIABETIC DRUGS-glipizide 7. ANTIMALARIALS -hydroxychloroquine, quinine 8. ANTIPSYCHOTICS -chlorpromazine, fluphenazine 9. CALCIUM CHANNEL BLOCKERS - diltiazem 10. DIURETICS -bumetanide, furosemide, hydrochlorothiazide II. PARA-AMINOBENZOIC ACID (TOPICAL) 12. RETINOIDS-acitretin, isotretinoin 13. SALICYLATES (TOPICAL) t risk of photosensitivity reactions Attributed to additive effects Avoid exposure of skin and eyes to direct sunlight for 30 days after porfimer therapy... 

Interactions. Several types of drug interfere with lithium excretion by the renal tubules, causing the plasma concentration to rise. These include diuretics (thiazides more than loop type), ACE inhibitors and angiotensin-11 antagonists, and nonsteroidal anti-inflammatory analgesics. Theophylline and sodium-containing antacids reduce plasma lithium concentration. The effects can be important because lithium has such a low therapeutic ratio. Diltiazem, verapamil, carbamazepine and pheny-toin may cause neurotoxicity without affecting the plasma lithium. Concomitant use of thioridazine should be avoided as ventricular arrhythmias may result. 

Both the NORDIL and INSIGHT trials (Lancet 2000 356 359-365,366-372) confirmed that a calcium chaimel blocker (diltiazem and nifedipine respectively) had the same efficacy as older therapies (diuretics and /or p-blockers) in hypertension with no evidence of increased sudden death. 

Similarly, verapamil should be used with caution in patients with heart failure, and both diltiazem and nifedipine can cause problems in patients with poor cardiac reserve. However, the PRAISE study (18) suggested that amlodipine may be used safely, even in the presence of severe heart failure optimally treated with diuretics. 

Drug interactions Amphotericin B or potassium-wasting diuretics may contribute to digoxin toxicity ACE-I, amiodarone, bepridii, diltiazem.guinidine, and verapamil may increase digoxin levels. 

Case Conclusion Diuretics and beta-blockers are first-line agents for treating HTN. Because this patient has asthma, beta-blockers should be avoided. Calcium channel blockers are favorable therapeutic options in patients with both angina and HTN. Because her heart rate is low, diltiazem and verapamil are not optimal choices because they can slow down AV nodal conduction. A long-acting dihydrof ridine, amlodipine, was started. 

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