Please Reply to the following 2 Discussions
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DISCUSSION POST # 1 Reply to Helena
Initial antihypertensive treatment should include a thiazide diuretic, calcium channel blocker, ACE inhibitor, or ARB in the general population (James et al., 2014). For African Americans, a thiazide diuretic or calcium channel blocker are the initial antihypertensive treatment. The ACC/AHA’s guidelines also recommend combination therapy for African American patients for more severe HTN, such as SBP ≥140 mm Hg or DBP ≥90 mm Hg and an average SBP/DBP >20/10 mm Hg above their target BP (Whelton et al., 2022).
The first line treatment for HTN is thiazide diuretics and/or calcium channel blockers for African American population (James et al., 2014). This patient has problems following simple instructions to fill her BP log, so I would consider starting with polytherapy with two medications to decrease the pill burden to encourage schedule adherence. For this patient, I will initially use Caduet (5 mg/10mg) which is a combination drug of amlodipine 5mg and atorvastatin 10mg, one tablet once per day PO and adjust the therapy based on the patient’s status.
Amlodipine is a calcium channel blocker, and atorvastatin is a cholesterol lowering drug. A statin is needed to treat the patient’s hyperlipidemia. If the patient needs to take a statin, I prefer a calcium channel blocker over thiazide due to drug safety.
Calcium channel blockers prevent calcium ion from entering into cardiomyocytes, blood vessels, smooth muscle, and pancreas, by blocking voltage-gated calcium channel (McKeever & Hamilton, 2022). Calcium ions cause the muscle to contract more strongly.
Statins inhibit cholesterol synthesis in the liver, by competitively blocking the active binding site of HMG-CoA reductase in the mevalonate pathway. The mevalonate pathway is the fundamental for cholesterol synthesis, and HMG-CoA reductase is the rate-limiting enzyme of the cholesterol biosynthesis, thus inhibiting HMG-CoA reductase binding slows down cholesterol synthesis. .
Side effects of amlodipine include edema of the extremities, headache, upset stomach, nausea, stomach pain, dizziness, drowsiness, excessive tiredness, flushing, arrhythmia, fainting, more frequent or severe chest pain (National Library of Medicine, 2022a).
Side effects of atorvastatin include gastrointestinal symptoms, forgetfulness, joint pain, and confusion (National Library of Medicine, 2022b). Serious side effects include myalgia or muscle pain, rhabdomyolysis, or muscle breakdown, lack of energy, fever, chest pain, weakness and extreme tiredness, unusual bleeding, flu-like symptoms, rash, itching, difficulty breathing or swallowing, and hepatotoxicity (National Library of Medicine, 2022b). This drug is teratogenic.
There is no known drug interaction between amlodipine and atorvastatin. Calcium channel blockers are considered to be safe when using with statins.
Lifestyle changes including smoking cessation, moderate alcohol consumption, increasing physical activity are recommended. Diet modification is significant to control HTN and hyperlipidemia, so I will write a referral to a dietitian as well.
DISCUSSION POST # 2 Reply to Talia
According to the American Family Physician (AFP) JNC 8 guidelines for the management of hypertension in adults, hypertension is one of the most important preventable contributors to disease and death in the United States (Armstrong, 2014). It is a leading cause of myocardial infarction, stroke, and renal failure when left undetected and untreated. The AFP JNC 8 recommends treatment with pharmacologic intervention for the general population younger than 60 years of age when the systolic pressure is 140 mmHg or higher or the diastolic is higher than 90 mmHg (Armstrong, 2014). The ACC and American Heart Association (AHA) guidelines for the detection, prevention, management, and treatment of high blood pressure recommends a lower definition of high blood pressure to allow for earlier intervention (Muntner et al., 2018).
Hypertension should be treated earlier, and additive lifestyle changes should be encouraged. Given that this patient has previously had higher blood pressure and did not follow through with lifestyle changes or follow-up healthcare, she should be started on pharmacologic therapy and referred for a nutritional consult. Lifestyle changes that include a heart healthy diet and increased physical activity are non-pharmacological interventions that would benefit this patient. Suggesting a daily walk, yoga, and light exercise at first may be more successful than a rigorous work-out plan. Encouraging small changes in her diet may lead to bigger changes as results may encourage healthier choices. In addition to lifestyle changes, pharmacologic interventions will benefit her in the lowering of her blood pressure and cholesterol. Thus, lowering her risk for a cardiovascular event. Recommended medications for this patient include a statin and a mild hypertension medication such as a thiazide diuretic. These are very common medication and are relatively inexpensive, even without health insurance.
Hydrochlorothiazide, also known as Urozide, is an antihypertensive/diuretic medication that is used for mild to moderate hypertension (Vallerand & Sanoski, 2020). The starting dose is 12.5 mg taken daily and can increase up to 50 mg per day taken in 1 or 2 doses, not to exceed 50 mg per day for hypertension (Vallerand & Sanoski, 2020). It is also used for edema associated with heart failure, renal disfunction, and other indications (Vallerand & Sanoski, 2020). Hydrochlorothiazide increases excretion of sodium and water by inhibiting reabsorption in the distal tubule and may produce arterial dilation (Vallerand & Sanoski, 2020). Side effects include drowsiness, hypotension, rash, Stevens Johnson Syndrome, glaucoma, electrolyte imbalances, GI upset, and hypercholesterolemia (Vallerand & Sanoski, 2020). This drug will have additive hypotensive effects with other antihypertensive medications (Vallerand & Sanoski, 2020).
Atorvastatin, also known as, Lipitor is a lipid-lowering agent used for the primary management of hypercholesterolemia and mixed dyslipidemia (Vallerand & Sanoski, 2020). The starting dose is 10-20 mg once daily initially and may be increased every 2-4 weeks up to 80 mg daily (Vallerand & Sanoski, 2020). This drug inhibits 3-hydroxy-3methylglutaryl-coenzyme A (HMG-CoA) reductase, an enzyme that is responsible for the early steps of cholesterol synthesis, thus lowering LDL and triglycerides (Vallerand & Sanoski, 2020). Side effects include edema, electrolyte imbalances, GI upset, and headaches (Vallerand & Sanoski, 2020). (Vallerand & Sanoski, 2020).
