HTN Case No.5 Hypertension Management

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HTN Case No.5 Hypertension Management

হাইপারটেনশন_ম্যানেজমেন্ট_A_Z

এই একটা পোস্ট হতে পারে আপনার হাইপারটেনশন ম্যানেজমেন্ট এর জন্য যথেষ্ট —

গতকালের হাইপারটেনশন Drug adjustment নিয়ে একটা কুইজ ছিলো,

১৪৯ জন উত্তর দিয়েছেন-

তার মধ্যে ৭৬ জন সঠিক উত্তর দিয়েছেন-

বাকি ৭৩ জন ভুল উত্তর দিয়েছেন-

সঠিক উত্তর- D

এবার explanation সহ একবার দেখে নিই–

HTN management এর NICE গাইডলাইন হচ্ছে

বয়স ৫৫ থেকে কম হলে আমরা একটা ACEI অথবা ARBS দিয়ে চিকিৎসা শুরু করবো-

বয়স ৫৫ থেকে বেশি হলে Calcium channel blocker অথবা Amlodipin দিয়ে শুরু করবো-

ধরুন, কারো Amlodipin দিয়ে শুরু করলেন, যদি এতে প্রেশার কন্ট্রোল না হয়, তাহলে আমরা ACEI/ARBS অথবা Diuretics যে কোনো একটা add করতে পারবো-

এরমধ্যে আমার মতে ARBs তথা Olmesartan add করা ভালো- কারণ ACEI, Dry cough করে, আবার Diuretics সমূহ Electrolyte imbalance করে-

তাই আগে ARBs add করুন, Amlodipin + Olmesartan.

এই দুইটাই প্রেশার কন্ট্রোলে না আসলে Diuretics add করবেন, এখন most common Diuretics এর মধ্যে আছে

Hydrochlorothiazide, Indapamide.

Example tablet 1:- Acuren 50 mg (As a Hydrochlorothiazide As A Thiazide diuretics & related drugs).

Indications of tablet 1:- Acuren 50 mg (As a Hydrochlorothiazide As A Thiazide diuretics & related drugs).

Edema associated with congestive heart failure, hepatic cirrhosis, premenstrual tension and oedema due to various forms of renal dysfunction (i.e. nephrotic syndrome, acute glomerulonephritis, chronic renal failure). Hypertension, either alone or as an adjunct to other antihypertensive drugs.

Pharmacology tablet 1:- Acuren 50 mg (As a Hydrochlorothiazide As A Thiazide diuretics & related drugs).

Thiazides such as hydrochlorothiazide promote water loss from the body (diuretics). They inhibit Na⁺/Cl^– reabsorption from the distal convoluted tubules in the kidneys. Thiazides also cause loss of potassium and an increase in serum uric acid. Thiazides are often used to treat hypertension, but their hypotensive effects are not necessarily due to their diuretic activity. Thiazides have been shown to prevent hypertension-related morbidity and mortality although the mechanism is not fully understood. Thiazides cause vasodilation by activating calcium-activated potassium channels (large conductance) in vascular smooth muscles and inhibiting various carbonic anhydrases in vascular tissue.

Dosage & Administration tablet 1:- Acuren 50 mg (As a Hydrochlorothiazide As A Thiazide diuretics & related drugs).

Edema: initially 25 to 50 mg daily, reduced for maintenance if possible; maximum 100 mg daily.

Hypertension: 25 mg daily, increased to 50 mg daily if necessary.

Elderly: in some patients, especially the elderly an initial dose of 12.5 mg daily may be sufficient.

Children: An initial dose for children has been 1 to 2 mg per kg body-weight in 2 divided doses. Infants under 6 months may need doses up to 3 mg per kg daily.

Interaction

Alcohol, barbiturates or narcotics: Co-administration may potentiate orthostatic hypotension. Oral and parenteral antidiabetic drugs may require adjustment of dosage with concurrent use. Other antihypertensive drugs may have an additive effect. Discontinuation of diuretic therapy 2-3 days before the initiation of treatment with an ACE inhibitor may reduce the likelihood of first-dose hypotension. The antihypertensive effect of the drug may be enhanced in the post-sympathectomy patient.

Cholestyramine and colestipol resin: Absorption of Acuren is impaired in the presence of anionic exchange resin. Single doses of either cholestyramine or colestipol resins bind the Acuren and reduce its absorption from the gastrointestinal tract by up to 85% and 43%, respectively. Corticosteroids or ACTH may intensify any Thiazide-induced electrolyte depletion, particularly hypokalaemia. Pressor amines such as adrenaline may show decreased arterial responsiveness when used with Acuren, but this reaction is not enough to preclude their therapeutic usefulness. Non-depolarising muscle relaxants such as tubocurarine may possibly interact with Acuren to increase muscle relaxation. Non-steroidal anti-inflammatory drugs may attenuate the diuretic and antihypertensive effects of diuretics.

Drug/laboratory tests: Because thiazides may affect calcium metabolism, Acuren may interfere with tests for parathyroid function.

Contraindications tablet 1:- Acuren 50 mg (As a Hydrochlorothiazide As A Thiazide diuretics & related drugs).

Anuria, hypersensitivity to Hydrochlorothiazide or to other sulphonamide-derived drugs, severe renal or hepatic failure, Addison’s disease, hypercalcemia, concurrent lithium therapy.

Side Effects tablet 1:- Acuren 50 mg (As a Hydrochlorothiazide As A Thiazide diuretics & related drugs).

Gastro-intestinal system: Anorexia, gastric irritation, nausea, vomiting, cramps, diarrhoea, constipation, jaundice (intrahepatic cholestatic jaundice), pancreatitis, salivary gland inflammation.

Central nervous system: Dizziness, vertigo, paraesthesiae, headache, yellow vision.

Heamatological: Leucopenia, agranulocytosis, thrombocytopenia, aplastic anaemia, haemolytic anaemia.

Cardiovascular: Hypotension, including orthostatic hypotension.

Hypersensitivity: Purpura, photosensitivity, rash, urticaria, necrotising angiitis (vasculitis, cutaneous vasculitis), fever, respiratiory distress including pneumonitis and pulmonary oedema, anaphylactic reactions, toxic epidermal necrolysis.

Metabolic: Hyperglycaemia, glycosuria, hyperuricaema, electrolyte imbalance including hyponatraemia and hypokalaemia.

Renal: Renal dysfunction, interstitial nephritis, renal failure.

Other: Muscle spasm, weakness, restlessness, transient blurred vision, impotence. Whenever side-effects are moderate to severe, thiazide dosage should be reduced or therapy was withdrawn.

Pregnancy & Lactation

Use in pregnancy: Thiazides cross the placental barrier and appear in cord blood. The use of Hydrochlorothiazide when pregnancy is present or suspected requires, therefore, that the benefits of the drug be weighed against possible hazards to the fetus. These hazards include fetal or neonatal jaundice, thrombocytopenia, and possibly other adverse reactions, which have occurred in the adult. The routine use of diuretics in otherwise healthy pregnant women with or without mild oedema is not recommended, because their use may be associated with hypovolaemia, increased blood viscosity and decreased placental perfusion.

Use in breastfeeding mothers: Thiazides appear in breast milk. If use of the drug is deemed essential, the patient should stop breast-feeding.

Precautions & Warnings tablet 1:- Acuren 50 mg (As a Hydrochlorothiazide As A Thiazide diuretics & related drugs).

Patients should be carefully monitored for signs of fluid and electrolyte imbalance (hyponatraemia, hypochloraemic alkalosis, hypokalaemia and hypomagnesaemia). It is particularly important to make serum and urine electrolyte determinations when the patient is vomiting excessively or receiving parenteral fluids. Warning signs or symptoms of fluid and electrolyte imbalance include: dryness of mouth, thirst, weakness, lethargy, drowsiness, restlessness, seizures, confusion, muscle pains or cramps, muscle fatigue, hypotension, oliguria, tachycardia, and gastro-intestinal disturbances such as nausea and vomiting. Hypokalaemia may develop, especially with brisk diuresis, when severe cirrhosis is present, or after prolonged therapy. Hypokalaemia can sensitise or exaggerate the response of the heart to the toxic effects of digitalis (e.g. increased ventricular irritability). Sensitivity reactions may occur in patients with or without history of allergy or bronchial asthma. Hypokalaemia may be avoided or treated in the adult by concurrent use of amiloride hydrochloride, a potassium conserving agent. It may also be avoided by giving potassium chloride or foods with a high potassium content. Diuretic-induced hyponatraemia is usually mild and asymptomatic. Dilutional hyponatraemia may occur in oedematous patients in hot weather; and, except in rare instances when hyponatraemia is life-threatening, appropriate therapy is water restriction rather than administration of salt. Thiazides may decrease serum protein bound iodine levels without signs of thyroid disturbances. Thiazides may decrease urinary calcium excretion, and may also cause intermittent and slight elevation of serum calcium in the absence of known disorders of calcium metabolism. Thiazides should be discontinued before carrying out tests for parathyroid function. When creatinine clearance falls below 30ml/min, thiazide diuretics become ineffective. Uraemia may be precipitated or increased by chlorothiazide. Cumulative effects of the drug may develop in patients with impaired renal function. If increasing uraemia and oliguria occur during treatment of renal disease, Acuren should be discontinued. Thiazides should be used with caution in patients with impaired hepatic function or progressive liver disease, since minor alterations of fluid and electrolyte balance may precipitate hepatic coma. Hyperuricaemia may occur, or gout may be precipitated, in certain patients receiving thiazide therapy. Thaizide therapy may impair glucose tolerance. Increases in cholesterol and triglyceride levels may be associated with thiazide diuretic therapy. The possibility of exacerbation or activation of systemic lupus erythematosus has been reported. Latent diabetes may become manifest during thiazide administration.

Overdose Effects tablet 1:- Acuren 50 mg (As a Hydrochlorothiazide As A Thiazide diuretics & related drugs).

The most common signs and symptoms observed are those caused by electrolyte depletion (hypokalaemia, hypochloraemia, hyponatraemia) and dehydration resulting from excessive diuresis. If digitalis has also been administered, hypokalaemia may accentuate cardiac arrhythmias. In the event of overdosage, symptomatic and supportive measures should be employed. If ingestion is recent, emesis should be induced or gastric lavage performed. Dehydration, electrolyte imbalance, hepatic coma and hypotension should be corrected by established methods. If required, give oxygen or artificial respiration for respiratory impairment.

Therapeutic Class tablet 1:- Acuren 50 mg (As a Hydrochlorothiazide As A Thiazide diuretics & related drugs).

Thiazide diuretics & related drugs

Indapamide:-

Or tablet2: Repres SR 1.5 mg (As A indapamide As a Thiazide diuretics & related drugs).

Indications of tablet2: Repres SR 1.5 mg (As A indapamide As a Thiazide diuretics & related drugs).

Repres SR tablet is indicated in the treatment of essential hypertension. It is effective in treating hypertension in patients with renal function impairment, although its diuretic effect is reduced. Repres SR is also indicated for the treatment of salt and fluid retention associated with congestive heart failure. One tablet daily, preferably in the morning. In more severe cases, Repres SR tablet can be combined with other categories of antihypertensive agents.

Pharmacology tablet2: Repres SR 1.5 mg (As A indapamide As a Thiazide diuretics & related drugs).

Indapamide is an oral antihypertensive agent. The mechanism whereby Indapamide exerts its antihypertensive action has not been completely elucidated; both vascular and renal actions have been implicated. The possible beneficial pharmacological effects of Indapamide in the treatment of hypertension include a reduction in cardiac hypertrophy and a reduction in the thickening of arterial walls, a prevention of the accumulation of the embryonic isoform of fibronectin in coronary vessels, free radical scavenging leading to stimulation of vasodilator eicosanoid formation, and interaction with renal carbonic anhydrase. The renal site of action of Indapamide is the proximal segment of the distal tubule. Indapamide appears to have natriuretic properties (sodium and chloride being excreted in equivalent amounts) with less effect on kaliuresis or uric acid excretion. Only at doses greater than 1.5 mg Indapamide sustained release tablet/day is an appreciable increase in urinary volume observed in man. No significant changes in plasma sodium levels have been observed in clinical studies. Significant hypokalemia (plasma potassium <3.2 mmol/L) has been reported in 4% of patients.

Absorption: The fraction of Indapamide released is rapidly and totally absorbed via the gastrointestinal digestive tract. Ingestion with food slightly increases the rate and extent of absorption. These changes are unlikely to be clinically significant. Peak serum level following a single dose occurs about 12 hours after ingestion; repeated administration reduces the variation in serum levels between 2 doses.

Distribution: Indapamide is widely distributed throughout the body, with extensive binding to some specific sites. In blood, it is highly bound to red blood cells (80%) and more specifically to carbonic anhydrase (98%) without having any significant inhibiting activity on this enzyme. Binding of Indapamide to plasma proteins is 79%. The plasma elimination half-life is 14 to 24 hours (mean 18 hours). The drug has a volume of distribution of approximately 60L. Steady state is achieved after 7 days. Repeated administration does not lead to accumulation.

Metabolism: The drug is extensively metabolized in the liver, with only 5 to 7% of the dose excreted in the urine as unchanged drug.

Elimination: Elimination is essentially urinary (70% of the dose) and faecal (22%) in the form of inactive metabolites.

Dosage & Administration tablet2: Repres SR 1.5 mg (As A indapamide As a Thiazide diuretics & related drugs).

One tablet daily preferably in the morning. In more sever case Indapamide can be combine with other categories of anti-hypertensive agent. The safety and effectiveness in pediatric patients have not been established.

Use in Pediatric Patients: The safety and effectiveness in pediatric patients have not been established.

Interaction tablet2: Repres SR 1.5 mg (As A indapamide As a Thiazide diuretics & related drugs).

Other Antihypertensive: Repres SR may add to or potentiate the action of other antihypertensive drugs. In limited controlled trials that compared the effect of Repres SR combined with other antihypertensive drugs with the effect of the other drugs administered alone, there was no notable change in the nature or frequency of adverse reactions associated with the combined therapy.

Norepinephrine: Repres SR, like the thiazides, may decrease arterial responsiveness to norepinephrine, but this diminution is not sufficient to preclude effectiveness of the pressor agent for therapeutic use.

Contraindications tablet2: Repres SR 1.5 mg (As A indapamide As a Thiazide diuretics & related drugs).

This drug must not be taken in the following conditions: known allergy to this drug or to sulphonamides, renal failure, serious liver disease, hypokalemia.

Side Effects tablet2: Repres SR 1.5 mg (As A indapamide As a Thiazide diuretics & related drugs).

Side effects include dizziness, headache, anorexia, nausea, vomiting, constipation, diarrhea and postural hypotension. Electrolyte imbalances include hypochloremic alkalosis, hyponatremia, hypokalemia and hyperuricemia; hypersensitivity reactions which include skin rashes, cholestatic jaundice and blood dyscrasias including thrombocytopenia, leucopenia, aplastic anemia.

Pregnancy & Lactation tablet2: Repres SR 1.5 mg (As A indapamide As a Thiazide diuretics & related drugs).

There is no adequate and well-controlled studies in pregnant women and so Indapamide is not recommended. Mothers taking Indapamide should not breastfeed.

Precautions & Warnings tablet2: Repres SR 1.5 mg (As A indapamide As a Thiazide diuretics & related drugs).

The drug should be used cautiously in the following situations- disturbed water/electrolyte balance, diabetes, gout and kidney problems. Monitoring of potassium and uric acid serum levels is also recommended.

Therapeutic Class tablet2: Repres SR 1.5 mg (As A indapamide As a Thiazide diuretics & related drugs).

Thiazide diuretics & related drugs

আমরা কোনটা add করবো?

NICE Guidline always যেসব ড্রাগের সাইড ইফেক্ট কম, তা প্রথমত choice করে-

আমরা যদি Hydrochlorothiazide এর Molecular structure দেখি, সেখানে একটা steroid Nucleus আছে, যার কারণে hydrochlorothiazide দিকে স্টেরয়েড এর মত দুইটা সাইড ইফেক্ট দেখায়–

1. Dyslipidemia. 2. Impaired Glucose tolerance

অপরদিকে Indapamide এর Molecular structure এর মধ্যে স্টেরয়েড নিউক্লিয়াস না থাকায় indapamide এইসব সাইড ইফেক্ট দেখায়না

আবার Thiazide যে পরিমান Electrolyte imbalance করে, Indapamide সেটা করেনা–

তাই কেউ যদি প্রথমে Amlodipin পায়, BP control না হলে ARBs add koren.. অথবা কেউ আগে থেকে প্রথমত ARBs পেয়ে থাকলে Next line Amlodipin শুরু করেন –

এখন Amlodipin + Olmesartan ২ টাতেই যদি Control না হয়, তাহলে Diuretics add করবে-

Diuretics মধ্যে Drug of choice Indapamide –

3.Amlodipin:-

Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

Indications Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

Essential hypertension: Amlotab is efficacious as monotherapy in the treatment of hypertension. It may be used in combination with other antihypertensive agents.

Angina pectoris: Amlotab is indicated for the treatment of chronic stable angina pectoris and is efficacious as monotherapy. It may be used in combination with other antianginal agents.

Vasospastic angina: Amlotab is indicated for the treatment of confirmed or suspected vasospastic angina. It may be used as monotherapy or in combination with other antianginal drugs.

Pharmacology Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

Amlodipine is a dihydropyridine calcium-channel blocker, with a long duration of action, used for the treatment of hypertension and angina pectoris. Amlodipine influences the myocardial cells, the cells within the specialized conducting system of the heart, and the cells of vascular smooth muscle. Administration of Amlodipine results primarily in vasodilation, with reduced peripheral resistance, blood pressure and afterload, increased coronary blood flow and a reflex increase in coronary heart rate. This in turn results in an increase in myocardial oxygen supply and cardiac output.

Dosage & Administration Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

Hypertension: Usual dose is 5 mg once daily. The maximum dose is 10 mg once daily. Elderly patients with hepatic insufficiency may be started on 2.5 mg once daily; this dose may also be used when adding Amlodipine to other antihypertensive therapy.

Angina (Chronic stable or Vasospastic): 5 to 10 mg, using the lower dose for elderly and in patients with hepatic insufficiency. Most patients require 10 mg.

Administrations: May be taken without regard to meals.

Interaction Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

Drug Interactions-

Potentially hazardous interactions: Little or no data are available in patients with markedly impaired cardiac left ventricular function; however, as with other calcium antagonist drugs, the combination of Amlotab and p-blockers should be avoided in such patients.

Other Significant Interactions-

Digoxin: Absence of any interaction between Amlotab and Digoxin in healthy volunteers has been documented in a controlled clinical study.
Cimetidine: An unpublished clinical study indicated no interaction between, Amlotab and Cimetidine in healthy volunteers.
Warfarin: An unpublished clinical study in healthy volunteers indicates that Amlotab did not significantly alter the effect of Warfarin on prothrombin time.
Food: Food does not alter the rate or extent of absorption of Amlotab.

Contraindications Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

Hypersensitivity to dihydropyridine derivatives. Pregnant woman.

Side Effects Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

The most common adverse effects of amlodipine are associated with vasodilatory action, such as dizziness, flushing, headache, hypotension and peripheral edema. Gastrointestinal disturbances, increased micturition frequency, lethargy, eye pain and mental depression may also occur. A paradoxical increase in ischaemic chest pain may occur at the start of the treatment and in a few patients excessive fall in blood pressure has led to cerebral or myocardial ischaemia or transient blindness. Rashes, fever and abnormalities in liver function due to hypersensitivity reaction of Amlotab may occur.

Pregnancy & Lactation Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

Pregnancy Category C. There are no adequate and well-controlled studies of Amlodipine in pregnant women. Amlodipine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. It is not known whether Amlodipine is excreted in human milk. In the absence of this information, it is recommended that nursing be discontinued while Amlodipine is administered.

Precautions & Warnings

Precaution should be taken in patients with hepatic impairment and during pregnancy and breast feeding.

Use in Special Populations Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

Children with hypertension from 6 years to 17 years of age: 2.5 mg once daily as a starting dose, up-titrated to 5 mg once daily if blood pressure goal is not achieved after 4 weeks. Doses in excess of 5 mg daily have not been studied in pediatric patients.

Children under 6 years old: The effect of amlodipine on blood pressure in patients less than 6 years of age is not known.

Elderly: Amlotab used at similar doses in elderly or younger patients is equally well tolerated. Normal dosage regimens are recommended in the elderly, but increase of the dosage should take place with care.

Renal impairment: Changes in amlodipine plasma concentrations are not correlated with degree of renal impairment, therefore the normal dosage is recommended. Amlotab is not dialysable.

Hepatic impairment: Dosage recommendations have not been established in patients with mild to moderate hepatic impairment; therefore dose selection should be cautions and should start at the lower end of the dosing range. The pharmacokinetics of Amlotab have not been studied in severe hepatic impairment. Amlotab should be initiated at the lowest dose (2.5 mg once daily) and titrated slowly in patients with severe hepatic impairment.

Overdose Effects Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

Symptoms: Available data suggest that large overdosage could result in excessive peripheral vasodilatation and possibly reflex tachycardia. Marked and probably prolonged systemic hypotension up to and including shock with fatal outcome have been reported.

Management: Clinically significant hypotension due to amlodipine overdosage calls for active cardiovascular support including frequent monitoring of cardiac and respiratory function, elevation of extremities, and attention to circulating fluid volume and urine output.

A vasoconstrictor may be helpful in restoring vascular tone and blood pressure, provided that there is no contraindication to its use. Intravenous calcium gluconate may be beneficial in reversing the effects of calcium channel blockade. Gastric lavage may be worthwhile in some cases. In healthy volunteers the use of charcoal up to 2 hours after administration of amlodipine 10 mg has been shown to reduce the absorption rate of amlodipine. Since amlodipine is highly protein-bound, dialysis is not likely to be of benefit.

Therapeutic Class Tablet 3:-Amlotab 10mg (AS A Amlodipin Besilate AS A Calcium-channel blockers).

Calcium-channel blockers

4.Olmesartan:-

Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

Indications of Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

Olmecar tablet is indicated for the treatment of hypertension. It may be used alone or in combination with other antihypertensive agents.

Pharmacology of Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

Angiotensin II is formed from angiotensin I in a reaction catalyzed by angiotensin converting enzyme (ACE, Kininase II). Angiotensin II is the principal pressor agent of the renin-angiotensin system, with effects that include vasoconstriction, stimulation of synthesis and release of aldosterone, cardiac stimulation and renal reabsorption of sodium. Olmesartan blocks the vasoconstrictor effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT 1 receptor in vascular smooth muscle. An AT 2 receptor is found also in many tissues, but this receptor is not known to be associated with cardiovascular homeostasis. Olmesartan has more than a 12,500-fold greater affinity for the AT 1 receptor than for the AT 2 receptor. Olmesartan medoxomil does not inhibit ACE (kininase II), it does not affect the response to bradykinin. Blockade of the angiotensin II receptor inhibits the negative regulatory feedback of angiotensin II on renin secretion, but the resulting increased plasma renin activity and circulating angiotensin II levels do not overcome the effect of olmesartan on blood pressure.

Dosage & Administration of Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

Dosage must be individualized. The usual recommended starting dose of Olmesartan is 20 mg once daily when used as monotherapy in patients who are not volume-contracted. For patients requiring further reduction in blood pressure after 2 weeks of therapy, the dose of Olmesartan may be increased to 40 mg. Doses above 40 mg do not appear to have a greater effect. Twice-daily dosing offers no advantage over the same total dose given once daily.

No initial dosage adjustment is recommended for elderly patients, for patients with moderate to marked renal impairment (creatinine clearance <40 ml/min) or with moderate to marked hepatic dysfunction. For patients with possible depletion of intravascular volume (e.g. patients treated with diuretics, particularly those with impaired renal function), Olmesartan should be initiated under close medical supervision and consideration should be given to use of a lower starting dose. Olmesartan may be administered with or without food.

Paediatric use: Safety and effectiveness in paediatric patients have not been established.

Interaction of Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

No significant drug interactions were reported in studies in which Olmecar was co-administered with digoxin or warfarin in healthy volunteers. The bioavailability of olmesartan was not significantly altered by the co-administration of antacids. Olmecar is not metabolized by the cytochrome P450 system and has no effects on P450 enzymes; thus, interactions with drugs that inhibit, induce, or are metabolized by those enzymes are not expected. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) including selective Cyclooxygenase-2 Inhibitors (COX-2 Inhibitors) in patients who are elderly, volume-depleted (including those on diuretic therapy), or with compromised renal function, co-administration of NSAIDs, including selective COX-2 inhibitors, with angiotensin II receptor antagonists, including Olmecar, may result in deterioration of renal function, including possible acute renal failure. These effects are usually reversible. Monitor renal function periodically in patients receiving Olmecar and NSAID therapy. The antihypertensive effect of angiotensin II receptor antagonists, including Olmecar may be attenuated by NSAIDs including selective COX-2 inhibitors.

Contraindications of Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

Olmesartan is contraindicated in patients who are hypersensitive to any component of this product.

Side Effects of Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

Olmecar has been evaluated for safety in more than 3825 patients/subjects, including more than 3275 patients treated for hypertension in controlled trials. Treatment with Olmecar was well tolerated, with an incidence of adverse reactions similar to placebo. The overall frequency of adverse reactions was not dose related. Analysis of gender, age and race groups demonstrated no differences between Olmecar and placebo treated patients. The rate of withdrawals due to adverse reactions in all trials of hypertensive patients was 2.4% of patients treated with Olmecar and 2.7% of control patients. In placebo controlled trials, the only adverse reaction that occurred in more than 1% of patients treated with Olmecar and at a higher incidence versus placebo was dizziness (3% vs. 1%)

The following adverse reactions occurred in placebo-controlled clinical trials at an incidence of more than 1% of patients treated with Olmecar, but also occurred at about the same or greater incidence in patients receiving placebo: back pain, bronchitis, creatine phosphokinase increased, diarrhea, headache, hematuria, hyperglycemia, hypertriglyceridemia, influenza-like symptoms, pharyngitis, rhinitis and sinusitis. The incidence of cough was similar in placebo (0.7%) and Olmecar (0.9%) patients.

Pregnancy & Lactation of Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

When pregnancy is detected, discontinue this product as soon as possible. When used in pregnancy during the second and third trimesters, drugs that act directly on the renin-angiotensin system can cause injury and even death to the developing fetus. It is not known whether Olmesartan is excreted in human milk, but Olmesartan is secreted at low concentration in the milk of lactating rats. Because of the potential for adverse effects on the nursing infant, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.

Precautions & Warnings of Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

As a consequence of inhibiting the renin-angiotensin-aldosterone system, changes in renal function may be anticipated in susceptible individuals treated with Olmecar. In patients whose renal function may depend upon the activity of the renin-angiotensin-aldosterone system (e.g. patients with severe congestive heart failure), treatment with angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists has been associated with oliguria and/or progressive azotemia and (rarely) with acute renal failure and/or death. Similar results may be anticipated in patients treated with Olmecar.

Overdose Effects of Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

There is no experience of overdose with Olmecar. The most likely effects of Olmecar overdosage are hypotension and tachycardia; bradycardia could be encountered if parasympathetic (vagal) stimulation occurred. If intake is recent, gastric lavage or induction of emesis may be considered. Clinically significant hypotension due to an overdose of Olmecar requires the active support of the cardiovascular system, including close monitoring of heart and lung function, the elevation of the extremities, and attention to circulating fluid volume and urine output.

Therapeutic Class of Tablet 4.Olmecar 40mg (AS A Olmesartan Medoxomil Angiotensin-ll receptor blocker).

Angiotensin-ll receptor blocker

এবার ধরুণ,

কারো এই ৩ টা মেডিসিন দিয়েও প্রেশার নিয়ন্ত্রণ হচ্ছেনা,

তাহলে তাকে Resistant hypertension এর কেস হিসাবে বিবেচনা করে তার HTN এর secondary কোনো Cause আছে কিনা, তা দেখে নিবেন, থাকলে সেটার চিকিৎসা দিবেন-

আর যদি কোনো cause না থাকে, তাহলে

4th line Drug কোনটা add করবেন?

according to NICE তার একটা serum electrolyte করেন, যদি Serum Potassium <4.5 mmol/L হয়,

তাহলে Spironolactone add করুন-

Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

Indications of Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

Inospiron is indicated in Congestive heart failure, Hepatic cirrhosis with ascites and oedema, Nephrotic syndrome, Primary hyperaldosteronism, Essential hypertension, For the treatment of patients with hypokalemia

Description Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

Inospiron is a long-acting aldosterone antagonist. Inospiron is a specific pharmacologic antagonist of aldosterone, acting primarily through competitive binding of receptors at the aldosterone dependent sodium-potassium exchange site in the distal convoluted renal tubule. Inospiron causes increased amounts of sodium and water to be excreted, while potassium and magnesium is retained.

Pharmacology Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

Spironolactone is a specific pharmacologic antagonist of aldosterone, acting primarily through competitive binding of receptors at the aldosterone-dependent sodium-potassium exchange site in the distal convoluted renal tubule. Spironolactone causes increased amounts of sodium and water to be excreted, while potassium is retained. Spironolactone acts both as a diuretic and as an antihypertensive drug by this mechanism. It may be given alone or with other diuretic agents which act more proximally in the renal tubule. Aldosterone interacts with a cytoplasmic mineralocorticoid receptor to enhance the expression of the Na⁺ K⁺ ATPase and the Na⁺ channel involved in a Na⁺ K⁺ transport in the distal tubule . Spironolactone bind to this mineralcorticoid receptor, blocking the actions of aldosterone on gene expression. Aldosterone is a hormone; its primary function is to retain sodium and excrete potassium in the kidneys.

Dosage & Administration Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

Edema in adults (congestive heart failure, hepatic cirrhosis, or nephrotic syndrome): An initial daily dosage of 100 mg of Spironolactone administered in either single or divided doses is recommended, but may range from 25 to 200 mg daily. Combined therapy with other diuretics is indicated when more rapid diuresis is desired.

Primary hyperaldosteronism: After the diagnosis of hyperaldosteronism has been established, Spironolactone may be administered in doses of 100 to 400 mg daily in preparation for surgery. For patients who are considered unsuitable for surgery, Spironolactone may be employed for long-term maintenance therapy at the lowest effective dosage determined for the individual patient.

Essential hypertension: For adults, an initial daily dosage of 50 to 100 mg of Spironolactone administered in either single or divided doses is recommended.

Hypokalemia: Spironolactone in a dosage ranging from 25 mg to 100 mg daily is useful in treating a diuretic-induced hypokalemia.

Interaction Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

ACE inhibitors: Concomitant administration of ACE inhibitors with potassium-sparing diuretics has been associated with severe hyperkalemia.

Alcohol, barbiturates, or narcotics: Potentiation of orthostatic hypotension may occur.

Corticosteroids, ACTH: Intensified electrolyte depletion, particularly hypokalemia, may occur.

Lithium: Lithium generally should not be given with diuretics. Diuretic agents reduce the renal clearance of lithium and add a high risk of lithium toxicity.

Digoxin: Inospiron has been shown to increase the half-life of digoxin.

Contraindications Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

Spironolactone is contraindicated in patients with acute renal insufficiency, significant impairment of renal function, anuria, hyperkalaemia or sensitivity to Spironolactone.

Side Effects Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

Gynaecomastia may develop in association with the use of Inospiron. Other adverse reactions are: GI symptoms including cramping and diarrhoea, drowsiness, lethargy, headache, urticaria, mental confusion, impotence, irregular menses or amenorrhoea and post-menopausal bleeding.

Pregnancy & Lactation

Pregnancy: Spironolactone should not be used during pregnancy

Lactation: Canrenone, an active metabolite of Spironolactone, appears in breast milk. If use of the drug is deemed essential an alternative method of infant feeding should be instituted.

Precautions & Warnings Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

All patients receiving diuretic therapy should be observed for evidence of fluid or electrolyte imbalance. Hyperkalemia may occur in patients with impaired renal function or excessive potassium intake and can cause cardiac irregularities, which may be fatal.

Overdose Effects Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

Symptoms of overdosage include drowsiness, mental confusion, dizziness, diarrhea and vomiting etc. Patients should induce vomiting or evacuate the stomach by lavage during Inospiron overdoasge.

Therapeutic Class Tablet 5:-inospiron 100 mg (As A spironolactone As A Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists).

Potassium-sparing diuretics, Potassium-sparing diuretics & Aldosterone antagonists

আর যদি serum potassium > 4.5 mmol/L থাকে, তাহলে Beta blocker /Alpha blocker add করুন–

Tablet6:Betalock 50 mg (As a metoprolol tartrate as a Beta blocker).

Indications of Tablet6:Betalock 50 mg (As a metoprolol tartrate as a Beta blocker).

ln the management of hypertension and angina pectoris. Cardiac arrhythmias, especially supraventricular tachyarrhythmias. Adjunct to the treatment of hyperthyroidism. Early intervention with Betaloc in acute myocardial infarction reduces infarct size and the incidence of ventricular fibrillation. Pain relief may also decrease the need for opiate analgesics. Betaloc has been shown to reduce mortality when administered to patients with acute myocardial infarction.

Pharmacology of Tablet6:Betalock 50 mg (As a metoprolol tartrate as a Beta blocker).

Metoprolol is a selective beta1-blocker. Metoprolol reduces or inhibits the agonistic effect on the heart of catecholamines (which are released during physical and mental stress). This means that the usual increase in heart rate, cardiac output, cardiac contractility and blood pressure, produced by the acute increase in catecholamines, is reduced by Metoprolol. Metoprolol interferes less with Insulin release and carbohydrate metabolism than do non-selective beta-blockers. Metoprolol interferes much less with the cardiovascular response to hypoglycaemia than do non-selective beta-blockers.

Dosage & Administration of Tablet6:Betalock 50 mg (As a metoprolol tartrate as a Beta blocker).

Film-coated tablet–

Hypertension: Total daily dosage Metoprolol 100-400 mg to be given as a single or twice-daily dose. The starting dose is 100 mg (two Metoprolol-50 tablets) per day. This may be increased by 100 mg per day at weekly intervals. lf full control is not achieved using a single daily dose, a b.i.d. regimen should be initiated. Combination therapy with a diuretic or other antihypertensive agents may also be considered.
Angina: Usually Metoprolol 50 mg (one Metoprolol-50 tablet) to 100 mg (two Metoprolol-50 tablets) twice or three times daily.
Cardiac arrhythmias: Metoprolol 50 mg (one Metoprolol-50 tablet) b.i.d or t.i.d should usually control the condition. It is necessary the dose can be increased up to 300 mg per day in divided doses. Following the treatment of an acute arrhythmia with Metoprolol injection, continuation therapy with Metoprolol tablets should be initiated 4-6 hours later. The initial oral dose should not exceed 50 mg t.i.d.
Hyperthyroidism: Metoprolol 50 mg (one Metoprolol-50 tablet) four times a day. The dose should be reduced as the euthyroid state is achieved.
Myocardial infarction: Orally, therapy should commence 15 minutes after the last injection with 50 mg every 6 hours for 48 hours. Patients who fail to tolerate the full intravenous dose should be given half the suggested oral dose. Maintenance- The usual maintenance dose is 200 mg daily given in divided doses. Elderly’ There are no special dosage requirements in otherwise healthy elderly patients. Significant hepatic dysfunction: A reduction in dosage may be necessary.

Extended-release tablet-

Hypertension: The usual initial dosage is 25 to 100 mg daily in a single dose, whether used alone or added to a diuretic.
Angina Pectoris: The dosage of extended-release Metoprolol Succinate should be individualized. The usual initial dosage is 100 mg daily, in a single dose.
Heart Failure: The recommended starting dose of sustained-release Metoprolol Succinate is 25 mg once daily for two weeks in patients with NYHA class II heart failure and 12.5 mg once daily in patients with more severe heart failure. The dosage may be increased at weekly (or longer) intervals until optimum blood pressure reduction is achieved. If treatment is to be discontinued, the dosage should be reduced gradually over a period of 1-2 weeks.

IV Injection-

Arrhythmias: By intravenous injection, up to 5 mg at a rate of 1-2 mg/minute, repeated after 5 minutes if necessary, total dose 10-15 mg.
In surgery: By slow intravenous injection 2-4 mg at induction or to control arrhythmias developing during anaesthesia; 2 mg doses may be repeated to a maximum of 10 mg.
Myocardial Infarction: Early intervention within 12 hours of infarction, by intravenous injection 5 mg every 2 minutes to a maximum of 15 mg, followed after 15 minutes by 50 mg by mouth every 6 hours for 48 hours; maintenance 200 mg daily in divided doses.

Interaction of Tablet6:Betalock 50 mg (As a metoprolol tartrate as a Beta blocker).

Catecholamine‐depleting drugs (e.g. Reserpine, Monoamine Oxidase (MAO) inhibitors) may have an additive effect when given with beta‐blocking agents. Drugs that inhibit CYP2D6 such as quinidine, fluoxetine, paroxetine and propafenone are likely to increase Betaloc concentration. These increases in plasma concentration would decrease the cardioselectivity of Betaloc. Concomitant use of digitalis glycosides and beta‐blockers can increase the risk of bradycardia. Beta‐blockers may exacerbate the rebound hypertension which can follow the withdrawal of clonidine.

Contraindications of Tablet6:Betalock 50 mg (As a metoprolol tartrate as a Beta blocker).

AV block, Uncontrolled heart failure, severe bradycardia, sick-sinus syndrome, cardiogenic shock and severe peripheral arterial disease. Known hypersensitivity to Metoprolol or other B-blockers. Metoprolol is also contra-indicated when myocardial infarction is complicated by significant bradycardia, first-degree heart block, systolic hypotension (<100mmHg) and/or severe heart failure.

Side Effects of Tablet6:Betalock 50 mg (As a metoprolol tartrate as a Beta blocker).

Tiredness, dizziness, depression, diarrhea, itching or rash, shortness of breath, slow heart rate, mental confusion, headache, somnolence, nightmares, insomnia, dyspnea, Nausea, dry mouth, gastric pain, constipation, flatulence, digestive tract disorders, heartburn, pruritus, musculoskeletal pain, blurred vision, decreased libido, and tinnitus have also been reported, intensification of AV block.

Pregnancy & Lactation of Tablet6:Betalock 50 mg (As a metoprolol tartrate as a Beta blocker).

Pregnancy Category C. There are no adequate and well‐controlled studies in pregnant women. This drug should be used during pregnancy only if clearly needed. Metoprolol is excreted in breast milk in very small quantities. Caution should be exercised when Metoprolol is administered to a nursing woman.

কেস সিনারিওতে রাশেদার বয়স ৭০

তার প্রথমত Amlodipin দিয়ে চিকিৎসা শুরু হয়-

Amlodipin এ Control না হওয়ায় Olmesartan add করা হয়, তারপরেও প্রেশার Control না হলে করনীয় হবে indapamide add করা—

এবার সিনারিওটা দেখেন–

রাশেদা ৭০ বছর-

Amlodipin and Olmesartan পাচ্ছে, bp control hocchena.. Secondary cause of HTN excluded.

BP 150/95 mmHg, H-R 78 bpm.

এখন কোন ড্রাগ এড করবেন? According to NICE

A… Bisoprolol

B… Hydrochlorothiazide

C… Spironolactone

D… Indapamide

তাহলে সঠিক উত্তর হবে- D

Raiyyan Tahsan Date:26-01-2025 Sunday Time:26-01-2025

Raiyyan Tahsan

Raiyyan Tahsan