kuliah antihipertensi

Farmakoterapi Hipertensi

Edy Junaidi

Factors involved in the pathogenesis of hypertension

Straka, R.J., et al., 2008

Saseen, J.J. & Carter, B.L., 2005

JNC7JNC7

JNC 7

ESC/ESHESC/ESH

ESC/ESH Guidelines, 2007ESC/ESH Guidelines, 2007

Goal BP Value Recommended by the JNC7

Most patients < 140/90 mmHg Patients with diabetes < 130/80 mmHg Patients with Chronic Kidney Disease <

130/80 mmHg Estimated GFR < 60 ml/min Serum creatinine > 1.3 mg/dl in women

or >1.5 mg/dl in men, or Albuminuria > 300 mg/day, or ≥ 200 mg/g creatinine

Initiation of Antihypertensive Treatment(ESC/ESH Guideline, 2007)(ESC/ESH Guideline, 2007)

Classification of Antihypertensive drugs by Their Primary Site or Mechanism of Action Diuretics

Thiazides & related agents Loop diuretics K+-sparing diuretics

Symphatolytic drugs Centrally acting agents (methyldopa, etc) Adrenergic neuron blocking agents (guanadrel,

reserpine, etc) Beta-blockers Alpha-blockers Mixed adrenergic antagonists (labetalol, carvedilol)

Vasodilators Arterial (Hydralazine, Minoxidil, diazoxide, fenoldopam) Arterial & Venous (Nitroprusside)

Calcium channel blockers (CCB) Dihydropyridine (nifedipine, amlodipine, etc) Verapamil & Diltiazem

ACE Inhibitors Captopril, enalapril, etc

Ang II receptor Blockers (ARB) Valsartan, Losartan, etc

Lüllmann, H., et al., 2005

Lüllmann, H., et al., 2005

Lüllmann, H., et al., 2005

1 = ACEIs; 2 = ARBs; 3 = Beta-blockers; 4 = CCBs; 5 = Diuretics; 1 = ACEIs; 2 = ARBs; 3 = Beta-blockers; 4 = CCBs; 5 = Diuretics; 6 = Aldosterone antagonists6 = Aldosterone antagonists

11

22

3344

55

66

Saseen, J.J. & Carter, B.L., 2005

Diagram of Renin – Angiotensin – Aldosterone System (RAAS)

Straka, R.J., et al., 2008

Flowchart of various Beta-Blockers

Straka, R.J., et al., 2008

There are some controversies exist There are some controversies exist on diuretics and Beta-blockers as on diuretics and Beta-blockers as first-line therapyfirst-line therapy

Saseen, J.J. & Carter, B.L., 2005

Saseen, J.J. & Carter, B.L., 2005

Clinical trial & guideline basis for compelling indications for individual drug classes

Adapted from JNC7, 2004Adapted from JNC7, 2004

Cutler, J.A & Davis, B.A., 2008

Incidence of hospitalized (Hosp) Heart Failure (HF) outcome by Antihypertensive Treatment Group (Amlodipine/Lisinopril vs. Chlortalidone)

Preferred drugs in related conditionsLVH = left ventricular hypertrophyESRD = end-stage renal disease /

renal failureISH = isolated hypertensionACEI = ACE inhibitorCA = Calcium antagonist / CCBARB = Angiotensin II receptor

blockerBB = Beta-blockers

ESH/ESC guideline, 2007

ESC/ESH guideline, 2007

Possible combinations between some classes of antihypertensive drugs.The preferred combination in the general hypertensive population are represented as Thick Line. Thick Line. The frame indicate classes of agents proven to be beneficial in controlled intervention trialsESC/ESH Guideline, 2007

Rate of persistence on treatment after 6, 12, and 24 months in difference subgroup of patients treated with ARBs, CCBs, BBs, ACEIs,Lercanidipine, & Diuretics* ** *** p<0.05, 0.01, 0.005 vs ARBs

Veronessi, M., et al., 2007

Adverse Effects of drugs : percentage of people with one or more symptoms attributable to treatment*; according to category of drug and dose

in randomized trial

Bramlage, P. & Hasford, J., 2009

Kesselheim, A.S., et al., 2008

Bourgoult, C., et al., 1999

Bourgoult, C., et al., 1999

Bourgoult, C., et al., 1999

Fischer, M.A. & Avorn, J., 2004

Monthly cost of antihypertensive drugs in UK was found £23.44

Hypertension expenditures in Italy represents 42.7% of total expenditure for medicines