A number of drug classes is effective for the initial and continues to run the treatment of hypertension. For drug selection and use in the treatment of stable hypertension, overview of hypertension: drugs. For drug treatment of hypertensive emergencies, see table: Parenteral drugs in hypertensive emergencies.
(See also overview of hypertension.) A number of drug classes is effective for the initial and continues to run the treatment of hypertension. For drug selection and use in the treatment of stable hypertension, overview of hypertension: drugs. For drug treatment of hypertensive emergencies, see table: Parenteral drugs in hypertensive emergencies. Diuretics The main classes (see table: Oral diuretics for hypertension) are thiazide-like diuretics Loop diuretics potassium arms Diuretics Diuretics reduce the plasma volume moderate, and reducing vascular resistance, possibly via a sodium shift from intracellular to extracellular. Thiazide-like diuretics are most commonly used. In addition to other antihypertensive effects they cause slight vasodilation, if intravascular volume is normal. In equivalent doses every thiazides are effective in the same way. However, thiazide-like diuretics have longer half-lives and are relatively effective at the same dose. Thiazide type diuretics may slightly increase serum cholesterol (mainly LDL cholesterol) increase and triglyceride levels, although this effect could last no longer than> 1 year. In addition, the levels appear to increase only in a few patients. The increase is seen within 4 weeks of treatment and can be improved by a low fat diet. The possibility of a slight increase in serum lipids is not a contraindication to the use of diuretics in patients with hyperlipidemia. Loop diuretics are used for the treatment of hypertension only in patients who have lost> 50% of renal function. These diuretics are administered two times a day. Although the potassium-sparing diuretics cause hypokalemia, hyperuricemia or hyperglycemia, they are not as effective as thiazide-type diuretics in the control of hypertension and are therefore not used as initial therapy. Potassium-sparing diuretics or supplements are not needed when an ACE inhibitor or an angiotensin II receptor antagonist is given, as these drugs increase the serum potassium. All diuretics, except the potassium-sparing, which act on the distal tubule, causing a significant loss of potassium, so serum potassium should be measured every month until the value has stabilized. Until the serum potassium is normal, the potassium channels of the arterial wall and the resulting vasoconstriction close makes achieving the target blood pressure value difficult. Patients with serum potassium level is <3.5 mEq / l get potassium supplements. The supplements can be continued with a low dose in the long term, or a potassium-sparing diuretic (z. B. daily 25-100 mg spironolactone, triamterene 50-150 mg, 5-10 mg, amiloride) may be supplemented. The supplements or the addition of potassium-sparing diuretics is also recommended for all patients taking cardiac glycosides, which have a known heart disease, an abnormal ECG, an ectopic or arrhythmias or develop during treatment with diuretics. In most patients with diabetes mellitus, the thiazide-type diuretics do not affect the setting of diabetes. Rarely solve diuretics type 2 diabetes, or worsen these in patients with metabolic syndrome. A hereditary predisposition may explain the few cases of gout, caused by diuretic-induced hyperuricemia. The diuretic-induced hyperuricemia without gout requires no treatment and no discontinuation of the diuretic. Diuretics can cause mortality in patients, slightly increasing with history of heart failure that do not have pulmonary congestion, especially in those who also take ACE inhibitors or angiotensin II receptor antagonist, and those who do not drink at least 1400 ml daily. The increased mortality is likely to be attributed to the diuretic-induced hyponatremia and hypotension. Oral diuretic antihypertensive drug Usual dose * Selected side effects thiazides and thiazide-type diuretics (chlorthal Dion and indapamide) bendroflumethiazide 2.5-5 mg of 1-times daily (maximum 20 mg) hypokalemia (which digitalis toxicity increased), hyperuricemia, glucose intolerance, hypercholesterolemia, hypertriglyceridemia, hypercalcemia, sexual dysfunction in males, weakness, skin rash; Lithium potentially increased blood levels chlorothiazide 62.5 to 500 mg 2 times daily (maximum 1000 mg) chlorthalidone 12.5-50 mg of 1-times daily hydrochlorothiazide 12.5-50 mg of 1-times daily hydroflumethiazide 12.5-50 mg 1 times daily indapamide 1.25 to 5 mg of 1 times a day Methyclothiazide 2.5-5 mg of 1-times daily metolazone (immediate-release) 0.5-1 mg of 1-times daily metolazone (extended-release) 2.5-5 mg of 1-times daily potassium arms diuretics amiloride 5-20 mg 1 times daily hyperkalemia (especially in patients with renal insufficiency and in patients who are treated with an ACE inhibitor, angiotensin II receptor antagonists or NSAIDs), nausea, GI distress, gynecomastia, Menstruationsstöru nts (spironolactone); Lithium potentially increased blood levels of eplerenone 25-100 mg of 1-times daily spironolactone 25-100 mg of 1-times daily triamterene 25-100 mg of 1-times daily loop diuretics bumetanide 0.5-2 mg 2 times daily hyperkalemia, hyponatremia, Hypomagnesmie, dehydration, orthostatic hypotension, tinnitus, hearing loss Ethacrynic 25-100 mg 1 times daily furosemide 20-320 mg two times daily torsemide 5-100 mg 1 times daily * Higher doses may be necessary in patients with renal failure. aldosterone receptor antagonists Beta blockers Beta blockers (see table: Oral beta-blockers for hypertension) slow down the heart rate and reduce myocardial contractility and thereby blood pressure. All beta-blockers are similar in their antihypertensive effect. In patients with diabetes mellitus, chronic peripheral arterial occlusive disease or COPD a cardioselective beta-blockers (acebutolol, atenolol, betaxolol, bisoprolol, metoprolol) may be preferable, although the cardioselectivity is relatively and decreases as soon as the dose is increased. Even cardioselective beta blockers are bronchial asthma or in patients with contraindicated patients with COPD with standing in the foreground bronchospastic component. Oral beta-blockers for hypertension drug Usual dose Selected side effects Comments acebutolol *, 200-800 mg 1 time a day bronchospasm, fatigue, insomnia, sexual dysfunction, worsening of heart failure, masking of symptoms of hypoglycemia, triglyceridemia, elevated total cholesterol and decreased high -Density lipoprotein cholesterol (except in pindolol, acebutolol, penbutolol, carteolol and Iabetalol) is contraindicated in patients with bronchial asthma, heart block should be greater than grade I or a sick sinus syndrome b ei patients with heart failure or with insulin-treated diabetes should be used with caution in patients with coronary artery disease not be stopped abruptly carvedilol and metoprolol are approved for the treatment of heart failure Atenolol * 25-100 mg 1 times daily betaxolol * 5-20 mg of 1- times daily bisoprolol * 2.5-20 mg 1 times daily carteolol 2.5-10 mg 1 time a day Carvedilol 6.25 to 25 mg 2 times daily carvedilol (controlled-release) 20-80 mg 1 time a day labetalol , § 100-900 mg two times daily metoprolol * 25-150 mg two times daily metoprolol (extended-release) 501400 1 mg twice daily nadolol 40-320 mg of 1-times daily Nebivolol 5-40 mg of 1-times daily penbutolol 10-20 mg of 1-times daily pindolol 5-30 mg 2 times daily Propranolol 20-160 mg 2 times daily propranolol, long-acting 60-320 mg of 1-times daily timolol 10-30 mg 2 times a day * Kardioselektiv. With intrinsic sympathomimetic activity. Alpha-beta blockers. Labetalol can i.v. are placed in hypertensive emergencies. For i.v. Administration is begun with 20 mg up to 300 mg. be given §Kann in hypertensive emergencies; at i.v. Administration is begun with 20 mg up to 300 mg. Beta blockers are particularly useful in patients with angina pectoris, those who had a myocardial infarction, or those with heart failure, although atenolol prognosis in patients with coronary artery disease (CAD) may deteriorate. These drugs are not considered problematic for older patients. Beta-blockers with intrinsic sympathomimetic activity (. ISA, for example, acebutolol, carteolol, penbutolol, pindolol) does not affect serum lipids negative; they cause severe bradycardia also less likely. Beta blockers have CNS side effects (insomnia, fatigue, lethargy) and reinforce depression. Nadolol affects at least on the CNS and could be the best choice when CNS effects must be avoided. Beta-blockers are contraindicated in patients with a degree AV block II or III, bronchial asthma or a sick sinus syndrome. Calcium channel blockers dihydropyridines (see Table: Oral calcium antagonists against hypertension) are potent vasodilators and peripheral lower the blood pressure by the decrease of the absolute peripheral vascular resistance (TPR); they sometimes cause Refletachykardie. The Nondihydropyridine verapamil and diltiazem slow the heart rate, myocardial contractility reduce AV conduction and decrease. These drugs should not be prescribed for patients with AV block grade II or III or with left ventricular heart failure. Oral calcium channel blockers for hypertension drug Usual dose Selected side effects Comments benzothiazepine derivatives diltiazem, sustained-release 60-180 mg two times daily headache, dizziness, asthenia, flushing, edema, negative inotropic effect; possibly liver dysfunction contraindicated in heart failure due to systolic dysfunction, sick sinus syndrome or heart block greater than grade I diltiazem extended-release 120-360 mg 1 time a day Diphenylalkylaminderivate Verapamil 40-120 mg 3 times daily As with benzothiazepine derivatives, plus As with constipation benzothiazepine derivatives verapamil sustained-release 120 to 480 mg of 1 times a day Dihydropyridines amlodipine 2.5-10 mg 1 times daily dizziness, flushing, headache, weakness, nausea, heartburn, pedal edema, tachycardia contraindicated in heart failure, possibly may be associated with the exception of amlodipine use of short-acting nifedipine with a higher MI rate felodipine 2 , 5-20 mg 1 times daily isradipine 2.5-10 mg 2 times a day Nicardipine 20-40 mg 3 times daily nicardipine, sustained-release 30-60 mg 2 times daily nifedipine, extended-release 30-90 mg 1 times a day nisoldipine 10-60 mg 1 time per day long-acting nifedipine, verapamil or diltiazem is used for the treatment of hypertension, short-acting nifedipine and diltiazem but are associated with a high rate of myocardial infarction and are therefore not recommended. A calcium antagonist is preferred in patients with angina and bronchospastic diseases, coronary artery spasm or Raynaud's syndrome to beta-blockers. ACE inhibitors ACE inhibitors (see table: Oral ACE inhibitors and angiotensin II receptor antagonists for hypertension) lower blood pressure by inhibiting the conversion of angiotensin I to angiotensin II and also the breakdown of bradykinin. Thus they lead to a decrease in peripheral vascular resistance without causing a reflex. These drugs lower blood pressure in many hypertensive patients regardless of the plasma renin activity. Because these drugs also provide renal protection, they are drugs of choice in diabetics. They are not recommended for the initial treatment of dark-skinned patients where they seem to increase the risk of stroke in disem case. A dry cough is the most common side effect, but angioedema is the most serious side effect and can be fatal if it affects the oropharynx. Angioedema occurs most often in dark-skinned people and smokers. ACE inhibitors may increase serum potassium and creatinine levels, especially in patients with chronic kidney disease and in patients receiving potassium-sparing diuretics, potassium supplements or taking a NSAID. ACE inhibitors are the antihypertensive agents that cause the least likely to erectile dysfunction. ACE inhibitors are contraindicated during pregnancy. In patients with renal failure the serum creatinine and potassium levels be monitored at least every 3 months. Patients with nephropathy stage 3 (estimated GFR of <60 ml / min to> 30 ml / min) and those which ACE inhibitors are added, typically can tolerate a 30 to 35% increase in serum creatinine above the base value. ACE inhibitors may occur in patients who have hypovolemic or severe heart failure, bilateral renal artery stenosis or severe renal artery stenosis in a solitary kidney have cause acute renal failure. Thiazide-type diuretics increase the antihypertensive effect of ACE inhibitors more pronounced than the other classes of antihypertensive agents. Spironolactone and eplerenone also appear to enhance the effects of ACE inhibitors. Oral ACE inhibitors and angiotensin II receptor antagonists for hypertension drug Usual dose Selected side effects ACE inhibitors * benazepril 5-40 mg 1 times daily rash, cough, angioedema, hyperkalemia (especially in patients with renal insufficiency or those NSAIDs , potassium-saving diuretics or potassium supplements take), taste disturbance, reversible acute renal failure when stenosis threatening kidney function in one or both kidneys, proteinuria (rare (at recommended doses), neutropenia rare ), Hypotension with the beginning of treatment (particularly in patients with high plasma renin activity or hypovolemia due to diuretics or other conditions) Captopril 12.5 to 150 mg two times daily enalapril 2.5-40 mg 1 times daily fosinopril 10-80 mg 1 times daily lisinopril 5-40 mg 1 times daily perindopril 4-8 mg 1 time a day Quinapril 5-80 mg of 1-times daily Ramipril 1.25 to 20 mg of 1-times daily trandolapril 1-4 mg of 1-times daily angiotensin II receptor antagonists Azilsartan 1 80 mg twice daily in patients> 65 starting dose is 40 1 mg twice daily dizziness, angioedema (very rare); theoretically same side effects such as ACE inhibitors on renal function (except proteinuria and neutropenia), serum potassium, and blood pressure candesartan 8-32 mg of 1-times daily eprosartan 400-1200 mg of 1-times daily Irbesartan 75-300 mg of 1-times daily Losartan 25 100 mg 1 times daily olmesartan 20-40 mg 1 time a day Telmisartan 20-80 mg of 1-times daily Valsartan 80-320 mg of 1-times daily * All ACE inhibitors and angiotensin II receptor antagonists are contraindicated in pregnancy (Category C during the first trimester, in the category D. 2 and third trimester). Angiotensin II receptor antagonists angiotensin II receptor blockers (see table: Oral ACE inhibitors and angiotensin II receptor antagonists for hypertension) block the angiotensin II receptor and thus interact with the renin-angiotensin system. Angiotensin II receptor antagonists and ACE inhibitors are as effective as antihypertensive agents. Angiotensin II receptor antagonists may offer additional benefits over a tissue ACE blockade. The two classes have in patients with left ventricular failure or nephropathy due to type 1 diabetes, the same beneficial effects. An angiotensin II receptor antagonist, should not be given together with an ACE inhibitor, but can reduce the rate of hospitalization in patients with heart failure, when given with a beta blocker. Angiotensin II receptor antagonists can safely <60 years, and an initial serum creatinine ? 3 mg / dl are used in humans. The frequency of side effects is low; Angioedema occur, but with far less frequency than with ACE inhibitors. The precautions in the use of angiotensin II receptor antagonists in patients with renovascular hypertension, hypovolemia and severe heart failure are the same as with ACE inhibitors (see table: Oral ACE inhibitors and angiotensin II receptor antagonists for hypertension) , Angiotensin II receptor antagonists are contraindicated in pregnancy. Direct renin inhibitor aliskiren, a direct renin inhibitors, is used in the treatment of hypertension. The dosage is 150-300 mg p.o. 1 times a day, with an initial dose of 150 mg. Clinical trials are underway to evaluate its effectiveness for reducing mortality in HF. As well as ACE inhibitors and angiotensin II receptor antagonists causes an increase in the aliskiren potassium, and creatinine i. S. aliskiren should (<60 ml / min estimated GFR) are not combined with ACE inhibitors or angiotensin II receptor antagonists in patients with diabetes or Nierenrkrankheit. Adrenergic substances adrenergic modifiers include centrally acting alpha-2 agonists, postsynaptic alpha-1 adrenergic blockers, and peripherally active antagonists (see Table: adrenergic agents against hypertension). Adrenergic substances for hypertension drug * Usual dose Selected side effects Comments Alpha-2 agonists (centrally acting) clonidine 0.05-0.3 mg two times daily somnolence, sedation, dry mouth, fatigue, sexual dysfunction, rebound hypertension abrupt with a interruption (in particular, when high doses given or simultaneous beta blockers be continued), localized skin reaction to clonidine patches; possibly liver damage, Coombs-positive hemolytic anemia with methyldopa If in elderly patients used with caution because of orthostatic hypotension disturb measurements of catecholamine in urine by fluorimetric methods Clonidine TTS (Patch) 0.1-0.3 mg 1 times daily guanabenz 2- 16 mg 2 times daily guanfacine 0.5-3 mg of 1-times daily methyldopa 250-1000 mg 2 times daily Alpha-1-Blocker Doxazosin 116 mg 1-mal täglich Synkope bei erster Dosis, orthostatische Hypotonie, Schwäche, Palpitationen, Kopfschmerzen Sollte bei älteren Patienten mit Vorsicht verwendet werden wegen orthostatischer Hypotonie Lindert Symptome der benignen Prostatahyperplasie Prazosin 110 mg 2-mal täglich Terazosin 120 mg 1-mal täglich