michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
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Treatment <strong>of</strong> Secondary Causes <strong>of</strong> Hypertension<br />
When renal artery stenosis, obstructive sleep apnea, primary aldosteronism,<br />
pheochromocytoma, or Cushing’s disease is suspected or confirmed, treatment will be specific for that<br />
particular disorder.<br />
Pharmacological Treatment<br />
The best approach to treat RH has not been directly evaluated in randomized trials and the<br />
choice <strong>of</strong> treatment regimen is based largely on physiological principles and clinical experience.<br />
Because volume overload is common among such patients, the most important therapeutic maneuver<br />
is generally to add or increase diuretic therapy. 23 It is important to ensure that the diuretic is<br />
appropriate to the level <strong>of</strong> kidney function. Also, sometimes utilization <strong>of</strong> more than one diuretic will<br />
be necessary in complex, multi-drug regimens. Another important therapeutic maneuver is to titrate<br />
BP medication up to ideal doses and, or to use effective combinations <strong>of</strong> BP medications 27 and. 2 The<br />
medication regimen should be examined closely for ineffective antihypertensive drug combinations.<br />
Withdrawal <strong>of</strong> Interfering Medications particularly NSAIDs and Cox II inhibitors if possible. 2<br />
Therefore, if analgesics are necessary, sulindac or acetaminophen or even mild narcotic pain<br />
medications may be preferable to most NSAIDs in subjects with resistant <strong>hypertension</strong>.<br />
Diuretic Therapy as explained above is very essential to overcome the inappropriate volume<br />
expansion seen in RH and it is in fact essential aspect <strong>of</strong> the definition <strong>of</strong> resistant HTN.<br />
Thiazide diuretics:<br />
While Hydrochlorothiazide is widely used and effective in treating HTN in patients with<br />
normal renal function; Chlorthalidone is the recommended and the most effective thiazide diuretic for<br />
resistant HTN. 2 The extremely long half-life <strong>of</strong> 40 to 60 hours for chlorthalidone differentiates it from<br />
HCTZ, which has a much shorter half-life from 3.2 to 13.1 hours. 28 However chlorthalidone might be<br />
associated with excessive degrees <strong>of</strong> hypokalemia and requires more monitoring 28 ; however, this is<br />
<strong>of</strong> much less concern when chlorthalidone is used together with RAAS blockers given that the latter<br />
reduces the incidence <strong>of</strong> hypokalemia by two-thirds to three quarters. Chlorthalidone also, in contrast<br />
to hydrochlorothiazide, is available only in few fixed-dose combinations and generally requires separate<br />
dosing. 2 Metolazone, a long-acting thiazide-like diuretic, is highly effective in persons with depressed<br />
kidney function<br />
230 Hypertension Core Curriculum