Questions and Case Studies – Drugs in Hypertension

00:01 Let's move on to some questions.

00:03 The first question, a 60 year old man has high blood pressure and diabetes.

00:09 He presents with severe swelling in the face and half of his tongue is really swollen.

00:15 When you take a look at him, this is what he looks like.

00:19 He had been given enalapril previously, hydrochlorothiazide, and an oral antidiabetic drug.

00:25 Which of the drugs is the likely culprit? Is it aspirin? Is it enalapril, hydrochlorothiazide, the new unnamed diabetic drug, or this is some kind of an environmental allergy? Right, this is enalapril.

00:47 Now, this patient is showing classical signs of angioedema, which is a relatively rare complication sometime seen in patients taking ACE inhibitors.

00:56 Treatment is supportive and withdraw the medication.

00:58 Angioedema often looks like the person has a huge red face as well, this is a more rare kind of presentation but remember, swelling in the face, redness in the face, or swelling of the tongue when you take a medication, think angioedema from the ACE inhibitor.

01:18 This next question is kind of fun for me because this is actually a real patient.

01:22 You have a 95 year old man with consistent blood pressures of 170/94.

01:28 He is on no medications and he has no other diseases and looks 30 years younger than his stated age.

01:34 You are considering starting him on an antihypertensive medication. Which statement is true? Number 1, do not use an ACE inhibitor as first line therapy.

01:46 B, do not use a beta blocker as first line therapy.

01:50 C, do not use a calcium channel blocker as first line therapy.

01:55 D, do not use a direct renin inhibitor as first line therapy.

02:00 And E, do not prescribe any drugs because he is too old.

02:06 This is a great question because it brings up a whole bunch of issues, both pharmacological and ethical.

02:12 First of all, let's talk about beta therapy.

02:15 Current guidelines suggest that we should avoid using beta blockers as first line therapy in the elderly.

02:24 All of the other choices are actually quite acceptable.

02:26 Now, treating a 95 year old male at this blood pressure will still reduce his chances of developing a stroke, or all-cause mortality, even in the next three months.

02:38 So, even though he is 95 years old, it is still worthwhile to treat blood pressure as long as extra diligence is practiced.

02:45 Now, there's a lot of ethical conundrums that are going to come up with this, and there's going to be people who debate the pro and cons.

02:51 But the classical thing that you want to look at in this particular clinical scenario, is the fact that the examiner made special mention that he looks 30 years younger than his current age.

03:04 And if he looks great, make an assumption that he is going to live a long enough time to benefit from that medication.

03:11 So, in the real world, this is one of my patients.

03:13 He is now 100 years old, and giving him that antihypertensive medication may have prevented a stroke from reducing his lifespan.

03:23 So, just because a person is 95, doesn't mean they won't live another 5 years.

03:29 Let's go onto a question about pregnancy.

03:34 Which of the following antihypertensive agents is one of the drugs of choice in pregnancy? Labetolol, clonidine, captopril, losartan, and hydrochlorothiazide.

03:50 Right, labetolol. So, labetolol is the most used drug for hypertension in pregnancy.

03:58 Clonidine is definitely not what we want to use.

04:02 Remember that of the alpha 2 blockers, clonidine is not our choice here.

04:09 We can use Aldomet, which is its sister drug.

04:14 We do not want to use ACE inhibitors. They are contraindicated in pregnancy.

04:17 We do not want to use ARBs.

04:19 They are also contraindicated in pregnancy, so C and D can cause fetal abnormalities.

04:25 And finally, hydrochlorothiazide is also believed to cause fetal abnormalities, and if we can avoid it, we should.

04:32 The only drugs we use for hypertension in pregnancy, with any assemblance of comfort is labetolol, alpha-methyldopa or Aldomet, and in some cases, a calcium channel blocker, but only after the first trimester is over.

04:47 In terms of breastfeeding patients, calcium channel blockers are the drug of choice because they are not secreted in milk.

04:54 Drugs like labetolol are seen in very microscopic levels in breast milk, so what I often do with my patients is I switch them from labetolol to a calcium channel blocker postpartum if they still need it.

05:07 Most cases of gestational hypertension, actually you can stop the medication and the blood pressure problems go away when they have delivered.

05:15 That's it. I hope you enjoyed the lecture and I hope that it illuminated some difficult concepts in hypertension management. Good luck.