Antihypertensive drugs: list of latest generation drugs

Hypotensive effect - what is it? This question is asked by women and men who are faced with the problem of high blood pressure or hypertension for the first time and who have no idea what the hypotensive effect of the drugs prescribed to them by their attending physician means. An antihypertensive effect is a decrease in blood pressure under the influence of a particular drug.

Experienced professional therapists of the highest category at the Yusupov Hospital Therapy Clinic, who are proficient in advanced treatment and diagnostic methods, will provide qualified assistance to patients with arterial hypertension and select an effective treatment regimen that eliminates the development of negative consequences.

Classification of antihypertensive drugs

Medicines that correct blood pressure are divided into two large groups: first-line and second-line drugs. Moreover, they can be of rapid or prolonged action, belong to different pharmacological groups, that is, control different processes in the body.

First line

This is a large group of antihypertensive drugs, which are prescribed from the very beginning for the treatment of already confirmed hypertension, and includes 5 types of medications:

Second line

Antihypertensive drugs of this group are recommended for the relief of essential (primary) hypertension only in certain patients, for example, pregnant women, the elderly, and all those for whom expensive drugs are an unbearable burden for a long time. There are also 5 types of them:

Most often, these drugs are not recommended as independent therapy; they are an auxiliary arsenal that purposefully enhances the effect of the main drugs.

Antihypertensive therapy for diabetes mellitus

Diabetes mellitus is a chronic disease, the development of which is associated with an absolute or relative deficiency of the hormone insulin. Lack of insulin or lack of sensitivity to it leads to an increase in blood glucose levels. This condition has a negative impact on all systems and organs of the human body, including the cardiovascular system.

Almost all patients suffering from diabetes complain of high blood pressure, which can be reduced with great difficulty without the help of a doctor.

Hypertension and diabetes mellitus

Hypertension in patients with diabetes is an integral and very dangerous component, which can several times increase the risk of developing the following diseases:

• 3-5 times - heart attack;
• 3-4 times - stroke:
• 10-20 times - blindness;
• 20-25 times – renal failure;
• 20 times - gangrene, requiring limb amputation.

If blood pressure readings exceed 140/90, there is no need to hesitate to contact a specialist, since hypertension that occurs against the background of diabetes mellitus can lead to the development of irreversible consequences, often incompatible with life.

Hypertension in type 1 diabetes mellitus

The main and most dangerous cause of arterial hypertension in type 1 diabetes mellitus is the presence of diabetic nephropathy in patients with this disease. The development of this complication is observed in almost 40% of people suffering from type 1 diabetes. Increased blood pressure is directly related to the amount of protein excreted in the urine.

Hypertension due to renal failure also develops due to poor excretion of sodium in the urine. As sodium increases in the blood, fluid accumulates to dilute it. Due to the increase in circulating blood volume, blood pressure increases. This process may also be associated with an increase in glucose concentration, which occurs in diabetes mellitus. As a result, to reduce blood density, the body produces even more fluid and the volume of circulating blood further increases for this reason.

Hypertension in type 2 diabetes mellitus

One of the factors that provokes the development of type 2 diabetes mellitus is insulin resistance, i.e. decreased sensitivity of tissues to the action of insulin.

To compensate for insulin resistance, excessive amounts of insulin circulate in the blood, which itself causes an increase in blood pressure. Over time, a narrowing of the lumen of blood vessels occurs, caused by atherosclerosis, which also contributes to the occurrence of hypertension. In parallel, patients experience the development of abdominal obesity, and, as is known, it is from adipose tissue that substances that increase blood pressure are released into the blood.

Hypertension in diabetes: features

In patients with diabetes mellitus, there is a disturbance in the natural daily rhythm of blood pressure fluctuations. In a healthy person, blood pressure levels in the morning and at night are usually 10-20% lower than in the daytime. In patients with diabetes, there is no decrease in blood pressure at night. Moreover, their nighttime pressure readings may be even higher than their daytime ones. According to experts, this phenomenon is caused by diabetic neuropathy. An increased concentration of sugar in the blood leads to damage to the autonomic nervous system, which is responsible for regulating the body's vital functions. There is a deterioration in the ability of blood vessels to regulate their tone - narrowing and relaxing depending on the load.

Antihypertensive drugs for diabetes mellitus

To date, eight groups of antihypertensive drugs are known, of which five are considered primary, and three are considered additional. Antihypertensive therapy for diabetes mellitus involves taking the following medications:

• diuretics;
• calcium channel blockers;
• beta blockers;
• centrally acting drugs;
• ACE inhibitors;
• angiotensin II receptor blockers;
• alpha-blockers;
• renin inhibitor (racillosis).

Medicines that make up additional groups are prescribed, most often, as components of combination treatment.

List of fast and long-acting drugs

The increase in pressure can be spontaneous, sudden or gradual, but steady. This requires the use of rapid or long-acting antihypertensive drugs.

Fast acting drugs:

• Lasix (Furosemide) is a loop diuretic, the drug of choice for emergency care, corrects electrolyte metabolism, causes frequent urination, tablets are effective within an hour, injectable within the first 20 minutes;
• Atenolol (Anaprilin, Sotagestal) - slows down the heart rate while leveling blood pressure, acts after 15 minutes;
• Adelfan - antihypertensive tablets under the tongue, effective in 10 minutes;
• Clonidine – the effect is observed after half an hour, minus – dryness of the mucous membranes;
• Nifedipine – begins to work 5 minutes after sublingual administration;
• Captopril - under the tongue, works in 20 minutes, minus - three times a day.
• Nitroglycerin has a hypotensive effect after 5 minutes, prevents vasospasm, leading to heart attacks.

These antihypertensive drugs are indicated for the relief of hypertensive crises. Complicated crises require injection therapy.

The prolonged group was developed for the convenience of treating hypertension; lifelong use of drugs once or twice a day does not interfere with leading a normal lifestyle:

• Sotalol, Propranol, Carvedilol - non-selective beta receptor blockers;
• Atenolol, Bisoprolol, Betaxol - selective beta blockers;
• Amlodipine, Verapamil, Diltiazem – calcium antagonists;
• Enalapril, Lisinopril, Perindopril – ACE inhibitors;
• Indapamide, Hydrochlorothiazide, Hypothiazide are diuretics.

These drugs are used in the combination treatment of second or third degree hypertension.

Antihypertensive therapy: drugs to lower blood pressure

During antihypertensive therapy, several main groups of drugs that help lower blood pressure are currently used:

• beta blockers;
• ACE inhibitors;
• calcium antagonists;
• diuretics;
• angiotensin II receptor blockers.

All of the above groups have comparable effectiveness and their own characteristics that determine their use in a given situation.

Beta blockers

Drugs in this group reduce the likelihood of developing coronary complications in patients suffering from angina pectoris, prevent cardiovascular accidents in patients with myocardial infarction, tachyarrhythmia, and are used in patients with chronic heart failure. Beta-blockers are not recommended for patients with diabetes mellitus, lipid metabolism disorders and metabolic syndrome.

ACE inhibitors

Angiotensin-converting enzyme inhibitors have pronounced hypotensive properties, they have organoprotective effects: their use reduces the risk of complications of atherosclerosis, reduces left ventricular hypertrophy, and slows the decline in renal function. ACE inhibitors are well tolerated and have no negative effects on lipid metabolism and glucose levels.

Calcium antagonists

In addition to antihypertensive properties, drugs in this group have antianginal and organoprotective effects, help reduce the risk of strokes, atherosclerotic lesions of the carotid arteries and left ventricular hypertrophy. Calcium antagonists may be used alone or in combination with other drugs that have antihypertensive properties.

Diuretics

Diuretic drugs are usually used in combination with other antihypertensive drugs in order to enhance the therapeutic effect.

Diuretics are also prescribed to persons suffering from pathologies such as refractory hypertension and chronic heart failure. To avoid the development of side effects, when taking these drugs continuously, minimal dosages are prescribed.

Angiotensin II receptor blockers

Drugs in this group, which have neuro- and cardioprotective effects, are used to improve control of blood glucose levels. They can increase the life expectancy of patients suffering from chronic heart failure. Antihypertensive therapy using angiotensin II receptor blockers can be prescribed to patients who have had a myocardial infarction, suffer from renal failure, gout, metabolic syndrome and diabetes mellitus.

Valid combinations

The compatibility of antihypertensive drugs is necessary in the treatment of high blood pressure. The most commonly used combinations are presented in the table:

The effectiveness of any combination of antihypertensive drugs depends on the presence of certain indications, taking into account the metabolic and hemodynamic properties of each component.

Antihypertensive therapy: general rules

Both symptomatic hypertension and hypertension require correction with drugs that have a hypotensive effect. Antihypertensive therapy can be carried out with drugs that differ in their mechanism of action: antiadrenergic agents, vasodilators, calcium antagonists, angiotensin antagonists, and diuretics.

You can obtain information about the hypotensive effect of the drug and what medications to take for high blood pressure not only from your doctor, but also from your pharmacist.

Arterial hypertension is a chronic disease that requires constant drug support, daily monitoring and regular use of prescribed medications. Not only the state of health, but also the life of a person depends on compliance with these rules.

Despite the general availability of treatment rules for reducing blood pressure, many patients have to be reminded what a treatment regimen for hypertension should look like:

• Antihypertensive medications should be taken regularly, regardless of the patient’s well-being and blood pressure level. This allows you to increase the effectiveness of blood pressure control, as well as prevent cardiovascular complications and target organ damage;
• It is necessary to strictly adhere to the dosage and use the form of the drug prescribed by the attending physician. Independently changing the recommended dose or replacing the drug may distort the hypotensive effect;
• even if you are constantly taking antihypertensive drugs, it is necessary to systematically measure blood pressure, which will allow you to evaluate the effectiveness of therapy, timely identify certain changes and adjust treatment;
• in the case of an increase in blood pressure against the background of constant antihypertensive treatment - the development of an uncomplicated hypertensive crisis, an additional dose of a previously taken long-acting drug is not recommended. Blood pressure can be quickly reduced using short-acting antihypertensive drugs.

Side effects

The negative consequences of taking antihypertensive drugs vary across groups. The main ones are presented in a table:

The latest generation of antihypertensive drugs listed in the table have a minimum number of side effects - this is a trend in modern pharmacological practice.

Hypotensive syndrome

Hypotensive syndrome is a whole complex of symptoms that reflects a persistent decrease in intracranial pressure in women. It occurs only in pregnant women aged 25 to 29 years. This syndrome significantly reduces the quality of life of the expectant mother and requires qualified medical care.

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Causes

The causes of this pathology are the following factors:

• severe dehydration after undergoing drug therapy;
• head injuries;
• leakage of cerebrospinal fluid due to a violation of the integrity of the skull bones or brain tissue;
• a decrease in blood pressure, leading to a decrease in intracranial pressure.

Every pregnant woman should be doubly attentive to her health, since she is also responsible for the life of the child. Any changes in health should be a reason to consult a doctor. Doctors at the Yusupov Hospital are ready to answer all their patients’ questions at any time, either in person or by phone.

Symptoms of hypotensive syndrome in pregnant women are:

• severe constricting sudden headaches;
• increased headaches when raising the head or in a sitting position;
• reduction in the intensity of headaches when lowering the head;
• prostration;
• feeling drowsy;
• irritability;
• attacks of nausea and vomiting.

Of course, many of the above symptoms occur in pregnant women and are a consequence of changes in the functioning of all organs and systems during the period of bearing a baby. They may have nothing to do with hypotensive syndrome.

But in any case, if the expectant mother’s health worsens, she must inform the doctor about it. Caution and attentiveness to your health will help you avoid the development of complications, identify hypotensive syndrome and undergo an effective course of therapy.

Diagnostics

If symptoms of the disease appear during pregnancy, it is necessary to undergo examinations by a gynecologist, neurologist and neurosurgeon. Doctors conduct examinations, analyze all the patient’s complaints and make a preliminary diagnosis. To confirm or refute it, the pregnant woman is prescribed a number of diagnostic measures, namely:

• general and biochemical blood test;
• general urine analysis;
• X-ray of the skull;
• spinal tap;
• MRI of the brain.

At the Yusupov Hospital, all diagnostic procedures are carried out using modern medical equipment, which allows you to obtain accurate data and promptly begin treatment.

Metabolic effects of antihypertensive drugs

Transcript of the author's broadcast by Professor Sergei Rudzherovich Gilyarevsky, held on February 29, 2012.

Drapkina O.M.: - Hello, dear colleagues! The program “Evidence-Based Cardiology” is on air, and its author, and leading professor Gilyarevsky, well, and such co-leading professor Oksana Mikhailovna Drapkina.

Gilyarevsky S.R.: - Good evening, dear colleagues.

Drapkina O.M.: - Hello! It turns out that we have been going on air at this time for many years. The gear ratio has been slightly changed. Well, today, Sergei Rudzherovich, we will probably talk about metabolism, metabolism in general.

Gilyarevsky S.R.: — Even, maybe not in general, but we will touch upon such a seemingly very banal topic as the metabolic effects of antihypertensive drugs. This topic, it seemed, is discussed at every conference, and everyone who represents a certain class of antihypertensive drugs always says that this class is the most metabolically neutral, and in general, when they discuss the problem, they usually still evaluate or discuss the effect antihypertensive drugs on blood glucose levels, on the risk of developing diabetes mellitus and on blood potassium levels, on electrolyte disturbances, especially diuretics.

Drapkina O.M.: — Can this be called pleiotropic effects?

Gilyarevsky S.R.: - Well, it’s hard to say...

Drapkina O.M.: - Well, multiple...

Gilyarevsky S.R.: - Well, these are more likely side effects, not pleiotropic ones.

Drapkina O.M.: - But if they improve insulin sensitivity.

Gilyarevsky S.R.: — And, if they improve insulin sensitivity, probably yes. It seems to me that when we talk about antihypertensive drugs, it is still very important to talk first of all about their safety. Indeed, it is difficult not to agree that there are some pleiotropic effects in some drugs, which still sometimes make one wonder and discuss what we have done.

I would like to turn to the results of a meta-analysis, because when side effects are discussed, they very often resort to meta-analysis, because if clinical effects are quite well identified during large randomized trials, then the statistical power of even large studies is not always sufficient in order to detect certain side effects. And therefore, in this situation, they often turn to meta-analyses or some large observational, population studies.

A well-known meta-analysis that focused on the effects of antihypertensive drugs and their impact on the risk of developing diabetes mellitus. And compared with diuretics, which are known to most increase the risk of developing diabetes, other drugs had a lesser effect on the risk of developing diabetes, including placebo, and, of course, the most positive effect, the greatest, was observed in receptor blockers, sartans and ACE inhibitors. Moreover, you can even remember that one of the sartans, valsartan, in the NAVIGATOR study, it was even proven that its use in people with prediabetes leads to a reduction in the risk of developing diabetes by 14%.

Therefore, questions of the effect of antihypertensive drugs on metabolic parameters concern, in general, everyone. And in this regard, the informational reason for our today's program is the publication of a very large case-control study, which was based on the analysis of a real database, a population database of the United Kingdom, in which data on the incidence of gout and in general were recorded. different diagnoses, including in patients with arterial hypertension who received different antihypertensive drugs.

And in the course of this study, they tried to answer the question of how different drugs affect the risk of developing gout. That is, this was the main goal of this analysis. Here, perhaps, we need to remember what role uric acid plays in general as a risk factor for the development of cardiovascular diseases and, it would seem, from our institute years we know well that gout is hyperuricemia, it is a risk factor for cardiovascular diseases. However, in 1999, the results of the Framingham study were published, which questioned the independence of gout and hyperuricemia as a risk factor for the development of cardiovascular diseases. Perhaps this was due to the fact that this study included individuals who had a fairly high risk of developing complications of cardiovascular diseases, and therefore hyperuricemia and gout no longer added something as a risk factor, but, nevertheless, later they were Several studies have been published, most of which provided evidence that hyperuricemia is an independent risk factor for the development of cardiovascular diseases, but there is still no exact answer.

But, be that as it may, if hyperuricemia is not even an independent risk factor for the development of cardiovascular diseases, then at least the development of gout is certainly a very unpleasant disease that worsens the patient’s quality of life and requires the use of additional medications , well, it is often accompanied by pain, hyperuricemia worsens kidney function. So here, really, if it is possible to prevent the development of gout, then regardless of whether it is an independent risk factor or not, this is very important.

Drapkina O.M.: - You just said, Sergei Rudzherovich, I remembered 1999 there, this is understandable, our student life, even earlier. But this year we celebrate the 180th anniversary of the birth of Sergei Petrovich Botkin, and in his clinical lectures, this was 1867, he said that hypertension is associated with an image with a lot of uric acid. Apparently this was already determined then. I remember now, could this be defined then in lectures?

Gilyarevsky S.R.: - But at least they could have a crystal.

Drapkina O.M.: - Moreover, with his such excellent propaedeutic qualities, he watched urates and tophi. Georgy Fedorovich Lang said the same thing, and Myasnikov, that is, about gout in general...

Gilyarevsky S.R.: - So in our real practice, in patients with gout, they very often had coronary heart disease, but the question arises: in whom an increase in the level of uric acid is accompanied by a greater influence on the risk of developing complications of cardiovascular diseases - in men or women.

Drapkina O.M.: — It seems to me that it’s in men.

Gilyarevsky S.R.: - But as often happens, it seems one at a time, but in fact, it turns out that it’s in women. This is probably due to the fact that in men the risk of complications of cardiovascular diseases is higher, so, probably, hyperuricemia is already dissolved in this. And by the way, in the LIFE study, where we recall that losartan is compared with atenolol, it was in women that the influence of uric acid levels was greater as a risk factor for the development of complications of cardiovascular diseases. So, in any case, such a problem exists, and it was partly solved during the implementation of this study. Very large studies: data were included on almost 25,000 newly diagnosed gout patients and 50,000 demographically matched controls who...these data were obtained from a UK online health database. And, moreover, during this analysis, even in order to clarify whether there were any errors, because doctors can make a diagnosis of gout, well, just like that. Some people see something wrong with the finger, arthrosis, Heberden’s nodes, but it seems to them that that’s all...

Well, of course, I’m exaggerating everything, but mistakes can happen if they are not based on a thorough analysis, on the determination of uric acid there. Therefore, here, for clarification, an additional analysis was performed, which included data only from patients who received treatment for gout. And yet, the results turned out to be about the same; in fact, the results were somewhat sensational. It turned out that calcium antagonists reduce the risk of developing gout by 13%. Well, the leader here turned out to be losartan, an angiotensin II receptor blocker, diuretics, these are natural results, diuretics more than doubled the risk of developing gout, beta blockers by 150%, that is, one and a half times, ACE inhibitors by 1.2% and angiotensin II receptor blockers – increased, yes.

Drapkina O.M.: - So this is a directly unique effect of losartan?

Gilyarevsky S.R.: - Yes, a unique effect, and indeed there is evidence that the severity of the uricosuric effect of losartan may be similar to that of the classic uricosuric drug probenecid, which is well known, that is, this effect exists. And they even tried to establish the reasons for this, the reasons for this effect, and it became obvious that this effect is not associated with angiotensin II receptor blockade, because, as we saw in the course of performing this analysis, other angiotensin II receptor blockers did not lead to a decrease, even by In their background, there was an increase in the risk of developing gout, including such well-known drugs as valsartan, which reduced the risk of developing diabetes, telmisartan, and candesartan. Only losartan.

Similarly, taking ACE inhibitors was also not accompanied by a decrease in uric acid levels. So, in the course of several experimental studies, it was shown that the use of losartan leads to blockade of the uric acid transporter in the kidneys - URAT-1, and thus the action of this transporter in the apical part of the tubular cells is suppressed due to direct inhibition, which is also typical for other uricosuric drugs agents such as probenecid and benzbromarone.

Drapkina O.M.: — There was, of course, a clawed frog.

Gilyarevsky S.R.: - Well, I looked on the Internet when I saw this, there really is such a frog, about its biological characteristics. For some reason she is a convenient model for studying URAT-1. So this is a unique action. Here, of course, the question arises, if... by the way, you didn’t specify, what is meant by hyperuricemia? What is the concentration of uric acid?

Drapkina O.M.: - It depends on what units it is measured in.

Gilyarevsky S.R.: — It is believed that approximately 600, about 647 mg per deciliter, this is the concentration of uric acid that precipitates at a temperature of 37 degrees, i.e. Crystal formation occurs precisely at this level of uric acid. I think it's 6.7 mg per deciliter. This is taken as the starting point.

By the way, one study showed that an increase in uric acid concentration above this level compared with a level less than 4.3 is accompanied by a statistically significant increase in the risk of heart failure by approximately 50% and the risk of stroke, but not coronary heart disease. That. So this is what you need to pay attention to.

The question arises: okay, why is it necessary to give a hypertensive drug, which in addition exhibits its pleiotropic effect, reduces the level of uric acid. Isn’t it better to give the patient a normal drug for the treatment of gout: allopurinol, which we talked about, or probenecid and reduce the level of uric acid. But still, it is believed that today such a concentration - asymptomatic hyperuricemia, even at a concentration of 6.7 - is not an indication for the prescription of allopurinol, that is, in my opinion, it should be a level of about 900 mg per deciliter or should be clinically overt gout.

So, let’s say, for primary prevention in the development of gout, these drugs are not very recommended for moderately elevated uric acid levels. In general, as a rule, in real practice you see, well, 500, well, 400-something. Therefore, of course, the role of losartan here is very high. Of course, when we talk about the use of losartan, we probably need to remember a number of studies and, in general, the evidence-based history of this drug. It started very interestingly with the ELITE study, and then in this study - it was not very large - there were, in my opinion, less than 1 thousand patients, and they wanted to see how much better losartan would be tolerated than captopril.

It was better tolerated in patients with heart failure, but unexpectedly it was found that it statistically significantly reduced the risk of deaths, including sudden death, compared to captopril, and then it seemed that the end of the era of ACE inhibitors had come, sartans would solve all problems, associated with the effect on the renin-angiotensin system.

But then there was the ELITE-2 study, a larger study, the study had statistical power to detect the risk of adverse outcomes, including mortality, and it failed, and captopril even had some advantages over losartan. Further history, also at least in heart failure, the HEAAL study was performed, which compared a dose of 150 mg and 50 mg, that is, the dose that was no better than captopril - and they proved that when using such a high dose of losartan there are statistically significant improvements in forecasts. Therefore, probably, in the treatment of arterial hypertension, a dose of 100 mg should still be used more often, and in case of heart failure, even formally, higher doses should still be used, naturally taking into account the level of potassium in the blood. So for the treatment of arterial hypertension this, of course, is of great importance. So the drug is not always the first of a certain class, it loses its relevance, this is interesting, because this is also the development of evidence-based medicine.

Drapkina O.M.: - Sergey Rudzherovich, does this mean, according to the data that you also show, the level of uric acid, well, let’s assume, does not exceed eight, so be it - it will be more than seven, but nine. Hypertensive, obese, say, high-risk hypertension, taking into account the effect on uric acid levels, a combination of losartan with a calcium channel blocker would probably be preferable for such a patient.

Gilyarevsky S.R.: - Yes, of course, we haven’t really discussed the effect of calcium antagonists, but they also have this possibility, so this idea of ​​​​prescribing amlodipine with an ACE inhibitor or sartan is good. And from this point of view, the combination of amlodipine and losartan is probably additive in individuals with a tendency to hyperuricemia. This study did not evaluate the effects of combined use of calcium antagonists and losartan, but...

Drapkina O.M.: - But we don’t have such a fixed combination.

Gilyarevsky S.R.: — For losartan, as far as I know, no. So this is also a reason to think.

Drapkina O.M.: — We should probably contact you, dear colleagues, if you have questions, write to us in the chat, we will answer. Take advantage of the moment, and if there are no questions or they come later, we will also answer in the next programs, yes, Sergei Rudzherovich?

Gilyarevsky S.R.: - Yes.

Drapkina O.M.: - Well, maybe we should announce what will await our viewers, our colleagues in the next program?

Gilyarevsky S.R.: - Yes, we can announce it. We wanted to discuss a problem that also seemed to have already been exhausted, the role of coronary artery stenting in the treatment of coronary heart disease, but there are also some informational reasons to return to the discussion of this problem.

Drapkina O.M.: - We are waiting for you on Wednesday. See you.

Gilyarevsky S.R.: - See you later. Goodbye.