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20-September-2008 09:55:47 - Antihypertensive Antihypertensives are a class of drugs that are used in medicine and pharmacology to treat hypertension high blood pressure. There are many classes of antihypertensives, which-by varying means-act by lowering blood pressure. Evidence suggests that reduction of the blood pressure by 5-6 mmHg can decrease the risk of stroke by 40%, of coronary heart disease by 15-20%, and reduces the likelihood of dementia, heart failure, and mortality from cardiovascular disease. Which type of medication to use initially for hypertension has been the subject of several large studies and resulting national guidelines.The fundamental goal of treatment should be the prevention of the important endpoints of hypertension such as heart attack, stroke and heart failure. Several classes of medications are effective in reducing blood pressure. However, these classes differ in side effect profiles, ability to prevent endpoints, and cost. The choice of more expensive agents, where cheaper ones would be equally effective, may have negative impacts on national healthcare budgets.1 In the United States, the JNC7 The Seventh Report of the Joint National Committee on Prevention of Detection, Evaluation and Treatment of High Blood Pressure recommends starting with a thiazide diuretic if single therapy is being initiated and another medication is not indicated.2 This is based on a slightly better outcome for chlortalidone in the ALLHAT study versus other anti-hypertensives and because thiazide diuretics are relatively cheap.3 A subsequent smaller study ANBP2 published after the JNC7 did not show this small difference in outcome and actually showed a slightly better outcome for ACE-inhibitors in older male patients.4 Despite thiazides being cheap, effective, and recommended as the best first-line drug for hypertension by many experts, they are not prescribed as often as some newer drugs. Arguably, this is because they are off-patent and thus rarely promoted by the drug industry.5 In the United Kingdom, the June 2006 Hypertension: management of hypertension in adults in primary care6 guideline of the National Institute for Health and Clinical Excellence, downgraded the role of beta-blockers due to their risk of provoking type 2 diabetes.7 Contents 1 Available drugs 1.1 Diuretics 1.2 Adrenergic receptor antagonists 1.3 Adrenergic receptor agonist 1.4 Calcium channel blockers 1.5 ACE inhibitors 1.6 Angiotensin II receptor antagonists 1.7 Aldosterone antagonists 1.8 Vasodilators 1.9 Centrally acting adrenergic drugs 2 Future treatment options 2.1 Blood pressure vaccine 3 Choice 4 See also 5 References 6 External links Available drugs Diuretics Hydrochlorothiazide, a popular thiazide diuretic Hydrochlorothiazide, a popular thiazide diuretic Diuretics help the kidneys eliminate excess salt and water from the body's tissues and blood. Loop diuretics: bumetanide ethacrynic acid furosemide torsemide Thiazide diuretics: chlortalidone epitizide hydrochlorothiazide and chlorothiazide bendroflumethiazide Thiazide-like diuretics: indapamide chlorthalidone metolazone Potassium-sparing diuretics: amiloride triamterene spironolactone Only the thiazide and thiazide-like diuretics have good evidence of beneficial effects on important endpoints of hypertension, and hence, should usually be the 1st choice when selecting a diuretic to treat hypertension. The reason why thiazides-type diuretics are better than the others is at least in part thought to be because of their vasodilating properties.citation needed Although the diuretic effect of thiazides may be apparent shortly after administration, it takes longer weeks of treatment for the full anti-hypertensive effect to develop. Adrenergic receptor antagonists Propranolol, the first beta-blocker to be successfully developed Propranolol, the first beta-blocker to be successfully developed Beta blockers no longer 1st line therapy in many countries - see Lancet 29 October 2005: atenolol metoprolol nadolol oxprenolol pindolol propranolol timolol Alpha blockers: doxazosin phentolamine indoramin phenoxybenzamine prazosin terazosin tolazoline Mixed Alpha + Beta blockers: bucindolol carvedilol labetalol Although beta blockers lower blood pressure, they do not have as positive a benefit on endpoints as some other antihypertensives.8 In particular, atenolol seems to be less useful in hypertension than several other agents.9 However, beta blockers have an important role in the prevention of heart attack in people who have already had a heart attack.10 Despite lowering blood pressure, alpha blockers have significantly poorer endpoint outcomes than other antihypertensives, and are no longer recommended as a first-line choice in the treatment of hypertension.11 However, they may be useful for some men with symptoms of prostate disease. Adrenergic receptor agonist Alpha-2 agonists: clonidine methyldopa Guanfacine Calcium channel blockers Calcium channel blockers block the entry of calcium into muscle cells in artery walls. dihydropyridines: amlodipine felodipine isradipine lercanidipine nicardipine nifedipineAdalat nimodipine nitrendipine non-dihydropyridines: diltiazem verapamil ACE inhibitors Captopril, the prototypical ACE inhibitor Captopril, the prototypical ACE inhibitor ACE inhibitors inhibit the activity of Angiotensin-converting enzyme ACE, an enzyme responsible for the conversion of angiotensin I into angiotensin II, a potent vasoconstrictor. captopril enalapril fosinopril lisinopril perindopril quinapril ramipril trandolapril benazepril Angiotensin II receptor antagonists Valsartan, an angiotensin II receptor antagonist Valsartan, an angiotensin II receptor antagonist Angiotensin II receptor antagonists work by antagonizing the activation of angiotensin receptors. candesartan eprosartan irbesartan losartan olmesartan telmisartan valsartan Aldosterone antagonists Aldosterone receptor antagonists: eplerenone spironolactone Aldosterone antagonists are not recommended as first-line agents for blood pressure,2 but spironolactone and eplerenone are both used in the treatment of heart failure. Vasodilators Vasodilators act directly on arteries to relax their walls so blood can move more easily through them; they are only used in medical emergencies. sodium nitroprusside Centrally acting adrenergic drugs Central alpha agonists lower blood pressure by stimulating alpha-receptors in the brain which open peripheral arteries easing blood flow. Central alpha agonists, such as clonidine, are usually prescribed when all other anti-hypertensive medications have failed. For treating hypertension, these drugs are usually administered in combination with a diuretic. Clonidine Guanabenz Methyldopa Moxonidine Adverse effects of this class of drugs include sedation, drying of the nasal mucosa and rebound hypertension. Some adrenergic neuron blockers are used for the most resistant forms of hypertension: Guanethidine Reserpine Future treatment options Blood pressure vaccine Blood pressure vaccinations are being trialed and may become a treatment option for high blood pressure in the future. Research published in The Lancet on the 8 March 2008 titled, Vaccination against high blood pressure: a new strategy showed patients experienced a drop in systolic and diastolic blood pressure after taking the vaccine. Effective blood pressure vaccines would assist those people who forget to take their medication. It would also help those who stop taking their medication due to side effects or falsely believing they don't need them anymore once their blood pressure is lowered.12 Choice The choice between the drugs is to a large degree determined by the characteristics of the patient being prescribed for, the drugs' side-effects, and cost. For example, asthmatics have been reported to have worsening symptoms when using beta blockers. Most drugs have other uses; sometimes the presence of other symptoms can warrant the use of one particular antihypertensive such as beta blockers in case of tremor and nervousness, and alpha blockers in case of benign prostatic hyperplasia. The JNC 7 report outlines compelling reasons to choose one drug over the others for certain individual patients.2 See also Blood pressure Hypertension Prehypertension Pulse pressure References ^ Nelson MR, McNeil JJ, Peeters A et al Jun 4 2001. PBS/RPBS cost implications of trends and guideline recommendations in the pharmacological management of hypertension in Australia, 1994-1998. Med J Aust 174 11: 565-8. PMID 11453328. ^ a b c Chobanian AV et al 2003. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 289: 2560-72. doi:10.1001/jama.289.19.2560. PMID 12748199. ^ ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group Dec 18 2002. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ALLHAT. JAMA 288 23: 2981-97. doi:10.1001/jama.288.23.2981. PMID 12479763. ^ Wing LM, Reid CM, Ryan P et al Feb 13 2003. A comparison of outcomes with angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly. NEJM 348 7: 583-92. doi:10.1056/NEJMoa021716. PMID 12584366. ^ Wang TJ, Ausiello JC, Stafford RS 1999. Trends in Antihypertensive Drug Advertising, 1985-1996. Circulation 99: 2055-2057. PMID 10209012. ^ Hypertension: management of hypertension in adults in primary care PDF. National Institute for Health and Clinical Excellence. Retrieved on 2006-09-30. ^ Sheetal Ladva 2006-06-28. NICE and BHS launch updated hypertension guideline. National Institute for Health and Clinical Excellence. Retrieved on 2006-09-30. ^ Lindholm LH, Carlberg B, Samuelsson O Oct 29-Nov 4 2005. Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 366 9496: 1545-53. doi:10.1016/S0140-67360567573-3. PMID 16257341. ^ Carlberg B, Samuelsson O, Lindholm LH Nov 6-12 2004. Atenolol in hypertension: is it a wise choice?. Lancet 364 9446: 1684-9. doi:10.1016/S0140-67360417355-8. PMID 15530629. ^ Freemantle N, Cleland J, Young P et al Jun 26 1999. Beta Blockade after myocardial infarction: systematic review and meta regression analysis. BMJ 318 7200: 1730-7. PMID 10381708. ^ ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group Sep 2003. Diuretic Versus alpha-Blocker as First-Step Antihypertensive Therapy. Hypertension 42 3: 239-46. doi:10.1161/01.HYP.0000086521.95630.5A. PMID 12925554. ^ http://www.my-blood-pressure.com/vaccine-study.html Blood pressure vaccine study promising v d e Antihypertensives C02 and diuretics C03 Sympatholytic agents Centrally acting/antiadrenergics α2 agonist Clonidine, Guanfacine, Methyldopa imidazoline receptor agonist Moxonidine, Rilmenidine adrenergic uptake inhibitor Rescinnamine, Reserpine Ganglion-blocking/nicotinic antagonist Mecamylamine, Trimethaphan Peripherally acting/antiadrenergics α1 blockers: Prazosin Indoramin Trimazosin Doxazosin Urapidil Guanidine derivatives: Betanidine Guanethidine Guanoxan Debrisoquine Guanoclor Guanazodine Guanoxabenz Vasodilators Diazoxide hydrazinophthalazine Hydralazine, Dihydralazine, Endralazine, Cadralazine Minoxidil Nitroprusside Phentolamine Other antihypertensives serotonin antagonist Ketanserin endothelin receptor antagonist Bosentan, Ambrisentan, Sitaxsentan MAOI Pargyline THI Metirosine Diuretics Low ceiling Thiazides at DCT Bendroflumethiazide Hydroflumethiazide Hydrochlorothiazide Chlorothiazide Polythiazide Trichlormethiazide Cyclopenthiazide Methyclothiazide Cyclothiazide Mebutizide Sulfonamides Quinethazone Clopamide Chlortalidone Mefruside Clofenamide Metolazone Meticrane Xipamide Indapamide Clorexolone Fenquizone Other Mersalyl Theobromine Cicletanine osmotic Mannitol, Urea carbonic anhydrase inhibitor at PT Acetazolamide High ceiling Loop diuretic at AL Bumetanide, Furosemide, Torasemide, Ethacrynic acid Potassium-sparing at CD ESC blockers Amiloride, Triamterene aldosterone antagonists Spironolactone, Eplerenone, Potassium canrenoate, Canrenone v d e Major drug groups Gastrointestinal tract/metabolism A stomach acid Antacids, H2 antagonists, Proton pump inhibitors Antiemetics Laxatives Antidiarrhoeals/Antipropulsives Anti-obesity drugs Anti-diabetics Vitamins Dietary minerals Blood and blood forming organs B Antithrombotics Anticoagulants, Antiplatelets, Thrombolytics Antihemorrhagics Cardiovascular system C cardiac therapy/antianginals Cardiac glycosides, Antiarrhythmics, Cardiac stimulant Antihypertensives Diuretics Vasodilators Beta blockers renin-angiotensin system ACE inhibitors, Angiotensin II receptor antagonists, Renin inhibitors Antihyperlipidemics Skin D Emollients Cicatrizant Antipruritics Reproductive system G Hormonal contraception Fertility agents SERMs Sex hormones Endocrine system H Corticosteroids Sex hormones Thyroid hormones Antithyroid agent Infections and infestations J, P Antibiotics Antivirals Vaccines Antifungals Antiparasitic Antiprotozoals, Anthelmintics Malignant and immune disease L Anticancer agents Immunostimulators Immunosuppressants Muscles, bones, and joints M Anabolic steroids Anti-inflammatories NSAID Antirheumatics Corticosteroids Muscle relaxants Brain and nervous system N Anesthetics General, Local Analgesics Anticonvulsants Mood stabilizers Psycholeptic Anxiolytics, Antipsychotics, Hypnotics/Sedatives Psychoanaleptic Antidepressants, Stimulants/Psychostimulants Respiratory system R Bronchodilators Decongestants H1 antagonists Other ATC V Antidotes Contrast media Radiopharmaceuticals Dressing External links Official Adalat Nifedipine site, Bayer Retrieved from http://en..org/wiki/Antihypertensive Categories: Antihypertensive agents | Blood pressureHidden categories: All articles with statements | Articles with statements since August 2007 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages العربية Català Deutsch Español Hrvatski Magyar Norsk nynorsk Polski Português ไทย This page was last modified on 9 August 2008, at 17:1
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