Question

• The ANP has been treating a 65-year-old Caucasian female for mildly elevated blood pressure that has been successfully managed with a thiazide diuretic. At the last routine office visit the medical assistant informs the ANP that the patient’s blood pressure is 142 / 90. This is confirmed by the ANP upon repeat of blood pressure management.
• You can assume that the diagnosis of hypertension requiring medication is correct. The patient has no other comorbidities and her only medication is the thiazide diuretic.
• Design a pharmacologic treatment regimen for this patient referring to the directions for completing the case studies and the grading rubric

What drug or drugs will you prescribe; provide the rationale

Provide the pharmacological data pertinent to each drug included (dose, route, dose interval)

How will you evaluate the efficacy of your treatment?
Laboratory monitoring, clinical assessment for therapeutic, drug incompatibilities, adverse and toxic effects, drug dose/route changes as needed                                              

What about future contingencies & revisions; consideration of needs for follow-up, medication monitoring, lifestyle modifications & patient teaching.

Are your decisions validated by supporting literature? yes you can include kidney function test

Answer 1

The 65 yr old Caucasian female is diagnosed to have hypertension even after taking thiazide diuretics the patient still have BP of 142/90. This BP is classified as essential hypertension or due to any kidney related disorders. Drugs such as angiotensin converting enzyme inhibitors(ACEIs), calcium channel blockers (CCBs), angiotensin-receptor blockers (ARBs), and beta-blockers are all considered acceptable alternative therapies in patients with hypertension.

1. Angiotensin-converting enzyme (ACE) inhibitors help relax your veins and arteries to lower your blood pressure. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance that narrows your blood vessels. This narrowing can cause high blood pressure and force your heart to work harder. Drug : Benazepril dosage : 10 mg daily orally
2. Calcium channel blockers lower your blood pressure by preventing calcium from entering the cells of your heart and arteries. Calcium causes the heart and arteries to contract more strongly. By blocking calcium, calcium channel blockers allow blood vessels to relax and open.Drug : Amlodipine 10mg once daily orally . There is no diet regards for this drug
3. Angiotensin II is a very potent chemical formed in the blood that causes muscles surrounding blood vessels to contract, thereby narrowing the vessels. This narrowing increases the pressure within the vessels and can cause high blood pressure (hypertension). Angiotensin II receptor blockers (ARBs) are medications that block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on the muscles surrounding blood vessels. As a result, blood vessels enlarge (dilate) and blood pressure is reduced.Drug: Telmisartan 20 -80 mg daily orally.

4. Beta-blockers work by blocking the effects of epinephrine (adrenaline) and slowing the heart's rate, thereby decreasing the heart’s demand for oxygen.Drug: Atenelol 25-50 mg per day orally .

These are the drugs provided to the patient in this situation. The efficacy of the treatment can be confirmed through BP monitoring using sphygmomanometer.when we are using these drugs we should accurately monitor the input output chart, vital signs and lab investigation like creatinine clearance test, liver function test etc. If any abnormality present means we have to intimate to the physician immediately. Then about the adverse effects like hypotension, tachycardia, respiratory difficulty , chest pain, edema or weight gain that should take into consideration .

Lifestyle modification and teaching includes Losing weight if you are overweight or obese. Quitting smoking. Eating a healthy diet, including the DASH diet (eating more fruits, vegetables, and low fat dairy products, less saturated and total fat),caffeine should be avoided. excercise regularly, reduce the stress and proper follow-up as scheduled .

Medication followup should be done as per physicians order

A treatment that once worked well may no longer work. The drug dosage may need to be changed or you may be prescribed a new medication. Periodically, at your follow-up visits, you should be screened for damage to the heart, eyes, brain, kidney, and peripheral arteries that may be related to high blood pressure. The drug should not be discontinued immediately, it should be only tapered .

Supporting literature:

Treatment of hypertension plays a central role in the management of CKD, including in patients with ESKD. Hypertension is both a cause and a consequence of CKD, and its prevalence is high among patients with CKD and ESKD (1,2). Patients with CKD have an outsized burden of cardiovascular disease; indeed, the presence of CKD represents a coronary risk equivalent on par with diabetes mellitus (3). Additionally, the treatment of hypertension is associated with improved cardiovascular outcomes in both CKD (4) and ESKD (5). Thus, the management of hypertension in CKD and ESKD is both a common and an important issue for patients and practitioners. Nonpharmacologic treatment of hypertension includes dietary sodium restriction (6) and additionally for the dialysis population, vigilant maintenance of an adequate dry weight (7). Despite best efforts, nonpharmacologic methods alone are insufficient in controlling hypertension. In a large CKD cohort, 60% of the patients were being treated with three or more antihypertensive medications, suggesting that resistant hypertension is very common in this population (1).

Given that the pharmacologic treatment of hypertension is an important consideration for the management of CKD, the objective of this review is to survey the clinical pharmacology of the major classes of antihypertensives from a nephrocentric point of view and provide practical insights when using them in patients with CKD and ESKD.

Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers (ARBs) are the mainstays of hypertension treatment in CKD. ACEis block the conversion of angiotensin I to the potent vasoconstrictor peptide angiotensin II, whereas ARBs competitively block the angiotensin II receptors (8). This blockade has the effect of reducing aldosterone secretion and reducing peripheral vascular resistance, effectively reducing systemic BP. Importantly, the blockade of angiotensin II also results in dilation of the efferent arteriole of the glomerulus, which reduces intraglomerular pressure and is the putative mechanism for the renoprotective effects of these agents. The use of ACEis and ARBs is now well established for the treatment of proteinuric CKD (9). Heart failure with reduced ejection fraction and acute myocardial infarction (10), both of which commonly coexist with CKD, are other important reasons to treat patients with ACEis or ARBs