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Farmakoterapi
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Farmako Anti Hipertensi
Asupan garam
berlebih
Jumlah nefron
berkurangStress
Perubahan genetis
Obesitas
Bahan-bahan yang berasal dari
endotel
Retensi natrium ginjal
Aktivitas berlebih
saraf simpatis
Penurunan permukaan
filtrasi
Renin angiotensin
berlebih
Perubahan membran
sel
Hiper-insulinesmia
↑ Volume cairan
Konstriksi vena
↑ Preload ↑ KontraktilitasKonstriksi fungsionil
Hipertrofi struktural
CURAH JANTUNG
TAHANAN PERIFER
TEKANAN DARAH
↑ curah jantung ↑ tahanan periferHipertensi
Autoregulasi
= X
Blood pressure goals in hypertensive patients (ESH-ESC)
SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;DBP, diastolic blood pressure.
Recommendations
SBP goal for “most”•Patients at low–moderate CV risk•Patients with diabetes•Consider with previous stroke or TIA•Consider with CHD•Consider with diabetic or non-diabetic CKD
<140 mmHg
SBP goal for elderly•Ages <80 years•Initial SBP ≥160 mmHg
140-150 mmHg
SBP goal for fit elderlyAged <80 years
<140 mmHg
SBP goal for elderly >80 years with SBP•≥160 mmHg
140-150 mmHg
DBP goal for “most” <90 mmHg
DB goal for patients with diabetes <85 mmHg
Lifestyle Modifications to Manage HTN
Modification Recommendations Approximate Systolic Blood Pressure
Reduction
Weight Reduction Maintain normal body weight (BMI 18.5-24.9)
5-20 mm Hg for each 10 kg weight loss
Adapt eating plan Consume diets rich in fruits, vegetables, low fat dairy and low saturated fat
8-14 mm Hg
Dietary sodium reduction Reduce sodium to no more than 2.4 g/day sodium or 6 g/day NaCl
2-8 mm Hg
Increase physical activity Engage in regular aerobic activity such as walking (30 min/day on most days)
4-9 mm Hg
Moderate alcohol consumption
Limit alcohol to no more than 2 drinks/d for men and 1 drinks/day for women.
2-4 mm HgSource: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.
Medical Education & Information – for all Media, all Disciplines, from all over the World Powered by
2013 ESH/ESC Guidelines for the management of arterial hypertension
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
Monotherapy vs. drug combination strategies to achieve target BP
Moving from a less intensive to a more intensive therapeutic strategyshould be done whenever BP target is not achieved.
Choose between
Single agent Two–drug combination
Previous agentat full dose
Switch to different agent
Previous combinationat full dose
Add a third drug
Two drug combination at full doses
Mild BP elevationLow/moderate CV risk
Marked BP elevationHigh/very high CV risk
Three drug combination at full doses
Switch to different two–drug
combination
Full dosemonotherapy
BP, blood pressure; CV, cardiovascular.
Medical Education & Information – for all Media, all Disciplines, from all over the World Powered by
2013 ESH/ESC Guidelines for the management of arterial hypertension
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
Possible combinations of classes of antihypertensive drugs
Green continuous lines: preferred combinations; green dashed line: useful combination (with some limitations); black dashed lines: possible but less well tested combinations; red continuous line: not recommended combination. Although verapamil and diltiazem are sometimes used with a beta-blocker to improve ventricular rate control in permanent atrial fibrillation, only dihydropyridine calcium antagonists should normally be combined with beta-blockers.
Thiazide diuretics
β-blockers Angiotensin-receptorblockers
Otherantihypertensives
ACE inhibitors
Calciumantagonists
Preferred hypertension treatment in specific conditionsCondition Drug
Asymptomatic organ damage
LVH LVH ACE inhibitor, calcium antagonist, ARB
Asymptomatic atherosclerosis Calcium antagonist, ACE inhibitor
Microalbuminuria ACE inhibitor, ARB
Renal dysfunction ACE inhibitor, ARB
Clinical CV event
Previous stroke Any agent effectively lowering BP
Previous myocardial infarction BB, ACE inhibitor, ARB
Angina pectoris BB, calcium antagonist
Heart failure Diuretic, BB, ACE inhibitor, ARB, mineralocorticoid receptor antagonists
Aortic aneurysm BB
Atrial fibrillation, prevention Consider ARB, ACE inhibitor, BB or mineralocorticoid receptor antagonist
Atrial fibrillation, ventricular rate control BB, non-dihydropyridine calcium antagonist
ESRD/proteinuria ACE inhibitor, ARB
Peripheral artery disease ACE inhibitor, calcium antagonist
Other
ISH (elderly) Diuretic, calcium antagonist
Metabolic syndrome ACE inhibitor, ARB, calcium antagonist
Diabetes mellitus ACE inhibitor, ARB
Pregnancy Methyldopa, BB, calcium antagonist
Blacks Diuretic, calcium antagonist
ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BB, beta-blocker; BP, blood pressure; CV, cardiovascular; ESRD, end-stage renal disease; ISH, isolated systolic hypertension; LVH, left ventricular hypertrophy.
Compelling indications for hypertension treatmentClass Contraindications
Compelling PossibleDiuretics(thiazides)
Gout Metabolic syndromeGlucose intolerancePregnancyHypercalcemiaHypokalaemia
Beta-blockers AsthmaA–V block (grade 2 or 3)
Metabolic syndromeGlucose intoleranceAthletes and physically active patientsCOPD (except for vasodilator beta-blockers)
Calcium antagonists(dihydropyridines)
TachyarrhythmiaHeart failure
Calcium antagonists(verapamil, diltiazem)
A–V block (grade 2 or 3, trifascicular block)Severe LV dysfunctionHeart failure
ACE inhibitors PregnancyAngioneurotic oedemaHyperkalaemiaBilateral renal artery stenosis
Women with child bearing potential
Angiotensin receptor blockers PregnancyHyperkalaemiaBilateral renal artery stenosis
Women with child bearing potential
Mineralocorticoidreceptor antagonists
Acute or severe renal failure (eGFR <30 mL/min)Hyperkalaemia
A-V, atrio-ventricular; COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerular filtration rate; LV, left ventricular.
Oral antihypertensive drugs*
Oral antihypertensive drugs* (continued)
ACEIs, angiotensin converting enzyme inhibitors; BBs, beta blockers; CCBs, calcium channel blockers* In some patients treated once daily, the antihypertensive effect may diminish toward the end of the dosing interval (trough effect).BP should be measured just prior to dosing to determine if satisfactory BP control is obtained. Accordingly, an increase in dosage or frequency may need to be considered. These dosages may vary from those listed in the Physician’s Desk Reference (57th ed.).† Available now or becoming available soon in generic preparations.Source: Physician’s Desk Reference. 57th ed. Montvale, NJ: Thompson PDR, 2003.
Tabel No 2 Obat-obat parenteral untuk penanganan hipertensi emergensi pd edema paru dan sindroma koroner akut
Obat Golongan Dosis Onset kerja
Masa kerja
Efek samping
Sodiumnitroprusid
VasodilatorArteri & vena
0,25-10Mg/kg/mnt
Segera stlh distop
1-2 mnt
Mual, hipotensi,keracunan tiosianat, methemoglobinemia dan sianida.
Nitrogliserin Vasodilator:Arteri & vena
5-300 mcg/mnt
1-5 mnt 3-5 mnt
Sakit kepala, mual, takikardia, muntah toleransi
Isosorbid dinitrat
Vasodilator:Arteri & vena
1- 10 mg/jam
1-5 mnt 3-5 mnt
Sakit kepala,mual, takikardia, muntah, toleransi
Nikardipin Kalsiumantagonis
5-15mg/jam
5-15menit
30-40 menit
Hipotensi,takikardi,mual muntah, muka merah
Furosemide Diuretik loop
20-40 mg 10-20 mnt
4-6 jam
HipokalemiHipovolemia
17
Kelompok umur Hipertensi bermakna
Hipertensi berat
Neonatus 7 hari Td S > 96 Td S > 106
8 – 30 hari Td S > 104 Td S > 110
Bayi < 2 tahun Td S > 112Td D > 74
Td S > 118Td D > 84
Anak 3-5 tahun Td S > 116Td D > 76
Td S > 124Td D > 84
Anak 6-9 tahun Td S > 126Td D > 78
Td S > 84Td D > 130
Anak 10 –12 Td S > 126Td D > 82
Td S > 134Td D > 90
Remaja 13-15 tahun Td S > 136Td D > 86
Td S > 144Td D > 92
Remaja 16-18 tahun Td S > 142Td D > 92
Td S > 150Td D > 98
Tabel 1. Klasifikasi Hipertensi menurut kelompok umur
18
Obat Cara pembelian
Dosis Awal Respons Awal
Lamanya Respon
Efek Samping/ Komen
Diazoksid IV cepat (1-2 menit)
2-5 mg/kg, bila dalam 30 menit respons (-) ulangi
3-5 menit 4-24 jam Nausea, hiperglikemia rentsni natrium
Natrium Infus pompa 0,5 sampai 8 mikrogram/kg/menit
Segera Selama infus
Perlu monitor resiko ketatiosianat
Hidralazin
IV atau IM 0.1 - 0.2 mg/kg
10-30 menit 2-6 jam Takikardia, flushing, saku kepala
Reserpin IM 0.07 mg/kg, maksimal 2,5 mg
1,5 – 3 jam 2-12 jam Hidung tersumbat, respon lambat
Klonidin IMIV
0.002 mg/kg/kali. Ulangi 4-6 jam. Dapat dinaikan sampai 3 X lipat
IV : 5 menitIM :
beberapa menit lebih
lama
Beberapa jam
Mengantuk, bradikardia, kering. Hipertensi reboun
Tabel 2. Obat Antihipertensi untuk Penanggulangan Krisis Hipertensi
19
Klasifikasi/Nama Obat Dosis (oral/hari) Interval Dosis
Awal Maksimal
Diurettik
Hidroklorotiazid 1 mg/kg 2 mg/kg Sekali sehari
Klortalidon 1 mg/kg 2 mg/kg Sekali sehari
Spironolakson 1 mg/kg 3 mg/kg Tiap 12 jam
Furosemid 1 mg/kg 10 mg/kg Tiap 12 jam
Penghambar Adrenergik
Penghambat beta Propranolol
1 mg/kg 5 mg/kg Tiap 6 jam
Penghambat alfa Prazosin
0,05 mg/kg 0,5 mg/kg Tiap 8 jam
Tabel 3 a. Dosis Obat anti Hipertensi Oral pada Anak
20
Antiadrenergik sentral
Kolonidin 0,005 mg/kg 0,03 mg/kg Tiap 8 jam
Methildopa 5 mg/kg 40 mg/kg Tiap 6-12 jam
Bekerja pada ujung saraf simpatetik
Reserpin 0,02-0,07 mg/kg
2,5 mg kg Tiap 12 jam
Guanetidin 0,2 mg/kg 2 mg/kg Sekali sehari
Vasodilato langsung
Hidralazin 1 mg/kg 5 mg/kg Tiap 8-12 jam
Minosidil 0,1 mg/kg 1 mg/kg Tiap 12 jam
Calcium Channel Blocker
Nifedipin 0,25 mg/kg 1 mg/kg Tiap 12 jam
Diltiazem 2 mg/kg 3,5 mg/kg Tiap 12 jam
ACE Inhibiter
Captopril 0,3 mg/kg 6 mg/kg Tiap 6-12 jam
Tabel 3 b. Dosis Obat anti Hipertensi Oral pada Anak
21
1. Krisis hipertensi disertai gagal jantung maka pengobatan selain anti hipertensi, diuretika, digitalisasi juga diperlukan.
2. Krisis hipertensi disertai dengan gagal ginjal dengan ditandai uremia maka tindakan dilaisis perlu dilakukan[10]
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