Review of Pharmacology - 9E (2015)

Review of Pharmacology
SALIENT FEATURES OF JNC-8 GUIDELINES
• Goal BP should be < 140/90 mmHg in all patients < 60 years irrespective of presence or
absence of diabetes (DM) or chronic kidney disease (CKD).
• Goal BP for elderly (> 60 years) without CKD and DM is relaxed to < 150/90 mmHg
• Goal BP for elderly (> 60 years) with CKD or DM or both is < 140/90 mmHg.
• Beta blockers are no longer considered as first-line drugs due to increased mortality.
• First line drugs include thiazides, ACE inhibitors, ARBs and calcium channel blockers
(CCBs).
• Rest of the drugs are considered later-line drugs as blood pressure should be controlled
by first line drugs alone or in combination.
• ACE inhibitors and ARBs should not be given simultaneously to a person.
• ACE inhibitors or ARBs are first choice drugs in patients with CKD irrespective of ethnic
backgrounds.
• For patients with African descent without CKD, CCBs or thiazides should be preferred.
COMPARISON OF JNC-VII AND JNC-VIII GUIDELINES
Cardiovascular System
Calcium channel blockers
(including amlodipine, diltiazem,
and nifedipine) are the first-line
therapy for idiopathic pulmonary
hyper tenstion.
1. Goal BP
– < 60 years without CKD or DM
– > 60 years without CKD or DM
– Any age with CKD or DM or both
2. First choice drug without compelling
indications
< 140/90
< 140/90
< 130/80
Thiazides
JNC-VII
3. First-line drugs Thiazides, beta-blockers,
ACEI, ARB, CCB
TREATMENT OF IDIOPATHIC PULMONARY HYPERTENSION
JNC-VIII
< 140/90
< 150/90
< 140/90
Thiazides, ACE
inhibitors, ARBs, CCBs
Thiazide, ACEI, ARB,
CCB
• If the patient responds to intravenous vasodilators, then oral calcium channel
blockers (including amlodipine, diltiazem, and nifedipine) are the first-line therapy.
• If these are ineffective or the patient does not respond to vasodilators, then therapy
depends on function.
––
If the patient has WHO Class 2 symptoms, then either phosphodiesterase
inhibitors (sildenafil or tadalafil) or endothelin receptor blockers (bosentan or
ambrisentan) are recommended.
––
If the patient has WHO Class 3 symptoms, then prostacyclin analogs
(epoprostenol intravenously, iloprost by inhalation, or beraprost or treprostinal
subcutaneously) should be added to the regimen.
––
For patients with WHO Class 4 symptoms, either epoprostenol or iloprost
should be used as the sole agent, though some experts still advocate combination
therapies.
• Most authorities advocate long-term oral anticoagulation.
• Supplemental oxygen, particularly at night, appears to improve symptoms and
helps reduce pulmonary pressures.
• Diuretics help with right heart edema.
• Pulmonary transplantation is a viable option in selected centers, though the operative
mortality is high (around 20–25%).
• Women with significant pulmonary hypertension should not get pregnant, and
permanent birth control measures should be considered.
• Future advances in therapy include the possible use of angiogenesis inhibitors,
growth factor inhibitors, and endothelial stem cells or progenitor cells.
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