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1 : Case Presentation Hypertension Gaurav Bhatia Pharm D 5th yr. Pharm D[P.B],Dept. of Clinical Pharmacy
2 : Patient Information. 65 years female admitted in medicine unit I with IP no. 5335 from 26 Apr, 2010 to 29 Apr, 2010 with presenting complains as follows: Giddiness X 2 months Nausea Appetite decreased Headche Epigastric burning X 10 months Pharm D[P.B],Dept. of Clinical Pharmacy
3 : PHARMACEUTICAL CARE PLAN Subjective. Giddiness Nausea Appetite decreased Headche Epigastric burning Past Medical History. K/C/O Hypertension X 10 years No D.M, IHD, T.B, Allergy. Past Medication History. On Tab. Atenolol 25 mg OD [From 10 years] Pharm D[P.B],Dept. of Clinical Pharmacy
4 : Family HistorY . No H/O any major medical illness. Social Habits. NA OTC H/0. NA Allergy. None Pharm D[P.B],Dept. of Clinical Pharmacy
5 : Objective. Pharm D[P.B],Dept. of Clinical Pharmacy
6 : Assessment. Provisional Diagnosis: Hypertension. Confirmed Diagnosis: Hypertension. Pharm D[P.B],Dept. of Clinical Pharmacy
7 : Classification. JNC VII for adults aged 18 years or older is as follows: Normal- Systolic lower than 120, diastolic lower than 80 Prehypertension - Systolic 120-139, diastolic 80-99 Stage 1 - Systolic 140-159, diastolic 90-99 Stage 2 - Systolic equal to or more than 160, diastolic equal to or more than 100 Pharm D[P.B],Dept. of Clinical Pharmacy
8 : For follow-up: Normal: Recheck in 2 years Prehypertension: Recheck in 1 year Stage 1 Hypertension: Confirm within 2 months Stage 2 Hypertension: Evaluate or refer to source of care within 1 month. For those with higher pressures (e.g., >180/110 mmHg), evaluate and treat immediately or within 1 week depending on clinical situation and complications. Pharm D[P.B],Dept. of Clinical Pharmacy
9 : Pathophysiology. Physiological mechanisms Cardiac output X Peripheral resistance Abnormal Na transport Renin­angiotensin­aldosterone system Vasodilator deficiency Pharm D[P.B],Dept. of Clinical Pharmacy
10 : Complications Of Hypertension. CNS: Stroke Eyes : Retinopathy Cardiovascular: LVH,MI,HF Renal:CKD Pharm D[P.B],Dept. of Clinical Pharmacy
11 : Identifiable causes of hypertension. Chronic kidney disease Coarctation of the aorta Cushing’s syndrome and other glucocorticoid excess states including chronic steroid therapy Obstructive uropathy Pheochromocytoma Primary aldosteronism and other mineralocorticoid excess states Renovascular hypertension Sleep apnea Thyroid or parathyroid disease Pharm D[P.B],Dept. of Clinical Pharmacy
12 : Screening tests for identifiable hypertension. Chronic kidney disease: Estimated GFR Coarctation of the aorta: CT angiography Cushing’s syndrome and other glucocorticoid History: Dexamethasone suppression test Pheochromocytoma: 24-hour urinary metanephrine and normetanephrine Primary aldosteronism and mineralocorticoid: 24-hour urinary aldosterone level Renovascular hypertension: Doppler flow study; Magnetic resonance angiography Sleep apnea: Sleep study with O2 saturation Thyroid/parathyroid disease: TSH; serum PTH Pharm D[P.B],Dept. of Clinical Pharmacy
13 : Plan: Goals of treatment To normalize BP. To increase Appetite. To control Nausea & Epigastric burning sensation. To prevent further complications. Pharm D[P.B],Dept. of Clinical Pharmacy
14 : Medication Order. 1. Tab. Atenolol[100mg] + Chlorthalidone [25mg] 1-0-0 Tab. Betahistine [8mg] 1-1-1 Tab. Pantoprazole [40mg] 1-0-0 Tab. Aspirin[150mg] + Clopidogrel[75mg] 0-1-0 2. ---Ct. all 3. Add Tab. Atorvastatin[10mg] + Ezetimibe [10mg] 0-0-1 Add Tab.Cefpodoxime [100mg] 1-1-1 Pharm D[P.B],Dept. of Clinical Pharmacy
15 : Post Discharge Order. Tab. Atenolol[100mg] + Chlorthalidone [25mg] 1-0-0 X Ct. Tab. Pantoprazole [40mg] 1-0-0 X 5 days Tab. Aspirin[150mg] + Clopidogrel[75mg] 0-1-0 X Ct. Tab. Atorvastatin[10mg] + Ezetimibe [10mg] 0-0-1 X Ct. Tab. Cefpodoxime [100mg] 1-1-1 X 5 days Follow up every 2 weeks on O.P.D basis. Pharm D[P.B],Dept. of Clinical Pharmacy
16 : Monitoring Parameter. Disease: BP Pulse rate Drugs: Aspirin : CBC monitoring, BP, ECG , HR monitoring. Clopidogrel: Signs of bleeding , Hb, heamatocrit . Atenolol: BP, I/O, Weight, Respiration. Pantoprazole : Hypersecretory disorders, Acid-output measurements. Atorvastatin: Lipid levels after 2-4 weeks, LFTs. Ezetimibe: Total cholesterol profile. Cefpodoxime: Observe signs & symptoms of anaphylaxis during first dose. Pharm D[P.B],Dept. of Clinical Pharmacy
17 : Goals achieved: BP was improved on 2nd day. Headache was decreased on 2nd day. Appetite normal on 2nd day. Pharm D[P.B],Dept. of Clinical Pharmacy
18 : Treatment options Pharm D[P.B],Dept. of Clinical Pharmacy
19 : Treatment options continue.. Pharm D[P.B],Dept. of Clinical Pharmacy
20 : Patient counseling. Disease: Treatment will control, not cure HTN. Chronic treatment is usually necessary. Treatment should not be discontinued abruptly. Medications: Aspirin : With food or large volume of water or milk to minimize GI upset. Atenolol: May be taken without regard to meals. Take at the same time each day. Pantoprazole: Take with or without food. Atorvastatin: May take with food if desired; may take without regard to time of day. Cefpodoxime: Take with food. Clopidogrel: May be taken without regard to meals. Don’t take OTC medicines without consulting your physician. Pharm D[P.B],Dept. of Clinical Pharmacy
21 : About lifestyle modifications: Weight reduction.Maintain normal body weight (body mass index 18.5–24.9 kg/m2 app. SBP reduction (5–20 mmHg/10kg) Adopt DASH(Dietary Approaches to Stop Hypertension) eating plan.(8–14 mmHg)Consume diet rich in fruits, vegetables, & lowfat dairy products with reduced content of saturated & total fat. Dietary Na reduction.(2–8 mmHg) Reduce dietary sodium intake 2.4 g Na or 6 g NaCl Physical activity.Engage in regular aerobic physical Activity (4–9 mmHg) Moderation of alcohol consumption.Limit consumption not more consumption 2 drink . (2–4 mmHg) Pharm D[P.B],Dept. of Clinical Pharmacy
22 : Rationality of Therapy. Any one of the following classes of drugs could be used as first step agents: Diuretics, Beta blockers, Calcium antagonists and Converting enzyme inhibitors. A. First line drugs for non -Emergency conditions Hydrochlorothiazide, 12.5- 50 mg/day, p.o. AND/OR Nifedipine, 10 -40 mg, p.o., tid. AND/OR Propranolol 40-160 mg p.o divided in to 2-4 doses B. Alterative Enalapril, 2.5- 40mg p.o., once or divided into two doses daily.AND /OR Methyldopa, 250-2000 mg p.o. in divided dosesOR Hydralazine, 10-20 mg, slow i.v. can be given in severe hypertension OR Atenolol, 50 - 100 mg p.o daily. Pharm D[P.B],Dept. of Clinical Pharmacy
23 : C. Treatment of Hypertensive Emergency Hydralazine, 5 mg i.v. every 15-min should be given until the mean arterial blood pressure is reduced by 25% (within minutes to 2 hours), then towards 160/100 mm Hg within 2-6 hours. Depending on the underlying condition/target organ damage, furosemide, 40 mg i.v. can be used according to blood pressure response. D. Treatment of Hypertensive Urgency Nifidipine, 20-120 mg p.o in divided doses per day could be used. OR Captopril, 25-50 mg p.o three times daily Pharm D[P.B],Dept. of Clinical Pharmacy
24 : Learning points. Identified Problems: Drug- Drug Interaction Clopidogrel+Aspirin: Concurrent use may result in an increased risk of bleeding CLOPIDOGREL +PANTOPRAZOLE: Concurrent use of CLOPIDOGREL and PANTOPRAZOLE may result in increased risk for thrombosis. Drug/Food Interactions Concurrent use of ATORVASTATIN and GRAPEFRUIT JUICE may result in increased bioavailability of atorvastatin resulting in an increased risk of myopathy. Other: Alcohol + Aspirin: may result in increased gastrointestinal blood loss. Follow up: Ideally should be 1 week after discharge. Pharm D[P.B],Dept. of Clinical Pharmacy
25 : Thank you! Pharm D[P.B],Dept. of Clinical Pharmacy

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