Let's move on to some questions. The first question,
a 60 year old man has high blood pressure and diabetes.
He presents with severe swelling in the face
and half of his tongue is really swollen.
When you take a look at him,
this is what he looks like.
He had been given enalapril previously, hydrochlorothiazide,
and an oral antidiabetic drug.
Which of the drugs is the likely culprit?
Is it aspirin? Is it enalapril, hydrochlorothiazide,
the new unnamed diabetic drug,
or this is some kind of an environmental allergy?
Right, this is enalapril.
Now, this patient is showing classical signs of angioedema,
which is a relatively rare complication
sometime seen in patients taking ACE inhibitors.
It would be inadvisable to start an ARB, because there's
a 10 % cross-reactivity between ACEi's and ARBs.
Treatment is supportive and withdraw the medication.
Angioedema often looks like the person has a huge red face
as well, this is a more rare kind of presentation
but remember, swelling in the face, redness in the face,
or swelling of the tongue when you take a medication,
think angioedema from the ACE inhibitor.
This next question is kind of fun for me
because this is actually a real patient.
You have a 95 year old man with consistent blood pressures
of 170/94. He is on no medications and
he has no other diseases
and looks 30 years younger than his stated age.
You are considering starting him on an
antihypertensive medication. Which statement is true?
Number 1, do not use an ACE inhibitor as first line therapy.
B, do not use a beta blocker as first line therapy.
C, do not use a calcium channel blocker as first line therapy.
D, do not use a direct renin inhibitor as first line therapy.
And E, do not prescribe any drugs because he is too old.
This is a great question because it brings up
a whole bunch of issues, both pharmacological and ethical.
First of all, let's talk about beta therapy.
Current guidelines suggest that we should avoid using
beta blockers as first line therapy in the elderly.
All of the other choices are actually quite acceptable.
Now, treating a 95 year old male at this blood pressure
will still reduce his chances of developing a stroke,
or all cause mortality, even in the next three months.
So, even though he is 95 years old,
it is still worthwhile to treat blood pressure
as long as extra diligence is practiced.
Now, there's a lot of ethical conundrums
that are going to come up with this,
and there's going to be people who debate the pro and cons.
But the classical thing that you want to look at
in this particular clinical scenario,
is the fact that the examiner made special mention
that he looks 30 years younger than his current age.
And if he looks great, make an assumption that he is going
to live a long enough time to benefit from that medication.
So, in the real world, this is one of my patients.
He is now 100 years old,
and giving him that antihypertensive medication
may have prevented a stroke from reducing his lifespan.
So, just because a person is 95,
doesn't mean they won't live another 5 years.
Let's go onto a question about pregnancy.
Which of the following antihypertensive agents
is one of the drugs of choice in pregnancy?
Labetolol, clonidine, captopril, losartan,
Right, labetolol. So, labetolol is the
most used drug for hypertension in pregnancy.
Clonidine is definitely not what we want to use.
Remember that of the alpha 2 blockers,
clonidine is not our choice here.
We can use Aldomet, which is its sister drug.
We do not want to use ACE inhibitors.
They are contraindicated in pregnancy.
We do not want to use ARBs. They are also contraindicated
in pregnancy, so C and D can cause fetal abnormalities.
And finally, hydrochlorothiazide is also believed
to cause fetal abnormalities,
and if we can avoid it, we should.
The only drugs we use for hypertension in pregnancy,
with any assemblance of comfort
is labetolol, alpha-methyldopa or Aldomet,
and in some cases, a calcium channel blocker,
but only after the first trimester is over.
In terms of breastfeeding patients, calcium channel blockers
are the drug of choice because they are not secreted in milk.
Drugs like labetolol are seen
in very microscopic levels in breast milk,
so what I often do with my patients is
I switch them from labetolol to a calcium channel blocker
postpartum if they still need it. Most cases of gestational
hypertension, actually you can stop the medication and
the blood pressure problems go away when they have delivered.
That's it. I hope you enjoyed the lecture and I hope that it
illuminated some difficult concepts in hypertension management.