Hypertension: Specific Treatment – Family Medicine | Lecturio

October 4, 2019

And, of course, there’s – JNC 8 includes
some specific recommendations based on the patient you may see and these are
good things that may come up on your examination. Certainly, come up in clinic. Black patients respond better to
drugs like calcium channel blockers and thiazide diuretics versus
drugs like ACE inhibitors. If they have chronic kidney disease, try to initiate an ACE inhibitor or an ARB
and titrate to at least moderate doses. It will slow the progression
of chronic kidney disease. Of course, watch the creatinine and
watch the potassium in those patients too. Among patients with
coronary artery disease, the best drugs are beta blocker and an ACE inhibitor or an
angiotensin receptor blocker for preventing recurrent cardiac events. In diabetes, start an ACE inhibitor or an
ARB because it can help with nephropathy. Interestingly though, remember that
patients who don’t have nephropathy don’t necessarily benefit from an ACE
or an ARB when they have diabetes, so it’s really only after they develop
nephropathy or when they have diabetes and hypertension that
you introduce an ACE or ARB. And then, finally, non-dihydropyridine calcium channel blockers can be effective. They can’t tolerate an ACE or an ARB
in those patients with diabetes. And we’ll talk – heart failure
requires a few different drugs. The core drugs are listed there,
either an ACE or an ARB, plus a beta blocker, and then consider
spironolactone for those patients too. That’s a lot. And you can feel really
stressed out and lost, and I understand that, but you don’t want to get too
overly focused on the initial choice. I see a lot of clinicians really struggling. Okay, what’s the best choice for my patient. JNC 8 gives you latitude between
several different classes of drugs, but don’t worry about
it too much because oftentimes you’re going to
be adding a second or even a third agent on to
those patients with hypertension. So, the one you start now will be a solo act for only the next two to four weeks
till you evaluate the patient again. If their blood pressure is still up,
you might add a second agent. And then, also when choosing drugs, don’t forget that, really it’s that number is the most important thing. So, say, you have a patient with
diabetes and nephropathy, but they really have a hard time
taking any of those drugs, the non-dihydropyridine calcium channel blocker, ACE inhibitor, ARB, they can’t tolerate any of them, but they really enjoy – and what they –
the only thing they can tolerate is an alpha antagonist
or a beta blocker. It’s not the ideal drug for that patient, but if it gets their blood
pressure down towards goal, that’s much more important than
getting them just on the right drug for their chronic medical condition. Hopefully, that was really helpful
in our brief review of hypertension. I enjoyed it. I enjoyed preparing it. And I think it’ll help a lot of your patients. Thanks.

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