1. Prescribing for Hypertension Case 2B Brillantes – del Rosario

2. GUIDE to GOOD Prescribing Define the Patient’s Problem Specify the Therapeutic Objective Choose an appropriate Treatment Write a Prescription and/or Start treatment Give Information, Instructions And Warnings Monitor the Patient

3. Defining the Patient’s Problem

4. General Data & Chief Complaint Mr. Paprika, 40/M Living in Manila Referred for “high blood” Defining Patient’s Problem

5. History 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. Defining Patient’s Problem

6. Review 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 Defining Patient’s Problem

7. Past Medical History Type 2 diabetes mellitus – diagnosed July 2008, on metformin 500 mg BID No Hx of PTB, asthma, allergies, thyroid disorders, gout Defining Patient’s Problem

8. Family Medical History Father – hypertension, suffered MI at 45 years old, still alive? Defining Patient’s Problem

9. Personal & Social History Sales manager Married, with 2 children Denies smoking, alcohol consumption, illicit drug use No food preferences Defining Patient’s Problem

10. Physical 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 6 th ICS L MCL, normal & regular HR and rhythm, (-) S3 or murmurs Defining Patient’s Problem

11. Physical 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 Defining Patient’s Problem

12. Laboratory and Imaging Studies CBC & chemistries | all w/in normal limits Urinalysis | 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 Defining Patient’s Problem

13. Problem List Type 2 diabetes mellitus Essential hypertension, grade 3 – very high added risk Defining Patient’s Problem

14. Specify the Therapeutic Objective

15. Therapeutic 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

16. Choose an Appropriate Treatment

17. Antihypertensive Drugs ACE inhibitor Alpha Blockers ARBs Beta bl0ckers CCBs Thiazide Diuretics Choosing the Right Treatment

18. Mechanisms of Actions ACE inhibitors ◦ Block the conversion of angiotensin I to angiotensin II by inhibiting angiotensin converting enzyme (ACE) Alpha-blockers ◦ Lower by by reducing the peripheral resistance Angiotensin II antagonists ◦ Block type I angiotensin II receptors Choosing the Right Treatment

19. Mechanism of Action Beta-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 Choosing the Right Treatment

20. Mechanism of Action Calcium 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 Choosing the Right Treatment

21. DrugsEfficacySafetySuitability Cost (Php per day) ACE inhibitors434 1-30 Alpha blocker 2 (not enough studies) 2 (postural hypotnsn) 3 (increasing dose) ARBs444 10-50 Beta blockers3 2 (diabetogenic) 0 (contraindicated in DM) 16-20 CCB:3 2 (diabetogenic) 0 (interaction w/ metformin) 15-25 Thiazide Diuretics32 (diabetogenic) 0 (contraindicated in DM) 4-8

22. DrugsEfficacySafetySuitability Cost (Php per day) ACE inhibitors434 1-30 Alpha blocker 2 (not enough studies) 2 (postural hypotnsn) 3 (increasing dose) ARBs444 10-50 Beta blockers3 2 (diabetogenic) 0 (contraindicated in DM) 16-20 CCB:3 2 (diabetogenic) 0 (interaction w/ metformin) 15-25 Thiazide Diuretics32 (diabetogenic) 0 (contraindicated in DM) 4-8

23. DrugsEfficacySafetySuitability Cost (Php per day) ACE inhibitors434 1-30 Alpha blocker 2 (not enough studies) 2 (postural hypotnsn) 3 (increasing dose) ARBs444 10-50 Beta blockers3 2 (diabetogenic) 0 (contraindicated in DM) 16-20 CCB:3 2 (diabetogenic) 0 (interaction w/ metformin) 15-25 Thiazide Diuretics32 (diabetogenic) 0 (contraindicated in DM) 4-8

24. DrugsEfficacySafetySuitability Cost (Php per day) ACE inhibitors434 1-30 Alpha blocker 2 (not enough studies) 2 (postural hypotnsn) 3 (increasing dose) ARBs444 10-50 Beta blockers3 2 (diabetogenic) 0 (contraindicated in DM) 16-20 CCB:3 2 (diabetogenic) 0 (interaction w/ metformin) 15-25 Thiazide Diuretics32 (diabetogenic) 0 (contraindicated in DM) 4-8

25. DrugsEfficacySafetySuitability Cost (Php per day) ACE inhibitors434 1-30 Alpha blocker 2 (not enough studies) 2 (postural hypotnsn) 3 (increasing dose) ARBs444 10-50 Beta blockers3 2 (diabetogenic) 0 (contraindicated in DM) 16-20 CCB:3 2 (diabetogenic) 0 (interaction w/ metformin) 15-25 Thiazide Diuretics32 (diabetogenic) 0 (contraindicated in DM) 4-8

26. P-Drug ACE INHIBITORS ARBs Choosing the Right Treatment

27. ACE Inhibitors Captopril Enalapril Lisonopril Choosing the Right Treatment

28. DrugEfficacySafetySuitabilityCost (per day) Captopril432 (BID and patient is noncompli ant) 1-2 Enalapril43410-30 Lisonopril43430

29. DrugEfficacySafetySuitabilityCost (per day) Captopril432 (BID and patient is noncompli ant) 1-2 Enalapril43410-30 Lisonopril43430

30. DrugEfficacySafetySuitabilityCost (per day) Captopril432 (BID and patient is noncompli ant) 1-2 Enalapril43410-30 Lisonopril43430

31. Angiotensin Receptor Blockers Losartan Telnisartan Valsartan Choosing the Right Treatment

32. DrugEfficacySafetySuitabilityCost Losartan4448-20 Telnisartan44440 Valsartan44440

33. DrugEfficacySafetySuitabilityCost Losartan4448-20 Telnisartan44440 Valsartan44440

34. DrugEfficacySafetySuitabilityCost Losartan4448-20 Telnisartan44440 Valsartan44440

35. DrugEfficacySafetySuitabilityCost Losartan4448-20 Telnisartan44440 Valsartan44440

36. Write a Prescription Start Treatment

37. Prescription Prescription and Starting Treatment

38. Giving of Information, Instructions and Warnings

39. 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

40. 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.” Infos, Instructions, Warnings

41. 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” Infos, Instructions, Warnings

42. 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.” Infos, Instructions, Warnings

43. 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.” Infos, Instructions, Warnings

44. 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 Infos, Instructions, Warnings

45. Non-Pharmacologic Treatment Strategies 1. Lifestyle Measures a)Smoking/Alcohol/Illicit Drugs Positive reinforcement Passive smoking b)Diet Sodium Restriction Glycaemic Control Other Dietary Changes c)Physical Exercise 2. Family Education Infos, Instructions, Warnings

46. Monitoring of Treatment

47. Monitoring 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

48. Monitoring 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