Summary of Medication Class Considerations

Thiazides Diuretics

• May be a problem in urine incontinent patients or in elderly who become urine incontinent
• Studies have shown that doses above 25mg a day of HCTZ (hydrochlorothiazide) does not decrease BP or morbidity and mortality
• watch chemistry levels (hyponatremia or hypokalemia)
• avoid in gout patients
• start at lower doses in elderly who may be very sensitive
• may slow demineralization in osteoporosis
• may be associated with erectile dysfunction

Loop Diuretics

• monitor electrolytes and creatinine
• start at lower doses in the elderly
• not included in JNC 8 treatment algorithm

Beta Blockers (BB)

• not first line agent in JNC 8
• check initial EKG and pulse prior to use
• you don’t have to avoid in diabetic patients as it does not mask hypoglycemia
• excellent for use in tachyarrhythmias / fibrillation, migraines, essential tremor, and perioperative hypertension
• usually avoided in patients with asthma and 3rd degree heart block

ACE Inhibitors

• watch potassium (hyperkalemia), sodium (hyponatremia), and elevated creatinine levels
• great for renal protection
• reduces microalbuminuria
• first line in renal disease
• shown to have direct heart remodeling effects
• a rise of up to 35% above baseline in creatinine is acceptable
• ACE inhibitor cough is common in 15 – 20% of patients due to bradykinin production
• Angioedema is a serious side effect to monitor in patients
• avoid in pregnant women as they are Category C drugs

ARBs (Angiotensin Receptor Blockers)

• reduces microalbuminuria and macroalbuminuria
• shown to have heart remodeling effects
• avoid in pregnant patients as they are Category C drugs
• less bradykinin production
• also first line in renal patients

Ca+ Channel Blockers (CCBs)

• may be useful in Raynaud’s Syndrome
• may be useful in certain arrhythmias
• often causes leg edema (15-30% depending on different studies)
• short acting calcium channel blockers are contraindicated for use in essential hypertension and hypertensive urgencies or emergencies

Aldosterone Antagonists and Potassium Sparing Diuretics

• may cause hyperkalemia
• avoid in patients with K ≥ 5 prior to starting meds
• low dose aldosterone antagonists reduce morbidity and mortality in congestive heart failure patients but increase sudden death at higher doses

Alpha Blockers

• no proven decrease in morbidity and mortality demonstrated in research studies
• not mentioned in JNC 7 or JNC 8 algorithms for treatment of essential hypertension
• only useful as adjunct in hard to control blood pressure
• may be useful in prostatism but should not be used as a first line anti-hypertensive in patients with BPH