Contraindications and precautions for common antihypertensive drugs

Contraindications and precautions for common antihypertensive drugs

October 10, 2017 Source: Medical News

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Dihydropyridine CCB: Clear vasodilatation, short-acting CCB will have a reflex heart rate at the same time as decompression, and it is relatively contraindicated in patients with hypertension and tachyarrhythmia.

No. 1 person: ACEI angiotensin converting enzyme inhibitor

Representative No. 1: enalapril, captopril, benazepril, lisinopril, etc.

ACEI is a class of drugs that exert a hypotensive effect by competitively inhibiting ACE (angiotensin converting enzyme). Since its introduction in the 1980s, a large number of evidence-based medical evidence shows that these drugs have good target organ protection and cardiovascular end point preventive effects for hypertensive patients. ACEI has become a significant antihypertensive effect and a wide range of applications. One of the cornerstones of hypertension treatment.

Although ACEI is well tolerated, rare and dangerous adverse reactions may occur, with contraindications as follows:

(1) Absolute contraindications:

1 Pregnancy: ACEI can affect embryonic development. Contraceptive measures should be taken when women of childbearing age use ACEI; women who plan pregnancy should avoid using ACEI;

2 angioedema: can cause laryngeal edema, respiratory arrest and other serious adverse reactions, the risk is high; clinically suspected angioedema, patients should avoid using ACEI for life;

3 bilateral renal artery stenosis: acute kidney injury caused by insufficient glomerular perfusion pressure in acute renal ischemia;

4 hyperkalemia (>6.0mmol / L): ACEI inhibition of aldosterone secretion leads to elevated blood potassium levels, more common in patients with chronic heart failure, renal insufficiency and potassium supplementation or combined with potassium-sparing diuretics.

(2) Relative contraindications:

1 serum creatinine level is significantly increased (> 265 μmol / L);

2 hyperkalemia (>5.5mmol / L);

3 symptomatic hypotension (<90mmHg), more common in patients with RAAS activation such as heart failure and hypovolemia;

4 women with possible pregnancy;

5 patients with left ventricular outflow obstruction.

Clinical medication considerations

(1) Try to choose long-acting preparations to stabilize blood pressure, and avoid using drugs that affect the antihypertensive effect, such as most non-steroidal anti-inflammatory drugs (wherein the dose of aspirin is ≥300mg), hormones, etc.

(2) Blood potassium, serum creatinine and estimated glomerular filtration rate (eGFR) should be measured before application of ACEI. The administration should start with a small dose and gradually increase to the standard dose on the premise that the patient can tolerate; treatment 2 After ~4 weeks, the effect should be evaluated and blood potassium, serum creatinine and eGFR should be reviewed. If blood potassium is elevated (>5.5mmol/L), eGFR is reduced by >30% or serum creatinine is increased by more than 30%, the drug dose should be reduced. And continue to monitor and stop the drug if necessary;

(3) When there are adverse reactions such as dry cough and hypotension, it should be actively treated to avoid the decline of patient compliance;

(4) If the blood pressure control of single drug treatment is not good, then the addition or combination therapy should be considered, and the combination of ACEI and ARB should be prohibited.

No. 2: ARB (Angiotensin Receptor Blocker)

Representative No. 2: losartan, valsartan, candesartan, etc.

ARB is a blood pressure-lowering drug that has a good effect on hypertension and cardiovascular disease after ACEI. Compared with ACEI, ARB has a good antihypertensive effect, and has no adverse reactions such as dry cough and angiotensin edema of ACEI. The patient has higher therapeutic compliance and has become a first-line antihypertensive drug, which has been widely used in clinical practice.

In addition to blood pressure, ARB also has cardiovascular and renal protection and improved glucose metabolism. The preferred population includes hypertension with left ventricular hypertrophy, cardiac insufficiency, atrial fibrillation, coronary heart disease, diabetic nephropathy, microalbuminuria or Proteinuria, metabolic syndrome, and patients who cannot tolerate ACEI should also pay attention to their adverse reactions and contraindications in the clinic.

Contraindications:

(1) ARB can be teratogenic and prohibited from being used in patients with pregnancy-induced hypertension;

(2) ARB dilates the glomerular outcrop small arteries, resulting in decreased glomerular filtration rate (GFR), elevated creatinine levels, and elevated serum potassium, so ARB is contraindicated in patients with hyperkalemia or bilateral renal artery stenosis.

Precautions:

(1) due to ARB expansion of glomerular outbulb small arteries > dilated glomeruli into the small arteries, glomerular filtration pressure decreased, renal dysfunction, decreased GFR, increased serum creatinine and serum potassium levels. Therefore, for patients with chronic kidney disease (CKD) stage 4 or 5, the initial dose of ARB is halved and the changes of serum potassium, serum creatinine and GFR are closely monitored; those with serum creatinine level ≥ 3 mg/dl should be used with caution;

(2) Patients with unilateral renal artery stenosis should pay attention to changes in the affected side and healthy side of the kidney when using ARB;

(3) patients with acute coronary syndrome or heart failure, starting with a small dose of ARB (about 1/2 of the conventional dose), to avoid first-pass hypotension, gradually increase the dose to the target dose that the patient can tolerate;

(4) Avoid ARB + ​​ACEI, especially ARB + ​​ACEI + mineralocorticoid receptor antagonists in patients with hyperkalemia and renal injury;

(5) The incidence of cough caused by ARB is much lower than that of ACEI, but there are still very few patients with cough.

No. 3: CCB (Calcium Channel Blocker)

　 Representative No. 3: verapamil, nifedipine, diltiazem, etc.

CCB can be used as a first-line antihypertensive drug for patients of all ages and various types of hypertension. The individual differences in efficacy are small, but due to its pharmacological effects, it also has corresponding contraindications, adverse reactions and precautions. :

Contraindications:

(1) Dihydropyridine CCB: a clear vasodilatation effect, short-acting CCB will have a reflex heart rate at the same time as blood pressure reduction, relatively contraindicated in patients with hypertension and tachyarrhythmia;

(2) Non-dihydropyridine CCB: due to the cardiac affinity of non-dihydropyridine CCB and its negative inotropic and negative conduction effects on myocardial, sinus node function, atrioventricular conduction, verapamil Diltiazem is contraindicated in patients with two to three degrees of atrioventricular block and is relatively contraindicated in patients with heart failure.

Precautions:

(1) Because CCB dilates blood vessels, it is necessary to have reflex sympathetic activation, heart rate acceleration, hemodynamic fluctuation and resistance to antihypertensive effect. Therefore, long-acting preparations should be used as much as possible, and the antihypertensive effect is stable, long-lasting and effective, and the adverse reactions are small. The patient is well tolerated and has high compliance;

(2) Nifedipine, verapamil and diltiazem have obvious negative inotropic effects, and hypertensive patients for left ventricular systolic dysfunction should be avoided;

(3) Non-dihydropyridine CCB has obvious negative conduction. Patients with hypertension with cardiac atrioventricular conduction dysfunction or sick sinus syndrome should be treated with verapamil and diltiazem with caution. At the same time, non-dihydropyridine CCB combined with beta blockers can induce or aggravate slow arrhythmias and cardiac insufficiency.

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