Anti Hypertensive Drugs

ACE Inhibitor and Angiotensin Receptor I Blocker

Presented to dr.Wartoto SpPd

Anti Hypertensive Agents

• Angiotensin Converting Enzyme

A Inhibitor

A • Angiotensin Receptor I Blocker

B • Beta Blocker

C • Calsium Channel Blocker

D • Diuretics
Anti Hypertensive Interaction
Renin Angiotensin Aldosterone
System
ACE Inhibitor and ARB Sites of
Action
Cont.

Renin

Angiotensinogen

Angiotensin I
ACE Non-ACE alternate
Angiotensin II pathways (eg, chymase)

X
Aldosterone
secretion
Renal tubular
ARB
X
Vasoconstriction

X
reabsorption of
sodium and water
AT1 receptors
X
Catecholamine
secretion
Antidiuretic hormone

X
(vasoprressin)
secretion
X
Stimulation of thirst center

 BP
 ACE I and ARBs

• ACE inhibitors and ARB’s:

Pharmacodynamics
– Vasodilation
– Reduced peripheral resistance
– Increased diuresis
– Reduced BP
– No change in HR
– No reduction in cardiac output
 ACE I and ARBs

• ACE Inhibitors/ARB’s: Potential Adverse

Effects
• ACE inhibitors
– Hyperkalemia
– Cough
– Hypotension, dizziness
– Headache
– Angioedema
• ARB’s
– Same as ACE inhibitors but cough is
uncommon
 ACE I and ARBs

• ACE inhibitors/ARB’s should be

carefully considered:
– Pre-existing kidney dysfunction (degree of
impairment, response to therapy)
– Renal artery stenosis (degree of stenosis)
• ACE inhibitors/ARB’s are
contraindicated:
– Pregnancy
– History of angioedema
– Hyperkalemia
 Starting Dose Target Dose Supplied
(mg) (mg) (mg)

ACE Inhibitor
Captopril 6,25 t.i.d 50 t.i.d 12.5 , 25
Fosinipril 10 o.d 80 o.d or 40 b.i.d 10, 20, 40
Lisinopril 2,5 – 5 o.d 20 – 40 o.d 2.5, 5, 10, 20, 40
Ramipril 2.5 o.d 5 b.i.d 1.25, 2.5, 5, 10
ARB
Irbesartan 150 o.d 300 o.d 75, 150, 300
Candesartan 4 or 8 o.d 32 o.d 4, 8, 16, 32
Valsartan 40 b.i.d 160 b.i.d 40, 80, 160, 320
Losartan 50 o.d 150 o.d 25, 50, 100
 ACE I and ARB
Could these drugs be combined?
PBM-MAP-VPE Clinical Recommendations: Angiotensin II
Receptor Antagonists update : 2014
Canadian Hypertension Guideline 2009
Case

Wanita 58 tahun dengan DM terdiagnosis

sejak 15 tahun tak terkontrol. Riwayat
hipertensi (+) Os datang ke IGD dengan
keluhan nyeri perut, pusing dan mual muntah.
Os berbadan gemuk, TD 170/100, GDS 530.
Hasil lab untuk fungsi ginjal ditemukan sedikit
elevasi kreatinin, 1,17.
UL ditemukan proteinuria +4 dan keton +3.
Apakah pasien ini hipertensi?
Hypertension  office BP ≥ 140/90

Immediate drug
≥ 180/90
treatment
Office BP
≥140/90

Asses organ
Repeat after 1- damage,
< 180/90 compelling
2 min
indication or ≥ 3
risks factors
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with diabetes

Recommendations Additonal considerations
Mandatory: initiate drug treatment in patients • Strongly recommended: start drug treatment
with SBP ≥160 mmHg when SBP ≥140 mmHg

SBP goals for patients with diabetes: <140 mmHg

DBP goals for patients with diabetes: <85 mmHg

All hypertension treatment agents are • RAS blockers may be preferred

recommended and may be used in patients with • Especially in presence of preoteinuria or
diabetes microalbuminuria

Choice of hypertension treatment must take comorbidities into account

Coadministration of RAS blockers not • Avoid in patients with diabetes

recommended

SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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 Bagaimana pemberian terapi pada
pasien ini? Single dose? Combination?
Apakah obat anti hipertensi yang tepat
untuk pasien ini?