ANTIHYPERTENSIVE DRUGS

1.​ ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS “pril”

Description
a. Inhibit ACE
o​ Angiotensin-converting enzymes inhibitors (ACE Inhibitors) are antihypertensive agents that act
in the lungs to prevent the conversion of angiotensin I into angiotensin II, which is a potent
vasoconstrictor.
o​ Inhibit production of angiotensin II, causing vasodilation (primarily in the arterioles and to a
lesser extent in the veins)
o​ ACE inhibitors target the ACE gene product resulting in downstream reduction of Angiotensin
II, decreasing aldosterone secretion and reducing blood pressure.
o​ Aldosterone (ALD) is a hormone that helps regulate the BP by managing the levels of
sodium (salt) and potassium in your blood and impacting blood volume
o​ Reduction in blood volume (through effects on the kidney)
o​ When blood volume increases, it expands your arteries and veins and leads to increased
blood pressure. Hypervolemia usually occurs because your body is not able to regulate
fluids properly due to impaired kidney or liver function.

Uses
a)​ Hypertension: Primarily indicated for hypertension and can be used alone or in combination
with other drugs. (ACE inhibitors prevent an enzyme in the body from making angiotensin 2, a
substance that narrows blood vessels. This narrowing can cause high blood pressure and forces
the heart to work harder)
b)​ Heart failure: Aside from its indication in treating hypertension, it is also combined with
diuretics and digoxin in the treatment of heart failure and left ventricular dysfunction. The
resultant effect is decreased in peripheral resistance and blood volume leading to decreased
cardiac workload.
c)​ Myocardial infarction (MI)
d)​ Diabetic and nondiabetic nephropathy: It is also approved for the treatment of diabetic
nephropathy, in which the renal artery is being damaged by diabetes. It is thought that
decreased stimulation of angiotensin receptors in the kidney will slow down the damage in the
renal artery.

Adverse reactions
a)​ A – Angioedema ( rapid swelling of face and neck)
b)​ C – Cough (dry )
c)​ E - Elevated K (Hyperkalemia) (inhibition of aldosterone release can cause potassium
retention by the kidney)- Cause cardiac dysrhythmia
d)​ Renal failure
e)​ Fetal injury (if used during the second and third trimesters of pregnancy)
f)​ Dysgeusia (impaired or distorted sense of taste), can cause anorexia and weight loss
g)​ Neutropenia
h)​ Gl. nausea, vomiting, diarrhea. abdominal pain
i)​ CNS: headache, dizziness, fatigue, paresthesia, and insomnia

Contraindications and precautions

a)​ Pregnancy and lactation: contraindicated during the second and third trimesters of pregnancy
because of increased risk of fetal renal damage. Can decrease milk production.
b)​ Hypersensitivity
c)​ Renal Impairement: Decreased renal blood flow effect of these drugs can exacerbate renal
impairment.

Drug Interactions
a)​ Diuretics: may intensify first-dose hypotension
b)​ Antihypertensive drugs: hypotensive effects of ACE inhibitors may have additive effects with
those of other antihypertensive drugs
c)​ Lithium: may result in accumulation to toxic levels

Nursing interventions
a)​ Determine blood pressure prior to treatment.
b)​ Begin with low doses and gradually increase the dose.
 c)​ Administer captopril (Capoten) and moexipril (Univasc) at least 1 hour before meals.
d)​ Monitor the blood pressure closely for 2 hours after the first dose and periodically thereafter.
Instruct the client to lie down if hypotension develops.
e)​ Inform the client about the possibility of persistent, dry, irritating, nonproductive cough.
f)​ Instruct the client to avoid potassium supplements and potassium- containing salt substitutes
unless they are prescribed by the physician. Potassium-sparing diuretics must also be avoided.
g)​ Discontinue ACE inhibitor and avoid its use if angioedema characterized by giant wheals and
edema of the tongue glottis, and pharynx occurs. It can be fatal.
●​ Treat severe reactions with SUBCUTANEOUS EPINEPHRINE.
h)​ Educate patient on importance of healthy lifestyle choices which include regular exercise,
weight loss, smoking cessation, and low-sodium diet to maximize the effect of antihypertensive
therapy.
i)​ Avoid high doses to minimize rash and dysgeusia (mainly seen with captopril).
j)​ Obtain a white blood cell count and differential prior to start of treatment.
●​ Neutropenia (mainly seen with CAPTOPRIL) poses a high risk of infection. Inform clients
about early signs of infection (fever, sore throat, mouth sores) and instruct them to notify
the physician if these occur.

Types

a)​ Benazepril hydrochloride (Lotensin)

b)​ Captopril (Capoten)
c)​ Enalapril maleate (Vasotec)
d)​ Enalaprilat (Vasotec I.V.)
e)​ Fosinopril sodium (Monopril)
f)​ Lisinopril(Prinivil, Zestril)
g)​ Moexipril (Univasc)

2.​ BETA BLOCKERS

Description
1.​ Compete with and block norepinephrine and epinephrine at the beta-adrenergic receptors
located throughout the body
2.​ The beta-adrenergic receptor sites can then no longer be stimulated by the neurotransmitters,
norepinephrine, and epinephrine, and sympathetic nervous system (SNS) stimulation is blocked.
Two types
1.​ Cardioselective beta, blockers, beta,- adrenergic blockers
a)​ Acebutolol (Sectral)
b)​ Atenolol (Tenormin)
c)​ Betaxolol (Kerlone)
d)​ Bisoprolol (Zebeta)
e)​ Esmolol (Brevibloc)
f)​ Metoprolol tartrate (Lopressor)
g)​ Metoprolol succinate (Toprol XL)
h)​ Nevibolol (Nebilet)

2.​ Nonspecific beta blockers, beta, and beta2-adrenergic blockers

a)​ Carteolol (Cartrol)
b)​ Carvedilol (Coreg)
c)​ Labetalol (Normodyne, Trandate)
d)​ Nadolol (Corgard)
e)​ Penbutolol (Levatol)
f)​ Pindolol (Visken)
g)​ Propranolol (Inderal)
h)​ Sotalol (Betapace)
3.​ CALCIUM CHANNEL BLOCKERS (CCB) “dipines” or “ine”
Description
a)​ Calcium channel blockers are medicines used to lower blood pressure (antihypertinsives).
●​ As antihypertensive agents it decrease blood pressure, cardiac workload, and myocardial
consumption of oxygen.
b)​ They stop calcium from entering the cells of the heart and arteries.
●​ Calcium causes the heart and arteries to constrict or contract strongly. By blocking calcium,
calcium channel blockers allow blood vessels to relax and dilate.
c)​ Some calcium channel blockers also can slow the heart rate. This can further lower blood pressure.
The medicines also may be prescribed to relieve chest pain, called angina, and control an irregular
heartbeat.

USES
a)​ Hypertension
b)​ Angina
c)​ Cardiac dysrhythmias

ADVERSE REACTIONS
a)​ Reflex tachycardia
b)​ Flushing
c)​ Dizziness
d)​ Headache
e)​ Peripheral Edema
f)​ Gingival Hyperplasia

CONTRAINDICATIONS AND PRECAUTIONS

a)​ Pregnancy
b)​ Lactation
c)​ Hypotension
d)​ Heart block (sick sinus syndrome). Can be exacerbated by conduction-slowing effect of the
drug.
●​ heart may beat slowly or skip beats. severe cases, heart block can affect your heart’s ability
to pump blood, causing low blood flow to your entire body.
e)​ Second- or third-degree heart block

DRUG INTERACTIONS
1.​ Beta-adrenergic blocking agents: depress the myocardial contractility and AV conduction
2.​ Cimetidine: increase effects of calcium channel blockers
3.​ Fentanyl (narcotic (opiate) analgesic) : severe hypotension
4.​ Increased serum level and toxicity of CYCLOSPORINE if taken with DILTIAZEM.
5.​ Grapefruit juice can increase serum level and toxicity of calcium-channel blockers.

NURSING INTERVENTIONS
1.​ Instruct the client to swallow the sustained-released drug whole, without crushing or chewing.
2.​ Instruct the client to notify the physician if the ankles and feet SWELL.
●​ switching from a dihydropyridine (DHP) agent to a non-dihydropyridine agent if clinically
suitable, such as verapamil, which may lead to resolution of the ankle oedema
●​ switching to a third generation dihydropyridine, such a lercanidipine, which has a lower
reported incidence of ankle oedema
3.​ Administer the prescribed diuretic for edema.
4.​ Assess for reflex tachycardia.
●​ If blood pressure decreases, the heart beats faster in an attempt to raise it.
5.​ Instruct the client to sit up from a reclining position slowly.
6.​ Educate patient on importance of healthy lifestyle choices which include regular exercise,
weight loss, smoking cessation, and low-sodium diet to maximize the effect of antihypertensive
therapy.
7.​ Monitor blood pressure and heart rate and rhythm to detect possible development of adverse
effects. Report sustained hypotension.
8.​ Provide comfort measures for the patient to tolerate side effects (e.g. small frequent meals for
nausea, limiting noise and controlling room light and temperature to prevent aggravation of
stress which can increase demand to the heart, etc.)
9.​ Emphasize to the client the importance of strict adherence to drug therapy to ensure maximum
therapeutic effects.
TYPES
1.​ DIHYDROPYRIDINES
a)​ Amlodipine (Norvasc)
b)​ Nicardipine (Cardene, Cardene SR)
c)​ Nifedipine (Adalat. Procardia)
d)​ Nimodipine
e)​ Nisoldipine (Sular)
f)​ Felodipine (Plendil)
g)​ Isradipine (DynaCirc)

2. Non-DIHYDROPYRIDINES
a)​ Verapamil (Calan)
b)​ Diltiazem

4.​ Diuretics
•​ Agents that increase the amount of urine produced by the kidneys
•​ Increase urine production result in decrease blood volume. When blood volume
increases, it expands your arteries and veins and leads to increased blood pressure.
•​ Used to promote the excretion of sodium and water from the body and prevent the reabsorption
of sodium - Too much salt can cause fluid to build up around the heart and lungs, making the
heart work harder
•​ Used in the treatment of edema, hypertension, and congestive heart failure
•​ Some water pills combine more than one type of diuretic. Others combine a diuretic with a
different medicine, such as one to treat blood pressure. Which type is best for you depends on
your health and the condition being treated.

Classes of Diuretics
Types of diuretics used to treat high blood pressure include:
●​ Thiazide.
●​ Loop.
●​ Potassium sparing.

General indications for the use of the diuretics

1.​ Treatment of edema
o​ Urine output will increase and excess fluid is flushed out of the body
2.​ Treatment of CHF
o​ The sodium loss in the kidney is associated with water loss
3.​ Treatment of Hypertension
o​ Diuretics will decrease the blood volume and serum sodium
4.​ Treatment of Glaucoma
o​ Diuretics will provide osmotic pull to remove some of the fluid from the eye to
decrease the Intraocular Pressure (IOP)

THIAZIDES
Prototype: Hydrochlorothiazide
●​ Bendroflumethiazide
●​ Benthiazide
●​ Chlorothiazide (Diuril)
●​ Hydroflumethiazide
 ●​ Methylclothiazide
●​ Trichlormethiazide

THIAZIDE-LIKE
●​ Indapamide
●​ Quinethazone
●​ Metolazone
●​ Chlorthalidone

Pharmacodynamics (MOA)
●​ These drugs BLOCK the chloride pump
●​ This will keep the Chloride and Sodium in the distal tubule to be excreted into the urine
●​ Potassium is also flushed out!!

Special Pharmacodynamics: Side effects

o​ Hypokalemia
o​ DECREASED calcium excretion - hypercalcemia
o​ DECREASED uric acid secretion - hyperuricemia
o​ Hyperglycemia

_________________________________________

LOOP DIURETICS

Prototype: Furosemide
1. Bumetanide
2. Ethacrynic acid
3. Torsemide

Pharmacodynamics
•​ High-ceiling diuretics
•​ BLOCK the chloride pump in the ascending loop of Henle
•​ SODIUM and CHLORIDE reabsorption is prevented
•​ Potassium is also excreted together with Na and Cl

Special Pharmacodynamics: side-effects

•​ Hypokalemia
•​ Bicarbonate is lost in the urine
•​ INCREASED calcium excretion Hypocalcemia
•​ Ototoxicity- due to the electrolyte imbalances

POTASSIUM SPARING DIURETICS

Prototype: Spironolactone
1)​ Amiloride
2)​ Triamterene
Pharmacodynamics
•​ Spironolactone is an ALDOSTERONE antagonist
•​ Triamterene and Amiloride BLOCK the potassium secretion in the distal tubule
•​ Diuretic effect is achieved by the sodium loss to offset potassium retention
Pharmacokinetics: Side effects
–​ HYPERkalemia!
–​ Avoid high potassium foods:
•​ Bananas •​ Nuts
•​ Potatoes •​ Prunes
•​ Spinach •​ Tomatoes
•​ Broccoli •​ Oranges
•​ Peach

CARDIAC GLYCOSIDES
■​ Make heart beat slower but stronger
■​ Improve pumping ability of heart
■​ Increase force of heart's contraction
■​ Decrease rate of contraction
■​ Increase cardiac output

Drugs
1.​ Digoxin (Lanoxin)
2.​ Digitoxin (Crystodigin)
■​ (+) inotropic (Increased heart contractility)
■​ (-) chronotropic (Decreased heart rate)

Uses
1.​ Congestive Heart Failure
2.​ Atrial flutter
3.​ Atrial fibrillation

Contraindications
a)​ Ventricular tachycardia
b)​ Ventricular fibrillation
c)​ Second-and third-degree heart block

Adverse Effects
1)​ Vision changes: yellow-green halos
2)​ N/V
3)​ Diarrhea
4)​ Anorexia
5)​ Bradycardia
6)​ Xanthopsia
7)​ Muscle weakness
8)​ Dysrhythmia

Nursing Interventions
1.​ Before giving glycosides, check apical pulse and heart rhythm. Report if <60 bpm
(adult); <90 bpm (infants).
2.​ Monitor digoxin levels for possible toxicity (therapeutic range = 0.5 to 2.0 mg/ml)
Antidote: DIGOXIN IMMUNE FAB (Digibind)
3.​ Monitor intake and output.
4.​ Health teaching
a.​ Take medications as prescribed.
b.​ Teach client how to take and record pulse daily
c.​ Identify and report signs of toxicity.
d.​ Daily weights: Report two-pound increase.