l3

• AT2 receptors


  • Na reabsorption mechanisms in kidney
• ACE inhibitor


  Angiotensin II Receptor Blocker
• Lisinopril


  Common side effects: Alopecia; angina; angioedema (may be delayed; more common in African-Caribbean patients); arrhythmias; chest pain; constipation; cough; diarrhoea; dizziness; drowsiness; dry mouth; dyspnoea; electrolyte imbalance; gastrointestinal discomfort; headache; hypotension; myalgia; nausea; palpitations; paraesthesia; renal impairment; rhinitis; skin reactions; sleep disorder; syncope; taste altered; tinnitus; vertigo; vomiting; Postural disorders
• Amlodipine


  Common/very common side effects: Dizziness; flushing; headache; nausea; palpitations; peripheral oedema; rash; tachycardia; vomiting; Constipation; diarrhoea; drowsiness; dyspnoea; gastrointestinal disorders; muscle complaints; oedema; vision disorders, sudden withdrawal may be associated with an worsening of myocardial ischaemia
• Thiazide-like diuretics


  Side effects: Hypokalaemia can occur and is dangerous in severe cardiovascular disease and in patients also being treated with cardiac glycosides; Constipation; electrolyte imbalance; headache; postural hypotension; Hypersensitivity; skin reactions. The elderly are particularly susceptible.
• Consider offering antihypertensive treatment to patients with stage 1 and 2 hypertension (not forgetting the importance of lifestyle modification)
• There is an evidence base for stepwise treatment in hypertension depending on patient risk factors
• In time you will learn to recognise the common and important side-effects of commonly used medications
• TASK 1:Which drug/drug class would you initially prescribe to a 46year-old Caucasian man recently diagnosed with hypertension?ACE inhibitor or a Angiotensin II Receptor Blocker
• NICE: Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg ormore) the same treatment as people with both raised systolic and diastolic blood pressure
• Common side effects of ACE inhibitors

  • Alopecia
  • Angina
  • Angioedema (may be delayed; more commonin African-Caribbean patients)
  • Arrhythmias
  • Chest pain
  • Constipation
  • Cough
  • Diarrhoea
  • Dizziness
  • Drowsiness
  • Dry mouth
  • Dyspnoea
  • Electrolyte imbalance
  • Gastrointestinal discomfort
  • Headache
  • Hypotension
  • Myalgia
  • Nausea
  • Palpitations
  • Paraesthesia
  • Renal impairment
  • Rhinitis
  • Skin reactions
  • Sleep disorder
  • Syncope
  • Taste altered
  • Tinnitus
  • Vertigo
  • Vomiting
• Lisinopril

  Postural disorders
• Renal function and electrolytes should be checked before starting
• Reports of cholestatic jaundice, hepatitis, hepatic necrosis, and hepatic failure with ACE inhibitors
• Hyperkalaemia and other side-effects of ACE inhibitors are more common in those with impaired renal function and the dose may need to be reduced
• Clinical evidence shows ACEi's are less effective than ARBs in African-Caribbean and black African patients
• Which drug/drug class would you initially prescribe to a 51 year-old man of African-Caribbean origin recently diagnosed with hypertension and who does not have type II diabetes? Calcium channel Blocker
• Which drug/drug class would you initially prescribe to a 65 year-old womanof Caucasian origin recently diagnosed with hypertension who does not havediabetes?

  calciumm channel blocker
• List 4 side effects of amlodipine. Contraindications: Cardiogenic shock; significant aortic valve disease; unstable angina,hepatic impairment - May need dose reduction—half-life prolongedSide effects:All Ca Blockers: Common/very commonDizziness; flushing; headache; nausea; palpitations; peripheraloedema; rash; tachycardia; vomitingAmlodipine: Common/very commonConstipation; diarrhoea; drowsiness; dyspnoea; gastrointestinal disorders; musclecomplaints; oedema; vision disorders, sudden withdrawal may be associated with anworsening of myocardial ischaemia
• The 46 year-old man of Caucasian origin following use of an ACE inhibitor does not show a significantimprovement towards his target blood pressure and it is decided to change his treatment. What wouldyou do next?Check medicine is being taken and in correct way.Keep him on the ACE inhibitor but add in either a Calcium channel blocker or thiazide-like diuretic
• The 51 year-old man of African-Caribbean origin following use of a Calcium channel blocker does notshow a significant improvement towards his target blood pressure and it is decided to change histreatment. What would you do next?Check medicine is being taken and in correct way.Keep him on the Calcium channel blocker but either add in a ARB, or a thiazide-like diuretic
• BNF Information on Thiazide-like Diuretics:eg. indapamideSide effects:All Thiazides: the elderly are particularly susceptibleHypokalaemia can occur and is dangerous in severe cardiovasculardisease and in patients also being treated with cardiac glycosidesConstipation; electrolyte imbalance; headache; postural hypotensionIndapamide: Hypersensitivity; skin reactions
• What drugs could be considered for patients still not responding toSTEP 3 of treatment?Consider low-dose spironolactone diuretic, if the serum potassium level is not elevated.If contraindicated or ineffective, consider an alpha- or beta-blocker.If still not responding to the combination of drugs, seek expert advice