PEMILIHAN OBAT

ANTI HIPERTENSI
 Oleh : Vita Rahmayani, SSi., M.Farm. Klin., Apt
 Clinical Pharmacy Rumah sakit Ibu dan
anak Pemerintah Aceh

 HP. 0821139916387
 Email : vita.pharm5@gmail.com
MACAM HIPERTENSI
 EMERGENSI DAN URGENSI –
 HT PADA KEHAMILAN (PREKLAMSIA
DAN EKLAMSIA)
 HT PULMONAR
 HT SEREBRAL (INTRACRANIAL
HYPERTENSION)
 KLASIFIKASI TEK DARAH
JNC-7

Normal <120 and <80

Prehypertension 120–139 or 80–89
Stage 1 140–159 or 90–99
Hypertension
Stage 2 >160 or >100
Hypertension

(JAMA, 2003= JNC-7)

Emergencies &
Urgencies
 HYPERTENSIVE
EMERGENCIES
 Require immediate blood
pressure reduction (not
necessarily to normal
range) to prevent or limit
target organ damage.

 HYPERTENSIVE
URGENCIES
 Require reduction of
blood pressure within a
few hours
Hypertension increases……. with the
age! (Ann Intern Med, 2003)

Ps-DZ, 2009
KLASIFIKASI HT
A.Hipertensi esensial (HT primer)= HT
Idiopatik, yg blm jelas
penyebabnya.Dipengaruhi usia, kelamin,
merokok, kholesterol, BB

B.Hipertensi sekunder. Dipengaruhi oleh obat,

penyakit ginjal, penyakit endokrin (DM, tiroid
, Cushing)
DiPiro, 2011)
Secondary hypertension (Braunwald, 2013)
(((DiPiro, 2011)
CARDIOVASKULAR RISK FACTOR
& TARGET ORGAN DAMAGE

JNC 7,
2003
Treatment Options for Hypertension

 Prevention is the best

treatment strategy
 The goal of treatment:
 Lower blood pressure to
prevent associated
complications
 Typically <140/90 mmHg
http://www.physicaltherapy.ca/c
ardio/Hypertension1.html
TERAPI :

NON – FARMAKOLOGI
FARMAKOLOGI
Tx NON-FARMAKOLOGI

PENCEGAHAN & TERAPI

1.Bagi yg obese, turunkan BB
2.Diet garam (≤ 2.4g/hr)
3.Kurangi konsumsi lemak
4.Tidak merokok, kurangi kopi &
alkohol
5.Istirahat cukup
6.Olahraga teratur.
(FARKOMNIK, 2008)
Tx FARMAKOLOGI
ABCD
A.ACE-1 / ACE-2 (ARB) / ALFA1-
BLOCKER
B.BETA-BLOCKERS
C.CA-ANTAGONISTS
D.DIURETICS
L
U
L
L
M
A
N
,
2
0
0
5
2007 ESH/ESC Hypertension Guidelines
Mechanisms for Controlling Blood
Pressure & site of action of
antihypertensive drugs

 1= vasodilators, 2= β-blockers 3=α-blockers

 4= AT II blocker 5= Centrally sympatholytics
 6= ACE inhibitors 7= diuretics
(Braunwald,2013)
Main Benefits of ACE inhibition
(Braunwald,2013)
(DRUG TOPICS 2004)
Sulfhydryl-containing
ACE-Inhibitors
 Captopril
 Active compound
 75% bioavailability, which
can be reduced by food
 Take 1 hour prior to food
consumption
 Eliminated in the urine
 Captopril, captopril disulfide
dimmers, and captopril-
cysteine disulfide

http://home.caregroup.org/clinical/altmed/interactions/Drugs/Captopril.htm
ACE INHIBITOR (Knoben, 2002)
(BRAUNWALD, 2013)
 Side Effects of ACE-Inhibitors
 Hypotension with the
first dose
 Dry cough 5-20% of
people
 Hyperkalemia (High K+
levels)
 Acute renal failure
 Fetopathic effects in
pregnant women
 Skin rash
http://www.beauregard.org/bldpress.htm
 Dysgeusia, loss of taste
(KNOBEN, 2002)
ALFA 1 BLOCKER
(Knoben, 2002)
Calcium Channel Blockers (CCB)
Classification:

(Pharmacology Corner)
 CCBs

 YES: (useful in)  No: (avoid in)

 Elderly patients
 pregnant hypertensives
 Patients with peripheral
vascular disease
 Patients with
cerebrovascular disease
 Patients with angina pectoris
 Asthma/COPD Pts.
 Patients with heart failure
 Patients with heart block
 Patients receiving b-blockers
 Unstable angina
 Recent MI
 Diuretika

(Braunwald, 2013)
 Diuretika

(Braunwald, 2013)
Renin Inhibitors
 Aliskiren directly inhibits renin
 It lowers blood pressure about as effectively as ARBs, ACE
inhibitors, and thiazides.
 It can also be combined other antihypertensives, such diuretics, ACE
inhibitors, ARBs, or calcium-channel blockers.
 Aliskiren can cause diarrhea, especially at the higher doses.
 Aliskiren can also cause cough and angioedema but probably less
often than ACE inhibitors.
 The drug is contraindicated during pregnancy. Hyperkalemia was
significantly more common in patients who received both valsartan
and aliskiren.
(DRUG TOPICS 2004)
OBAT HIPERTENSI LAIN
KLONIDIN (CATAPRES)
RESERPIN(SERPASIL)
SERAPES
INDAPAMID (NATRILIX)
SODIUM NITROPRUSIDE
TRIMETAZIDIN
Terapi Kombinasi
 Rasional kombinasi obat antihipertensi:
 Ada 6 alasan mengapa pengobatan
kombinasi pada hipertensi dianjurkan:
 1. Mempunyai efek aditif
 2. Mempunyai efek sinergisme
 3. Mempunyai sifat saling mengisi
 4. Penurunan efek samping masing-masing obat
 5. Mempunyai cara kerja yang saling mengisi
 pada organ target tertentu
 6. Adanya “fixed dose combination” akan
 meningkatkan kepatuhan pasien (adherence)
Fixed-dose combination yang
paling efektif adalah sebagai
berikut:
 1. Penghambat enzim konversi angiotensin (ACEI)
 dengan diuretik
 2. Penyekat reseptor angiotensin II (ARB) dengan
 diuretik
 3. Penyekat beta dengan diuretik
 4. Diuretik dengan agen penahan kalium
 5. Penghambat enzim konversi angiotensin (ACEI)
 dengan antagonis kalsium
 6. Agonis α-2 dengan diuretik
 7. Penyekat α-1 dengan diuretic
(Pharmacy Therapy, 2003)
 ALGORITMA Tx HT
Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications
Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs
May consider ACEI, ARB, BB, CCB, thiazide-type diuretic and (diuretics, ACEI, ARB, BB, CCB)
or combination. ACEI, or ARB, or BB, or CCB) as needed.

Not at Goal
Blood Pressure
(JNC-7, 2003)
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
(Pharmacy Therapy, 2003)
 ABCD Compare & Contrast (Braunwald,2013)

Parameter Diuretic ACEi, ARB βblocker Ca+ Blocker

Ischemia No effect Improves Improves Negative
LVH, LVF Improves Improves Improves* Negative
CV Mortality Improves Improves Improves Increases
Heart rate No effect No effect Bradycardia Tachycardia
Use in DM Negative Excellent Negative Negative
Lipid effects Negative Excellent Negative Neutral
Fluid & Na Enhances No effect Vasoconstr. Vasodilatory
K ex / bronchi Enhances No effect Bronchospa No effect
UA / Conduct. ↑ Uric acid No effect ↓conduction No effect
www.drsarma.in 55
In
dik B
asi r
dan a
u
Ko n
ntra w
Ind a
ika l
si d
,
2
AH 0
T 1
3
 Monitoring Antihypertensives
Class Parameters
Diuretics blood pressure
BUN/serum creatinine
serum electrolytes (K+, Mg2+, Na+)
uric acid (for thiazides)
β-Blockers blood pressure
heart rate
Aldosterone antagonists blood pressure
ACE inhibitors BUN/serum creatinine
Angiotensin II receptor blockers serum potassium
Direct Renin inhibitors
Calcium channel blockers blood pressure
heart rate
DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy:A Pathophysiologic
Approach, 7th Edition: http://www.accesspharmacy.com/ 57
INFORMASI LAIN
BENTUK SEDIAAN RASEMAT
 ORA / SUBLINGUALL  AMLODIPIN
 INKONVENSIONAL  BISOPROLOL,
 (NIFEDIPIN RETARD- METOPROLOL
OROS, FUROSEMID,
PROPANOLOL;  INTERAKSI OBAT-
INDAPAMID) MAKANAN
 PARENTERAL  KAPTOPRIL-NIFEDIPIN
(NIMODIPIN,
NIKARDIPIN DLL)
 INTERAKSI DG
GRAPEFRUIT-CCB
INFORMASI LAIN
OFF LABEL OFF LABEL
 PREKLAMSIA :  PROPANOLOL TX
NIFEDIPIN, METILDOPA
 HIPERTIROID
 TERAZOSIN-
 PORTAL
DOKSASOZIN TX BPH
HYPERTENSION
 SILDENAFIL TX
 STABILITAS CAHAYA
PULMONARY
UV
HYPERTENSION
 NIFEDIPIN RUSAK
 CAPTOPRIL 6.25-12,5MG
 TX HEART FAILURE
 CLONIDIN TX
AMFETAMIN
OVERDOSIS
OBAT-OBAT LAIN YG SERING DIGUNAKAN
UTK Px HT

ANTIPLATELET
LIPID LOWERING
OBAT DIABETES
NEUROPROTEKTAN
ANTIARITMIA
DLL-NYA
MENINGKATKAN ADHERENCE

A.MEMBANTU PENGGUNAAN OBAT :

B.MENJELASKAN MANFAAT OBAT
C.MENJELASKANN KOMPLIKASI HTN
D.MENJELASKAN ESO DAN CARA DETEKSI
ESO
E.MENJELASKAN CARA PENYIMPANAN
OBAT
F.MEMONITOR TEK DARAH
.