P-FORMULARY
CATEGORY of DRUG: ANTI HYPERTENSIVES: ACE INHIBITORS
GENERIC NAME(S): “PRIL” Captopril (Capoten), Lisinopril (Prinvil, Zestril),
Enalapril (Vasotec), is a prodrug ACE
DIAGNOSIS (es)/INDICATIONS: Hypertension, heart failure; May also be indicated to
slow progression of left ventricular hypertrophy after a myocardial infarction; Drug of
choice for diabetic patients (renal protective effects) Epidemiological and clinical studies
have shown ACE inhibitors reduce the progress of diabetic nephropathy independently
from their blood pressure-lowering effect. This action of ACE inhibitors is used in the
prevention of diabetic renal failure. A recent meta-analysis indicates that ACE
inhibitors and ARBs reduce CVD events in normotensive individuals with and
without diabetes (McAlister,2012) . Accordingly, the use of ACE inhibitors or ARBs
for vascular protection with persons with diabetes ≥55 years or with any evidence
of organ damage is recommended, even in the absence of hypertension.
Furthermore, for patients with diabetes and hypertension, an ACE inhibitor or
ARB should be considered as a first-line agent for BP control.
MECHANISM of ACTION: Inhibits angiotensin-converting enzyme, which is responsible
for converting angiotensin I to angiotensin II. ((powerful vasoconstrictor; stimulates
secretion of aldosterone =NA retention= increased BP); deactivates bradykinin which
causes vasodilation) pathway and reduced peripheral vascular resistance with
long-term use Angiotensin II acts as vasoconstrictor, so inhibiting its production
prevents increase in blood pressure and stops the renin-angiostensin-aldosterone
system. Furthermore, ACE inhibitors prevent breakdown of vasodilating substance
bradykinin, resulting in decreased systemic vascular resistance (afterload), vasodilation,
and therefore decreased blood pressure. Buildup of bradykinin that accompanies ACE
inhibition causes side effects.
THERAPEUTIC OBJECTIVE(S): Maintain blood pressure at less than 130/90 mm Hg;
For hypertensive patients that also have diabetes or renal disease, the blood pressure
goal is less than 130/80 mm Hg (JNC-7); Prevent complications due to hypertension
and prevent congestive heart failure
,DRUG(S) of CHOICE (with dose range):
1st Line (no contraindications): Captopril Start: 12.5 to 25 mg 2-3 times/day;
may increase by 12.5 to 25 mg/dose at 1- to 2-week intervals up to 50 mg 3 times/day.
Maximum: 150 mg 3 times/day.
Enalapril 2.5-40 mg once daily. It may also be administered twice daily in two
divided doses.
CONTRAINDICATIONS: Drug allergy (especially a previous reaction of angioedema
(laryngeal swelling) to an ACE inhibitor), lactating women, children, bilateral renal artery
stenosis or hyperkalemia; Taking with NSAIDs can reduce the antihypertensive effect,
taking with lithium can result in lithium toxicity, and taking with potassium supplements
and potassium-sparing diuretics may result in hyperkalemia
SIDE EFFECTS: Dizziness, mood changes, possible hyperkalemia, fatigue, headache,
impaired taste, dry non-productive cough* that reverses when therapy is stopped,
angioedema (rare but potentially fatal), first-dose hypotensive effect may occur> Some
evidence also suggests ACE inhibitors might increase inflammation-related pain,
perhaps mediated by the buildup of bradykinin that accompanies ACE inhibition.
*Angiotensin II Receptor Blockers (ARBs) are another category of
anti-hypertensives often used when ACE inhibitors aren’t tolerated (ie patient
develops the dry cough).
They block the activation of angiotensin II AT1 receptors. Blockage of AT1 receptors
directly causes vasodilation, reduces secretion of vasopressin, and reduces production
and secretion of aldosterone, among other actions. The combined effect reduces blood
pressure.
MONITORING PARAMETERS:
BP levels (systolic/diastolic), side effects, cardiovascular status
HEALTH TEACHING
Related to drug
● All of the above
Complimentary health strategies :
● Avoid foods high in sodium
● Use follow up for progress on hypertension and congestive heart failure
EVIDENCE/References :
McAlister, F. (2012) Renin Angiotensin System Modulator Meta-Analysis Investigators
Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are beneficial
,in normotensive atherosclerotic patients: a collaborative meta-analysis of randomized
trials Eur Heart J 33 505 514
, P-FORMULARY
CATEGORY of DRUG: ANTI-DIABETICS: Oral Antidiabetic Drugs
GENERIC NAME(S): 1. biguanides: Metformin (Glucophage®)
2. sulfonylureas: glyburide (Diabeta),
3. alpha-glucosidase inhibitors: acarbose
4. meglitinides: Repaglinide prandial glucose regulators
(GlucoNorm; Prandin)
5. GLP1 and DPP4 incretin agents
6. Thiazolidinediones: Pioglitazone; Rosiglitazone
DIAGNOSIS (es)/INDICATIONS : Used to treat patients with type II diabetes in
combination with behavioural and lifestyle changes to lower blood glucose levels in
patients with type II diabetes
MECHANISM of ACTION:
Biguanides (metformin) acts by decreasing hepatic glucose production, decreasing
glucose absorption, and increasing glucose uptake into skeletal muscle. Metformin
monotherapy can lower FPG by 60 to 70 mg/dl and lower hemoglobin A1c by 1.5 to 2%.
Metformin also decreases triglyceride concentrations, LDL cholesterol, total cholesterol,
and body weight, and increases HDL cholesterol. When used as monotherapy,
metformin has not been associated with hypoglycemia. Gastrointestinal disturbances
(20%) are common including: nausea, abdominal pain, bloating, anorexia, metallic taste
and diarrhea. Metformin is contraindicated in 1) patients with serum creatinine >1.5
CATEGORY of DRUG: ANTI HYPERTENSIVES: ACE INHIBITORS
GENERIC NAME(S): “PRIL” Captopril (Capoten), Lisinopril (Prinvil, Zestril),
Enalapril (Vasotec), is a prodrug ACE
DIAGNOSIS (es)/INDICATIONS: Hypertension, heart failure; May also be indicated to
slow progression of left ventricular hypertrophy after a myocardial infarction; Drug of
choice for diabetic patients (renal protective effects) Epidemiological and clinical studies
have shown ACE inhibitors reduce the progress of diabetic nephropathy independently
from their blood pressure-lowering effect. This action of ACE inhibitors is used in the
prevention of diabetic renal failure. A recent meta-analysis indicates that ACE
inhibitors and ARBs reduce CVD events in normotensive individuals with and
without diabetes (McAlister,2012) . Accordingly, the use of ACE inhibitors or ARBs
for vascular protection with persons with diabetes ≥55 years or with any evidence
of organ damage is recommended, even in the absence of hypertension.
Furthermore, for patients with diabetes and hypertension, an ACE inhibitor or
ARB should be considered as a first-line agent for BP control.
MECHANISM of ACTION: Inhibits angiotensin-converting enzyme, which is responsible
for converting angiotensin I to angiotensin II. ((powerful vasoconstrictor; stimulates
secretion of aldosterone =NA retention= increased BP); deactivates bradykinin which
causes vasodilation) pathway and reduced peripheral vascular resistance with
long-term use Angiotensin II acts as vasoconstrictor, so inhibiting its production
prevents increase in blood pressure and stops the renin-angiostensin-aldosterone
system. Furthermore, ACE inhibitors prevent breakdown of vasodilating substance
bradykinin, resulting in decreased systemic vascular resistance (afterload), vasodilation,
and therefore decreased blood pressure. Buildup of bradykinin that accompanies ACE
inhibition causes side effects.
THERAPEUTIC OBJECTIVE(S): Maintain blood pressure at less than 130/90 mm Hg;
For hypertensive patients that also have diabetes or renal disease, the blood pressure
goal is less than 130/80 mm Hg (JNC-7); Prevent complications due to hypertension
and prevent congestive heart failure
,DRUG(S) of CHOICE (with dose range):
1st Line (no contraindications): Captopril Start: 12.5 to 25 mg 2-3 times/day;
may increase by 12.5 to 25 mg/dose at 1- to 2-week intervals up to 50 mg 3 times/day.
Maximum: 150 mg 3 times/day.
Enalapril 2.5-40 mg once daily. It may also be administered twice daily in two
divided doses.
CONTRAINDICATIONS: Drug allergy (especially a previous reaction of angioedema
(laryngeal swelling) to an ACE inhibitor), lactating women, children, bilateral renal artery
stenosis or hyperkalemia; Taking with NSAIDs can reduce the antihypertensive effect,
taking with lithium can result in lithium toxicity, and taking with potassium supplements
and potassium-sparing diuretics may result in hyperkalemia
SIDE EFFECTS: Dizziness, mood changes, possible hyperkalemia, fatigue, headache,
impaired taste, dry non-productive cough* that reverses when therapy is stopped,
angioedema (rare but potentially fatal), first-dose hypotensive effect may occur> Some
evidence also suggests ACE inhibitors might increase inflammation-related pain,
perhaps mediated by the buildup of bradykinin that accompanies ACE inhibition.
*Angiotensin II Receptor Blockers (ARBs) are another category of
anti-hypertensives often used when ACE inhibitors aren’t tolerated (ie patient
develops the dry cough).
They block the activation of angiotensin II AT1 receptors. Blockage of AT1 receptors
directly causes vasodilation, reduces secretion of vasopressin, and reduces production
and secretion of aldosterone, among other actions. The combined effect reduces blood
pressure.
MONITORING PARAMETERS:
BP levels (systolic/diastolic), side effects, cardiovascular status
HEALTH TEACHING
Related to drug
● All of the above
Complimentary health strategies :
● Avoid foods high in sodium
● Use follow up for progress on hypertension and congestive heart failure
EVIDENCE/References :
McAlister, F. (2012) Renin Angiotensin System Modulator Meta-Analysis Investigators
Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are beneficial
,in normotensive atherosclerotic patients: a collaborative meta-analysis of randomized
trials Eur Heart J 33 505 514
, P-FORMULARY
CATEGORY of DRUG: ANTI-DIABETICS: Oral Antidiabetic Drugs
GENERIC NAME(S): 1. biguanides: Metformin (Glucophage®)
2. sulfonylureas: glyburide (Diabeta),
3. alpha-glucosidase inhibitors: acarbose
4. meglitinides: Repaglinide prandial glucose regulators
(GlucoNorm; Prandin)
5. GLP1 and DPP4 incretin agents
6. Thiazolidinediones: Pioglitazone; Rosiglitazone
DIAGNOSIS (es)/INDICATIONS : Used to treat patients with type II diabetes in
combination with behavioural and lifestyle changes to lower blood glucose levels in
patients with type II diabetes
MECHANISM of ACTION:
Biguanides (metformin) acts by decreasing hepatic glucose production, decreasing
glucose absorption, and increasing glucose uptake into skeletal muscle. Metformin
monotherapy can lower FPG by 60 to 70 mg/dl and lower hemoglobin A1c by 1.5 to 2%.
Metformin also decreases triglyceride concentrations, LDL cholesterol, total cholesterol,
and body weight, and increases HDL cholesterol. When used as monotherapy,
metformin has not been associated with hypoglycemia. Gastrointestinal disturbances
(20%) are common including: nausea, abdominal pain, bloating, anorexia, metallic taste
and diarrhea. Metformin is contraindicated in 1) patients with serum creatinine >1.5
