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A. What is the problem of the patient?

B. What are the basis of the problem using the history, physical examinations and
laboratory examinations?
65 years old, woman
History of Hypertension for 10 years
Family history of hypertension (noted on her mother and 1 sister)
(+) tobacco history 1 ppd x 30 years, quit 5 years ago
medications: Lisinopril 20mg PO
ROS: occasional headaches relieved with acetaminophen
PE: 101.4 kg and 165 cm
C. Enumerate the therapeutic objectives.
Promoting healthy lifestyle modification
Maintain BP w/in normal limits
Prevent further complications
D. Identify the non-pharmacological and pharmacological regimen

Non-pharmacological treatment
Diet modification: reduction in NaCl intake to <6g (100meq), low-fat dairy
products, address diabetic diet
Encourage the patient to have a regular physical activity such as brisk
Reduction of alcohol consumption

E. For the pharmacological regimen, identify the different drug class and then the
drug class of choice

Drug Class:
I. Agents that block production or action of Angiotensin
II. Diuretics
III. Direct Vasodilators
IV. Sympathoplegic agents

I. Agents that block production or action of Angiotensin

i) Angiotensin-Converting Enzyme Inhibitors
ii) Angiotensin Receptor Blockers
iii) Renin Inhibitor

II. Diuretics
i) Thiazides
ii) Loop diuretics
iii) Carbonic Anhydrase Inhibitors
iv) Potassium sparing diuretics
v) Osmotic diuretics
vi) Vasopressin antagonists

Note: Diuretics are contraindicated in diabetic patients because they impair

glucose tolerance.

III. Direct Vasodilators

i.) Hydralazine
ii.) Minoxidil
iii.) Sodium nitroprusside
iv.) Diazoxide
v.) Fenoldepam
vi.) Calcium Channel Blocker
a. Verapamil
b. Diltiazem
c. Nifedipine, amlodipine and other dihydropyridine

IV. Sympathoplegic agents

i) Methyldopa
ii) Clonidine
iii) Reserpine
iv) Guanethidine
v) -blockers
vi) -blockers
-Propanolol (Non-selective -blocker)
-Atenolol (1-selective blocker)

Note- -blockers are contraindicated in patients with COPD

Drug class Angiotensin- Beta-blockers Angiotensin II Calcium channel

converting enzyme receptor blockers blockers
(ACE) inhibitors (ARBs)

Efficacy +++ + +++ ++

Mechanism of action Reduction in blood CCBs promote

Angiotensin II is a Beta-blockers pressure secondary vasodilator activity
very potent chemical antagonise the to vasodilation (and reduce blood
produced by the body effects of following pressure) by reducing
that primarily sympathetic nerve angiotensin receptor calcium influx into
circulates in the blood. stimulation or blockade is greatest vascular smooth
It causes the muscles circulating when the renin- muscle cells by
surrounding blood catecholamines at angiotensin system is interfering with
vessels to contract, beta-adrenoceptors activated (e.g. voltage-operated
thereby narrowing which are widely following diuretic calcium channels (and
vessels. The distributed therapy or renal to a lesser extent
narrowing of the throughout body artery stenosis) but receptor-operated
vessels increases the systems. Beta1- ARBs also lower channels) in the cell
pressure within the receptors are blood pressure when membrane.
vessels causing predominant in the there is normal or Interference with
increases in blood heart (and kidney) low activity of the intracellular calcium
pressure while beta2- renin-angiotensin influx is also
(hypertension). receptors are system important in cardiac
Angiotensin II is predominant in other muscle, cardiac
formed from organs such as the conduction tissue and
angiotensin I in the lung, peripheral gastrointestinal
blood by the enzyme blood vessels and smooth muscle. In
angiotensin converting skeletal muscle. cardiac tissues, CCBs
enzyme (ACE). Kidney: Blockade of have potential for
(Angiotensin I in the beta1-receptors negative inotropic,
blood is itself formed inhibit the release of chronotropic and
from angiotensinogen, renin from juxta- dromotropic activity
a protein produced by glomerular cells and while the
the liver and released thereby reduce the gastrointestinal effects
into the body.) ACE activity of the renin- predispose to
inhibitors are angiotensin- constipation.
medications that slow aldosterone system.
(inhibit) the activity of Heart: Blockade of
the enzyme ACE, beta1-receptors in
which decreases the the sino-atrial node
production of reduces heart rate
angiotensin II. As a (negative
result, blood vessels chronotropic effect)
enlarge or dilate, and and blockade of
blood pressure is beta1-receptors in
reduced. This lower the myocardium
blood pressure makes decrease cardiac
it easier for the heart contractility
to pump blood and (negative inotropic
can improve the effect). Central and
function of a failing peripheral nervous
heart. In addition, the system: Blockade of
progression of kidney beta-receptors in the
disease due to high brainstem and of
blood prejunctional beta-
pressure ordiabetes is receptors in the
slowed. periphery inhibits the
release of
and decreases
sympathetic nervous
system activity
Safety ++ + +++ ++

Angiotensin Adverse effects Most patients treated with Calcium channel

converting enzyme are predictable ARBs are less likely blockers (CCBs) or
(ACE) inhibitors and Bronchospasm in to experience calcium antagonists,
angiotensin receptor susceptible respiratory adverse are among the most
blockers (ARBs) are individuals due to events,[23, 24] and widely used drugs in
often used in patients blockade of beta2- therefore ARBs may cardiovascular
with cardiovascular receptors which have a protective medicine with roles
disease. ACE mediate dilation in role. not only in
inhibitors are known the bronchi. Asthma hypertension but also
to have adverse effects is an absolute in angina and (for
on the respiratory contraindication for some CCBs)
system, in particular all beta-blockers. tachyarrhythmias.
an increased incidence Bradycardia and
of cough. Basic impairment of
investigation has myocardial
shown that bradykinin contractility.
and substance P Common but seldom
sensitise the sensory symptomatic.
nerves of the airways Peripheral
and enhance the cough vasoconstriction due
reflex,[11-13] which to reduced cardiac
may have a protective output and possibly
role on the blockade of beta2-
tracheobronchial receptors which
tree.[14, 15]
These subserve
mechanisms also vasodilatation in
improve swallowing blood vessels
by avoiding the supplying skeletal
exposure of the muscle beds
respiratory tree to typically resulting in
oropharynx secretions cold hands and feet,
and possibly
exacerbation of
phenomenon. Mainly
non-selective agents.

Tiredness and fatigue

due to reduced
cardiac output
exacerbated by
blockade of beta2-
receptors in skeletal
muscle associated
with increased
muscle activity.
Mainly nonselective
agents. Masking of
hypoglycaemia in
diabetes because of
blunting of
sympathetic nervous
activation. Mainly
non-selective agents.
Risk of new onset
Suitability ++++ +
+ +
Compelling Calcium channel
The most common Compelling indications include blockers (CCBs) or
side effects are: contraindications are ACE inhibitor calcium antagonists,
asthma, chronic intolerance, type 2 are among the most
obstructive diabetic widely used drugs in
Cough pulmonary disease nephropathy, cardiovascular
with significant hypertension with medicine with roles
Elevated blood reversibility and left ventricular not only in
potassium levels heart block. hypertrophy, heart hypertension but also
failure in ACE in angina and (for
Low blood inhibitor-intolerant some CCBs)
pressure, dizzin patients and post tachyarrhythmias.
ess myocardial



Abnormal taste
(metallic or
salty taste)


Cost + ++++ ++ ++

F. Discuss the drug class in regards to the pharmacokinetics, pharmacodynamics,

indications, drug adverse effects, drug interactions/ contraindications if any

Drugs Losartan ( Anzaplus) Irbesartan (Aprovel) Condesartan Eprosartan (Abbott)

Efficacy ++++ ++++ ++++ ++++
-clearance is not
affected by hepatic or
renal insufficiency
Safety +++ ++++ ++ ++
-it attenuates platelet -clearance is affected
aggregation, (once daily dosing for -plasma clearance by hepatic and renal
clearance is affected 150-300mg OD) are affected by renal insufficiency
by hepatic insufficiency
(at need twice daily (need to be
dosing) administered or
twice daily)
Suitability Treatment for HTN +++ Treatment for
-tx. For essential HTN essential HPN
and treatmentof renal Contraindicated-
disease in patients Hypersenitivity to
with HTN and Type 2 sulfonamides. Severe
DM, as part of an renal impairment

Cost 30 tablets : 631.50 1064 pesos Tablet 28s

pesos 1003.91 pesos
Pregnancy Safe : C Preganancy D Pregnancy D
and D ( 2nd and 3rd) Tab 50 mg x100s
(1,987.15 pesos)

ARBs Inhibitor
Personal DOC: Irbesartan
Drug Study: Irbesartan (Aprovel)
- for the treatment of essential HTN and treatment of renal disease in patients with HTN anf type 2 diabetes mellitus ,
as part as antihypertensive regimen.

- 150mg daily. Maybe increased to 300mg or combined with other antihypertensive agents if patient is
notsufficiently resolved.
- Pregnancy , 2nd or 3rd trimester lactation

- Intravascular vol. depletion, renovascular HTN, renal impairment and kidney transplantatiom, hyperkalemia,
aortic and mitral valve stenosis, Hypertensive patient with type 2 NIDDM and renal diseases
Adverse Reaction
- Musckulotskletal trauma and flushing
- Preg. Safety ;: D
1,064 pesos

G. Identify drug of choice and be able to write the prescription