WEBVTT 00:00.091 --> 00:04.855 [SPEAKER_02]: Hi everyone, and welcome to Red and Butter, our series on Corp Topics for Internus. 00:05.636 --> 00:16.605 [SPEAKER_02]: Today we'll be talking about hypertension management tips and tricks with Dr. Jennifer Kluitt, a primary care provider and hypertension expert, who runs a complex hypertension clinic at Beth Israel Deaconess Medical Center. 00:17.546 --> 00:21.850 [SPEAKER_02]: I'm Dr. Kira Takashel, an internal medicine primary care resident at BIDMC. 00:22.350 --> 00:25.273 [SPEAKER_02]: We're also joined as always by our own Dr. Shira Trevadi. 00:25.893 --> 00:27.375 [SPEAKER_02]: Dr. Kluitt, welcome to Korayam. 00:28.685 --> 00:30.626 [SPEAKER_00]: Thank you for having me, I'm so excited to be here. 00:30.646 --> 00:35.729 [SPEAKER_01]: Okay, Dr. Clue, or maybe we should say Jen, we could keep it first name basis, that's fair. 00:35.789 --> 00:36.429 [SPEAKER_01]: Absolutely. 00:36.449 --> 00:39.891 [SPEAKER_01]: Yeah, so Jen, before we jump into these cases, we didn't really excited. 00:39.911 --> 00:41.651 [SPEAKER_01]: I got so much out of learning from them. 00:42.212 --> 00:48.375 [SPEAKER_01]: What is kind of like your general approach someone with new hypertension, and what are the questions you're asking yourself and going through in your head? 00:49.957 --> 00:57.544 [SPEAKER_00]: Any time I see someone with a new diagnosis of hypertension, there's usually at least three or four things running through my mind. 00:58.205 --> 01:01.889 [SPEAKER_00]: The very first is, is this truly an accurate diagnosis. 01:01.969 --> 01:10.056 [SPEAKER_00]: So remember, we need at least two readings on two or more occasions a elevated blood pressure in order to make a diagnosis of hypertension. 01:10.777 --> 01:17.663 [SPEAKER_00]: You want to make sure that you're using out of office blood pressure readings typically home blood pressure readings to roll out white code effects. 01:17.923 --> 01:22.628 [SPEAKER_00]: And so up to 30% of patients have white code hypertension. 01:22.988 --> 01:28.973 [SPEAKER_00]: So using those out of office ratings is a way to confirm that this really is truly hypertension. 01:30.001 --> 01:37.206 [SPEAKER_00]: The second thing I think about is, is there any reason in this person to think about a secondary cause? 01:37.286 --> 01:44.890 [SPEAKER_00]: Going to just briefly touch on this here, but are they unusually young or unusually all to have a new diagnosis of hypertension? 01:45.030 --> 01:48.653 [SPEAKER_00]: Is there hypertension unusually severe or is it labile? 01:49.433 --> 01:59.882 [SPEAKER_00]: Are there features about this patient or their symptoms that warrant a secondary evaluation, like hypotelemia to look for panereautocernism or sleep apnea? 02:00.915 --> 02:05.857 [SPEAKER_00]: Once I've thought through those two initial things, I'm starting to think about our treatment. 02:06.717 --> 02:11.499 [SPEAKER_00]: And the first thing that comes to mind is, how far are they from their blood pressure goal? 02:11.899 --> 02:19.841 [SPEAKER_00]: And the latest blood pressure guidelines that came out in 2025, stuck with the same categories of blood pressure that were in the 2017 guidelines. 02:19.881 --> 02:29.805 [SPEAKER_00]: So stage one, stage two, but really this is coming down to, am I going to start this person on monotherapy or combination therapy out the gate? 02:30.305 --> 02:35.930 [SPEAKER_00]: And patients who spot pressures over 140 over 90, we really should be thinking about combination therapy up front. 02:37.191 --> 02:38.452 [SPEAKER_01]: I have one quick question about that. 02:38.992 --> 02:44.177 [SPEAKER_01]: Did they become stage two if it's either 140 or over 90 or they have to be both? 02:45.300 --> 02:45.680 [SPEAKER_01]: either. 02:46.000 --> 02:48.161 [SPEAKER_01]: You go with the worst of the two. 02:48.181 --> 02:49.061 [SPEAKER_01]: Okay. 02:49.642 --> 02:57.125 [SPEAKER_00]: So the way I say that is meets criteria for stage to hypertension based on their diastolic blood pressure or something along those lines. 02:57.345 --> 03:01.046 [SPEAKER_00]: And that's what qualifies them for the diagnosis of stage to hypertension. 03:02.226 --> 03:06.048 [SPEAKER_02]: And how does all these layout for you with real patients? 03:07.195 --> 03:15.441 [SPEAKER_00]: was taken example of a patient that I saw recently, a 51-year-old woman with hyperlipidemia and urinary incontinence, newly diagnosed hypertension. 03:15.922 --> 03:21.666 [SPEAKER_00]: She had been checking home blood pressures properly, and so we knew that this was an accurate diagnosis. 03:22.607 --> 03:28.814 [SPEAKER_00]: But our average from our home ratings was around 140s to 90s, so it was definitely in that mid-stage to range. 03:29.355 --> 03:40.167 [SPEAKER_00]: Again, I referenced those Neil ACCA shake guidelines that just came out this past year, recommending that any patient whose blood pressure is over 140 over 90 should be started in a combination pill upfront. 03:40.808 --> 03:54.961 [SPEAKER_00]: So, then I start to think about my choices of first line agents, which I consider to be air bees or ACE inhibitors, costume channel blockers, or thighside or thighside like dioretics, which of those should be start with and which combination. 03:56.051 --> 04:02.073 [SPEAKER_01]: I feel like I always blame on what are the, especially in the patient setting, like, yeah, what are those first line three again? 04:02.513 --> 04:13.837 [SPEAKER_01]: And so as much as I like, new monics, I was like, oh, it spells act, you know, the ace, arms, the calcium channel blocker, so then the thighs, the T. I was like, it can also be cat too if you're a cat person. 04:13.857 --> 04:14.877 [SPEAKER_01]: That's an aside. 04:15.918 --> 04:18.078 [SPEAKER_00]: I like act because it's goal oriented. 04:18.178 --> 04:18.659 [SPEAKER_00]: Oh, yeah. 04:18.739 --> 04:20.579 [SPEAKER_00]: What people do with hypertension treatment? 04:20.599 --> 04:22.740 [SPEAKER_00]: We want them to act in the, 04:26.227 --> 04:29.749 [SPEAKER_01]: So what did you do for her with her blood pressure in the 140s of her 90s? 04:30.709 --> 04:36.993 [SPEAKER_00]: So in this scenario, I would start a combination of usually an ARB with a calcium channel blocker. 04:37.073 --> 04:46.038 [SPEAKER_00]: And so for our region, for our hospital formulary, the one that's most cost effective for patients is a combination of amloaded pain valve start and that. 04:46.895 --> 04:47.115 [SPEAKER_01]: Yeah. 04:47.596 --> 04:53.941 [SPEAKER_01]: Also, just like to say it out loud, why is it that we want to do combo pills up front and not just max out one? 04:54.222 --> 05:02.209 [SPEAKER_01]: I think I have like vague memories from residency when the cardiology fellow snarkel that someone's med list that had licensed April 10. 05:02.249 --> 05:04.251 [SPEAKER_01]: And again, I think that was me being the setting of a cart failure. 05:04.271 --> 05:05.492 [SPEAKER_01]: Oh, that's just a baby dose. 05:05.532 --> 05:09.576 [SPEAKER_01]: And so yeah, curious what the thought is in hypertension with combo pills. 05:10.821 --> 05:23.955 [SPEAKER_00]: There's been a culture shift in the like 1970s, 1990s, the philosophy for trading hypertension is what's called a stepped caraproge where you start with one medication and maximize it before you add a second medication. 05:24.596 --> 05:25.818 [SPEAKER_00]: Now the evidence 05:26.358 --> 05:34.723 [SPEAKER_00]: support starting most patients with combination DRB at low or half or quarter standard dose and titrating those combinations. 05:34.944 --> 05:42.468 [SPEAKER_00]: And a lot of this actually comes from the Kaiser algorithms that were really effective at getting patients blood pressure to go. 05:42.829 --> 05:49.613 [SPEAKER_00]: But from a concept perspective, most blood pressure medications have a standard dose and a max dose. 05:49.653 --> 05:50.634 [SPEAKER_00]: So let's just take 05:55.917 --> 06:12.727 [SPEAKER_00]: You get the vast majority of your blood pressure lowering at the five milligrams, and going from five to 10, only gains you two, three, four millimeters of mercury, but you're getting a lot more blood pressure benefit from zero to five, and the same thing applies to other first-line categories of blood pressure and education. 06:13.548 --> 06:14.228 [SPEAKER_01]: I had no idea. 06:14.248 --> 06:17.650 [SPEAKER_01]: I think it's so helpful to know where you're getting the most dank for your buck that doses. 06:18.291 --> 06:23.294 [SPEAKER_01]: Like hydrocloth that you're going to get the most blood pressure lowering with 25 and going to 50 06:25.495 --> 06:32.917 [SPEAKER_00]: 50, as with, so this is another concept, just sort of conceptually modeling, side effects increase with higher doses. 06:33.177 --> 06:44.319 [SPEAKER_00]: And 50 milligrams of hydrochlorotheyside, there's almost no clinical situation in which I'd use that because the side effect profile is so much worse for 50 milligrams than it is for 25 milligrams. 06:44.839 --> 06:48.560 [SPEAKER_00]: And that's the same thing with many other blood pressure lowering medications. 06:49.500 --> 06:57.388 [SPEAKER_00]: even second-line agents like sprung a lactone, the incidence of gynecomastia and sexual side effects certainly increases as your dose gets higher. 06:57.408 --> 07:07.918 [SPEAKER_00]: For yeast inhibitors, the frequency of cough or anti-oadema is highest after dosing increases and the higher the dose, the more likely you are to have those side effects. 07:07.978 --> 07:10.721 [SPEAKER_00]: And so getting back to our core principle of 07:11.982 --> 07:20.048 [SPEAKER_00]: using lower dose combination therapy at the outset, you're both maximizing your blood pressure benefit, but you're also minimizing your side effect burdened. 07:20.729 --> 07:23.351 [SPEAKER_00]: Side effects increase with higher doses. 07:23.611 --> 07:25.593 [SPEAKER_00]: And this, you know, I say that's all the time. 07:25.853 --> 07:29.736 [SPEAKER_00]: Remember that for our patients, hypertension is an asymptomatic disease. 07:30.356 --> 07:37.883 [SPEAKER_00]: They usually don't feel hyper-tension, but they certainly can't feel side-of-fax from the treatments that we're giving them to try to lower their blood pressure. 07:38.083 --> 07:46.611 [SPEAKER_00]: So, and always trying to maximize the blood pressure benefit and minimize the side-of-fax when I'm helping patients get their blood pressure to go. 07:47.632 --> 07:49.873 [SPEAKER_02]: That is so helpful to think about. 07:50.633 --> 07:58.036 [SPEAKER_02]: Trying to start to put advice into effect, I would love to share this 45-year-old gentleman from Cape Verde. 07:58.597 --> 08:05.760 [SPEAKER_02]: He works for a local transit agency here in Boston and he has blood pressures in the 130s over 80s in the clinic and at home. 08:05.780 --> 08:07.560 [SPEAKER_02]: I know they're past medical history. 08:07.580 --> 08:10.962 [SPEAKER_02]: I'm curious, what would be a reasonable thing to start as my first line? 08:12.497 --> 08:28.104 [SPEAKER_00]: So, Carrie, you could really go with any of those act ARBs, ACE inhibitors, calcium channel blockers, or a thiasides for a patient like that, because he is likely at lower overall cardiovascular risk, monotherapy would be reasonable. 08:28.164 --> 08:33.447 [SPEAKER_00]: For him, although, you certainly could also make an argument for really low dose combination therapy. 08:34.087 --> 08:47.821 [SPEAKER_00]: For someone like this, you could consider depending on how easy your difficult it was for them to get in for lab, follow up in monitoring, and load a piece off and a go to first choice in somebody who may struggle to get in for follow up to get blood worked on. 08:48.962 --> 08:52.886 [SPEAKER_01]: And just to say, because of the thighs, you'd always want to check the potassium and the creatine. 08:53.516 --> 08:53.876 [SPEAKER_00]: for rap. 08:54.137 --> 09:05.185 [SPEAKER_00]: Yeah, just to be explicit, both ARBs, ACE inhibitors, and Thaisi diuretics all would require follow-up blood work to be done two to four weeks after initiating anidosin crathes. 09:05.985 --> 09:11.029 [SPEAKER_01]: This one's a game load piece of good go-to when coming back for lab checks might be an issue. 09:11.630 --> 09:16.173 [SPEAKER_01]: If we change up, we have stage one hypertension 130 over 80. 09:16.633 --> 09:18.235 [SPEAKER_01]: Well, this patient had diabetes or 09:23.860 --> 09:27.662 [SPEAKER_00]: So this can sit just some nuance between those first line agents. 09:27.702 --> 09:43.009 [SPEAKER_00]: We have good evidence to show that those three RAS floccade, so the air bees and ACE inhibitors, calcium channel blockers and biosides, not just lower the blood pressure number, but they also lower heart outcomes like MI's strokes and things like that. 09:43.069 --> 09:45.650 [SPEAKER_00]: So that's why we consider those our first line agents. 09:46.210 --> 09:49.734 [SPEAKER_00]: There are some nuances in terms of how you can choose amongst them. 09:49.834 --> 09:51.896 [SPEAKER_00]: You mentioned diabetes or create diabetes. 09:52.537 --> 09:56.260 [SPEAKER_00]: Diasides, minimally, very minimally will raise glucose. 09:56.420 --> 10:05.950 [SPEAKER_00]: And so when a patient who's on the cusp of diabetes, at a population level that increased may not be that important, but for an individual patient that might tip them over from create diabetes and to diabetes. 10:06.010 --> 10:09.194 [SPEAKER_00]: And so I probably wouldn't use a piaside first line. 10:09.794 --> 10:18.859 [SPEAKER_00]: overall the benefit of blood pressure lowering still out ways that increase and so certainly if somebody needed a thighside, we would not hesitate to use that. 10:19.319 --> 10:28.764 [SPEAKER_00]: But in those patients, we would like lay rates for an ARB or an ACE inhibitor because it error benefits of protecting kidneys and reducing proteinuria. 10:29.424 --> 10:46.557 [SPEAKER_00]: There's also going to have to check me on this care, but there is a paper that shows ARB's decreasing progression to outbreak diabetes and so certainly in that prediabatic population using ARB's may slow progression to frank diabetes. 10:47.677 --> 10:49.460 [SPEAKER_00]: You're going to have to double check me on that, and it's good. 10:49.820 --> 11:01.878 [SPEAKER_01]: You're always choosing arms, over ACEs, because I feel like I still see license of parole on people's med lists, and I think I could also do a better job about pausing there, but yeah, I curious about that. 11:03.295 --> 11:12.619 [SPEAKER_00]: I almost never start ACE inhibitors because ACE inhibitors have cough and angiodeema as potential side effects, neither of which we really see an ARBs. 11:13.159 --> 11:16.021 [SPEAKER_00]: And there's a mechanist-deck reason for both of those. 11:16.061 --> 11:23.184 [SPEAKER_00]: And it has to do with Brady Tynon, right down, and where ACE inhibitors in ARBs act in terms of that pathway. 11:23.784 --> 11:30.107 [SPEAKER_00]: So theoretically, you shouldn't see cough or angiodeema with ARBs, whereas both of those 11:32.508 --> 11:40.034 [SPEAKER_00]: I say theoretically because you can actually have idiot path again to you even from any medication, but this is another prescribing tip. 11:40.634 --> 11:50.722 [SPEAKER_00]: When you stop an ACE inhibitor, you can still see anti-rodeema for weeks after that ACE inhibitor has been stopped that is still attributed to that ACE inhibitor. 11:51.362 --> 12:03.289 [SPEAKER_00]: And so, while in theory, you could switch someone from their licensed apparel today to their vaults tartan tomorrow, they might still get anti-rodima episodes that then both the patient that clinician would be at risk to attribute to the ARB. 12:03.589 --> 12:18.457 [SPEAKER_00]: And so, while you can and theory switch someone directly from an ARB to an ACE inhibitor, I usually try depending on their blood pressure control, try to do at least a six week washout in between the two, to minimize the potential for having anti-rodima episode. 12:19.378 --> 12:27.202 [SPEAKER_00]: The other side effect that people find really problematic is the ACE inhibitor cough and it really can be a deterrent for patients to continue to take their medication. 12:28.483 --> 12:33.366 [SPEAKER_02]: Do you outright make the switch if you see someone on an ACE inhibitor or if they're tolerating it? 12:34.367 --> 12:35.007 [SPEAKER_02]: How do you approach it? 12:36.138 --> 12:39.620 [SPEAKER_00]: It really depends on the context as a hypertension consultant. 12:40.340 --> 12:49.644 [SPEAKER_00]: I try to have a lot of respect for the longitudinal and continuity relationship that the primary care clinician has, but that patient and the decisions that have gone into the therapy that they're on. 12:50.364 --> 12:57.107 [SPEAKER_00]: Certainly, if I'm at a point where I'm going to adjust a dose of a medication that they've been tolerating, you know, we mentioned several times. 12:57.227 --> 12:59.989 [SPEAKER_00]: The side effects tend to increase with increasing doses. 13:00.049 --> 13:02.870 [SPEAKER_00]: And so if I'm already making a change in a dose, 13:03.370 --> 13:07.133 [SPEAKER_00]: I will very frequently take that opportunity to switch them to an ARB. 13:07.153 --> 13:19.222 [SPEAKER_00]: If they're on something and they've been tolerating it for a long time and generally has it to make that switch unless I need to for potency or for some other to switch into a combination tab, I'll frequently use that opportunity. 13:19.983 --> 13:37.599 [SPEAKER_00]: The other thing is that Angeo Dima becomes more common just with age, and so over time people who have not had Angeo Dima at the same dose of anase inhibitor may spontaneously develop it, and there's other things like enzymes that also increase their risk of Angeo Dima that might happen concurrently for many reasons. 13:38.829 --> 13:40.211 [SPEAKER_02]: There's so much to think about there. 13:40.231 --> 13:45.497 [SPEAKER_02]: I'm just thinking about my own panel and patients that I've inherited and should I be making switches and not so it's really helpful. 13:46.338 --> 13:49.141 [SPEAKER_02]: I'm curious, how do you choose among the arms? 13:49.681 --> 13:51.564 [SPEAKER_02]: Are all arms created equal in your mind? 13:53.007 --> 13:53.807 [SPEAKER_00]: Absolutely not. 13:54.207 --> 14:09.772 [SPEAKER_00]: Amongst the ARBs, there's some that have specific upsides and downsides that prioritize one stale medications with high potency and long duration of action, cost and availability and combination tablets. 14:10.252 --> 14:14.893 [SPEAKER_00]: Outside of that, there's some really fun side perks to some ARBs. 14:15.013 --> 14:19.834 [SPEAKER_00]: So for instance, Candace Sarton is the only ARB that also carries an 14:22.635 --> 14:29.089 [SPEAKER_00]: Fighting a lot of times people think about beta blockers for migraine prophylaxis, but we'll recall that beta blockers are not first line agents. 14:29.994 --> 14:58.735 [SPEAKER_00]: Candace Arton being an ARB is one of our first line agents, and so when I have somebody who needs both hypertension treatment and migraine prevention, I often use Candace Arton, then again going back to what I said at the top of the podcast about helping patients reduce other side effects or treat other comorbidities sort of at two birds with one stone approach, I love Candace Arton for that reason, and I've had several patients in whom I've used Candace Arton to successfully decrease our migraine frequency or severity. 14:59.355 --> 15:03.716 [SPEAKER_00]: and treat their hypertension, which really helps both with adherence and persistence. 15:04.276 --> 15:11.077 [SPEAKER_00]: The other neat little tip I'll give you is loose-sartened increases your anaryurat acid secretion. 15:11.918 --> 15:21.379 [SPEAKER_00]: And so, I don't know if you've had gout, but patients hate gout, and if you can give them a blood pressure medication that also could reduce their frequency or severity of 15:24.640 --> 15:31.582 [SPEAKER_00]: Sizeides, unfortunately, tend to increase youric acid levels, but I have also successfully used with several patients. 15:32.182 --> 15:38.944 [SPEAKER_00]: Low-sortenit max-mundoces to reduce the youric acid level below six, and then sometimes you're able to sneak on allotos, die side. 15:39.364 --> 15:42.645 [SPEAKER_00]: Remember, you get your biggest blood pressure band yet those starting doses. 15:42.745 --> 15:47.867 [SPEAKER_00]: And so, even allotos die side is better than no-fi-side, and low-sorten can really help you get there. 15:48.587 --> 15:57.446 [SPEAKER_00]: The one downside to low-sarten is that it tends to be shorter acting, depending on the patient's blood pressure control, may need to be dose twice daily to get the maximum blood pressure beneath it. 15:58.321 --> 16:19.126 [SPEAKER_01]: Yeah, I always forget that in terms of the frequency and it reminds me of another question, which is the three first line that we have, the act, the ace, arms, the calcium channels in the thighs, are there any differences in terms of potency of how much blood pressure, thank for your buck you might get with the starting doses, or duration differences that we might need to know about. 16:20.113 --> 16:33.881 [SPEAKER_00]: On a population level, the general rule of thumb is, first line agents are largely equivalent, and you can expect maybe 910 millimeters of mercury for any of them at a standard dose. 16:34.121 --> 16:45.328 [SPEAKER_00]: In any individual patient that may not be the case, there's always this push and pull between personalized medication and population strategies. 16:46.350 --> 16:56.780 [SPEAKER_01]: I love the idea of personalized medicine, and so I think that just goes to show why we might see this one patient responding really well to this one medication versus another, and that's just their physiology. 16:57.281 --> 16:57.781 [SPEAKER_01]: Exactly. 16:57.801 --> 16:59.163 [SPEAKER_01]: What sounds great. 16:59.483 --> 16:59.763 [SPEAKER_01]: Awesome. 16:59.843 --> 17:05.909 [SPEAKER_01]: Any other differences to know in terms of duration, frequency, in terms of the first line three meds? 17:06.884 --> 17:11.108 [SPEAKER_00]: Those are all going to really differ amongst the individual agents within that class. 17:11.368 --> 17:19.136 [SPEAKER_00]: As a general rule of thumb, hydrochlorotheysi tends to be shorter acting, whereas endopimide and chlorothalidone are longer acting, and tend to be more potent. 17:19.336 --> 17:30.086 [SPEAKER_00]: But the diuretic comparison project did not demonstrate substantial difference in heart outcomes between hydrochlorotheysi and those longer or more potent medications. 17:30.907 --> 17:43.330 [SPEAKER_00]: for dye hydropuriting calcium channel blockers, which is amelodopine and philodopine, those all have similar duration of action appear using the extent of release nephatopine. 17:43.790 --> 17:53.712 [SPEAKER_00]: I will say nephatopine at all doses tends to have more side attacks, so headaches, flushing a little bit tougher for patients to take, and so I typically use more amelodopine or philodopine. 17:54.572 --> 17:55.713 [SPEAKER_00]: not used frequently. 17:55.733 --> 18:05.484 [SPEAKER_00]: I use Volodypine and patients who are on Symbestatin and for whatever reason can't switch to a different statin because I'm a Symbestatin have interactions at higher doses. 18:06.385 --> 18:10.049 [SPEAKER_00]: And then the ACE inhibitors and ARBs are so variable. 18:10.109 --> 18:14.915 [SPEAKER_00]: There's so many agents with variable potency and duration of actions, probably not worth going through. 18:22.771 --> 18:29.953 [SPEAKER_01]: So let's go back to Kira's patient, though one who had stage one hypertension, one thirties, over 80s, we start this person in bloated pain. 18:30.493 --> 18:34.675 [SPEAKER_01]: They come back for follow-up and what if they get some lower shami's swelling? 18:35.835 --> 18:38.156 [SPEAKER_02]: I can actually say that's actually happened to my patient. 18:38.376 --> 18:45.058 [SPEAKER_02]: He actually ended up coming into clinic in November in sandals because his feet were so big he could not fit into close-toe shoes. 18:45.738 --> 18:48.919 [SPEAKER_02]: So I ended up at that point just stopping the emlota pain when I switched from over to ball 18:50.659 --> 18:51.459 [SPEAKER_00]: We see this a lot. 18:51.819 --> 18:57.161 [SPEAKER_00]: The lower extremity of Dima from calcium channel blockers is one of the beans of my existence. 18:57.241 --> 19:00.402 [SPEAKER_00]: And so there are some tips and tricks to combat it. 19:00.602 --> 19:04.363 [SPEAKER_00]: It's important to think about the physiology of why this happens. 19:04.643 --> 19:12.865 [SPEAKER_00]: So calcium channel blockers selectively dilate arteries without compensatory venous dilation. 19:13.045 --> 19:19.427 [SPEAKER_00]: And so it causes this increased hydrostatic pressure across the capillaries that forces fluid into the interstitial space. 19:20.407 --> 19:22.368 [SPEAKER_00]: It is a dose related side effect. 19:22.668 --> 19:24.488 [SPEAKER_00]: It's terrible when you see it at five. 19:24.548 --> 19:26.188 [SPEAKER_00]: I see it a lot more at 10. 19:27.349 --> 19:37.191 [SPEAKER_00]: Oftentimes when I have somebody on five milligrams and I'm debating, should I go to 10 or keep them on five, you can actually add an ARB instead. 19:37.211 --> 19:41.972 [SPEAKER_00]: ARBs preferentially dilate the Venus circulation. 19:42.132 --> 19:45.053 [SPEAKER_00]: And so it equalizes the pressure across the 19:46.353 --> 19:48.594 [SPEAKER_00]: and mitigates that lower extremity swelling. 19:48.634 --> 19:53.495 [SPEAKER_00]: And so I can either use that sort of prophylactically or as a treatment. 19:53.535 --> 20:07.639 [SPEAKER_00]: So sometimes if somebody comes in on some kind of milligrams and they have some swelling, but it's indistarible as your patient instead of obviously increasing the envelope of pain, we're going to add an ARB or even an ACE inhibitor, both of those work mechanistically the same way. 20:08.519 --> 20:11.620 [SPEAKER_00]: The other thing you can do is go down on the dose. 20:11.660 --> 20:23.003 [SPEAKER_00]: And so again, I use this more for patients who are experiencing this volume of 10 milligrams, you can go back to the dose that they tolerated, remembering that they're getting their most blood pressure bang for that 5 milligram dose. 20:23.463 --> 20:31.085 [SPEAKER_00]: But sometimes I'll even use a 2.5 milligrams of envelope opinion, which they're getting some blood pressure benefit, but usually, tolerable lower extremities swelling. 20:31.945 --> 20:35.287 [SPEAKER_00]: dieousides, dieoretics do not help with this problem. 20:35.407 --> 20:39.270 [SPEAKER_00]: It isn't a fluid overload issue and it's not a sodium retention issue. 20:39.690 --> 20:42.072 [SPEAKER_00]: So dieoretics are not the solution to that. 20:43.168 --> 20:44.008 [SPEAKER_01]: Yeah, it's crazy. 20:44.028 --> 20:47.250 [SPEAKER_01]: I can see someone being like, oh, you have some swelling. 20:47.290 --> 20:50.131 [SPEAKER_01]: Let me just throw some Lacex or something at you. 20:50.771 --> 20:51.992 [SPEAKER_00]: It happens all the time. 20:52.232 --> 21:03.017 [SPEAKER_00]: I see patients come in who have clinicians add either Lacex, Toursamide, Fiaside to their regimen thinking that it's a fluid overload problem. 21:03.277 --> 21:09.988 [SPEAKER_00]: Now, as good doctors were always considering those other options, like there's a chance that this lower extremities swelling might be related to something else. 21:10.208 --> 21:16.559 [SPEAKER_00]: But in somebody who's recently had a dose change in Amlodapine or started on Amlodapine or other calcium channel blockers, it's very often. 21:17.498 --> 21:19.039 [SPEAKER_01]: That's such a great takeaway. 21:19.279 --> 21:23.622 [SPEAKER_01]: Gives me flashbacks, certainly about hydrostatic pressure in medical school, and like, when am I ever going to use this? 21:23.662 --> 21:37.630 [SPEAKER_01]: But, okay, so takeaway is like ammo to peen, just the arterial dilation, and then if you add an arbe, it'll help with the venous dilation, so that the equalizes the pressure in the capillaries that it's not going to the interstitium and causing the swelling. 21:43.847 --> 21:55.255 [SPEAKER_02]: I feel like we've covered a lot in terms of aces and arbs and calcium channel blockers from a side effect standpoint, thinking about duration and even mechanism of action to a certain degree. 21:55.895 --> 22:01.959 [SPEAKER_02]: We talked a little bit about thighsides as well, but I'm curious if there's anything else to round out our act here. 22:02.059 --> 22:05.342 [SPEAKER_02]: If there's anything else we should talk about from a thighside side effect profile, 22:06.472 --> 22:16.683 [SPEAKER_00]: Absolutely, and I feel like I was a little negative about thyasides earlier in the podcast, and I want to make it clear that thyasides are amazing blood pressure agents, and absolutely cannon should be used as first line agents. 22:17.064 --> 22:24.932 [SPEAKER_00]: Oh, quote, Keith Ferdinand, who's one of the hypertension giants, and he said if you ever want to look like a magician, change somebody's hydrochlorized thyaside to core-thallid on. 22:25.272 --> 22:30.836 [SPEAKER_00]: and despite the findings of the diuretic comparison project, I still use this track a lot. 22:31.057 --> 22:33.959 [SPEAKER_00]: I do find clinically at Clark Aladone at 25 milligrams. 22:34.399 --> 22:38.542 [SPEAKER_00]: It's just more effective in blood pressure lowering than hydrochlorothizedide at 20 sides. 22:39.523 --> 22:47.849 [SPEAKER_00]: We touched a little bit about the urinary frequency that some patients can experience, and I find this is particularly pronounced with something like hydrochlorothizedide. 22:48.470 --> 22:51.092 [SPEAKER_00]: I have a couple of tips that I can give patients to help 22:54.514 --> 23:03.827 [SPEAKER_00]: One of them, how many times have you had a patient come into clinic and say, oh, I always take my diuretic, but I didn't take it today because I was coming in here, and so I didn't take it today. 23:03.847 --> 23:06.111 [SPEAKER_00]: And their blood pressure's high and you have no idea what to do. 23:06.131 --> 23:08.514 [SPEAKER_00]: Is it high because they didn't pick their thighs like that morning? 23:09.095 --> 23:10.176 [SPEAKER_00]: They need to go suggest me. 23:10.915 --> 23:17.800 [SPEAKER_00]: So, it turns out, using the long grafting or potent dieocides can reduce urinary frequency because they don't wear off. 23:18.021 --> 23:21.924 [SPEAKER_00]: And, you know, the other time when medications wear off is when you don't take them intermittently. 23:22.024 --> 23:31.872 [SPEAKER_00]: And so, the way I try to build rapport and alliance around this issue with patients, if I say if you take these medications consistently, you're gonna have less urinary frequency. 23:32.472 --> 23:45.624 [SPEAKER_00]: The other thing is to lower the sodium in your diet, which helps independently lower blood pressure, but also helps with the urinary frequency, because if they have a high sodium load, there's more work for that by side to do. 23:45.904 --> 23:52.370 [SPEAKER_00]: And so, again, you can fill rapport and use it as a teaching opportunity for the patients. 23:52.970 --> 23:57.172 [SPEAKER_00]: If you notice that your urinary frequency is dramatically increased, did you forget? 23:57.472 --> 24:00.613 [SPEAKER_00]: Your medication the day before, did you have to take out the day before? 24:00.733 --> 24:02.633 [SPEAKER_00]: What might be some of the contributors to that? 24:03.254 --> 24:05.514 [SPEAKER_00]: So those are important sort of patient tips. 24:05.935 --> 24:08.636 [SPEAKER_00]: We haven't talked a lot about class killer side effects. 24:09.016 --> 24:12.697 [SPEAKER_00]: So if you're hip on a tramias, a class killer for dieasides. 24:12.857 --> 24:20.760 [SPEAKER_00]: Sometimes with mild or hip on a tramia, you can get away with fluid restrictions, so that's something I'll work on with patients if they have sodium levels that are just a little bit low. 24:21.530 --> 24:22.250 [SPEAKER_00]: What about cow? 24:23.051 --> 24:36.696 [SPEAKER_00]: So, by as I do increase your Acastate and we talked about a little bit about this earlier with the low-sartened innovation who has active cow, I really wouldn't start at that as I did unless they were on other medications to lower your Acastate. 24:36.736 --> 24:45.500 [SPEAKER_00]: Low-sartened as we talked about out of pure and all, but it's like I said, it's easy to make a patient feel worse but the blood pressure vacation and the gout player is one of those ways. 24:46.424 --> 24:56.638 [SPEAKER_01]: Yeah, I have some features to come in with out players, and I think I could do a better job looking at their med lists and seeing, are they on the hydrochlorotheyside, Cornell, or in Dap and Mag? 24:57.325 --> 25:13.791 [SPEAKER_00]: Just yesterday, I was sitting next to a colleague, a junior faculty colleague, and she said, you know, I want to run this patient by you, she's got this hypercalcemia, which I do about the hypercalcemia, and I said, well, is she on any medications that could cause the hypercalcemia? 25:14.071 --> 25:17.812 [SPEAKER_00]: No, I don't think so, and we looked at her medication list and lo and behold, she was on 25:21.383 --> 25:28.148 [SPEAKER_01]: I feel like Clarthalodone, I know it's so potent, long acting, but then you also run into the electrolyte abnormalities. 25:28.188 --> 25:32.531 [SPEAKER_01]: And is there anything you could do to mitigate that or just like hope that this is somebody who can tolerate it? 25:33.712 --> 25:34.813 [SPEAKER_00]: It really depends on what it is. 25:34.853 --> 25:37.555 [SPEAKER_00]: We talked about severe hyponectrinias, a class killer. 25:37.595 --> 25:39.957 [SPEAKER_00]: Dab in the hide, I think about as kind or gentler. 25:40.157 --> 25:45.281 [SPEAKER_00]: You do tend to see fewer electrolyte abnormalities but endopimide and with hydrochlorotheyside. 25:45.441 --> 25:46.642 [SPEAKER_00]: So, because we're to tell you. 25:46.662 --> 25:46.862 [SPEAKER_00]: Yeah. 25:48.453 --> 25:56.278 [SPEAKER_02]: You've coached me before, Jen, to use endopimide with some of my older patients, whom you see the start of some hyponeid treatment, it's been helpful. 25:56.778 --> 26:08.106 [SPEAKER_00]: They used endopimide in a high-bed trial, which is hypertension in the very elderly trial, which was a trial done many years ago, and used patients that were over 80 or 85. 26:08.606 --> 26:13.929 [SPEAKER_00]: And so those patients they prescribed endopimide with or without plenice inhibitor at the time 26:16.962 --> 26:22.093 [SPEAKER_02]: I'm curious, I feel like we've touched on the class killers, but is there anything else that we didn't touch on? 26:22.714 --> 26:25.139 [SPEAKER_02]: This is a no-go for the other groups. 26:26.547 --> 26:32.208 [SPEAKER_00]: gingable hyperplasia, which you don't see often by is a big bummer when you see it. 26:32.428 --> 26:34.809 [SPEAKER_00]: That is in calcium channel blockers. 26:34.869 --> 26:37.650 [SPEAKER_00]: And if it happens in one, I don't challenge with another one. 26:38.010 --> 26:48.993 [SPEAKER_02]: And to your redeemer, class killer for ACE inhibitors, we talked about strategies to use ARB's does severe hyperkalemia start to put the arms out of favor or do start to bring in the 26:51.533 --> 27:01.877 [SPEAKER_00]: So, if I see the potassium rising and they're not already on a thyside off and use that opportunity to get a thyside on, I find I use that strategy more than I'm trying to maximize the MRAs. 27:02.097 --> 27:06.819 [SPEAKER_01]: So, you know, the hyperkeleemia I find is a little bit more substantial for MRAs. 27:07.439 --> 27:15.762 [SPEAKER_00]: So, I'm often trying to use thysides or loops to lower potassium levels so that I can maximize the dose of the MRA to achieve blood pressure control. 27:17.262 --> 27:30.847 [SPEAKER_01]: It has been so helpful in terms of just hearing your tips and tricks with the big three first line that we have, the ACE Arabs, which as we shouldn't say ACEs anymore, the arms, the calcium channel blockers, and the thighs, that is the rebranding. 27:31.308 --> 27:34.029 [SPEAKER_01]: I am so grateful to be able to hear your thoughts. 27:34.109 --> 27:37.670 [SPEAKER_01]: I feel like I just want to be a fly on the wall in your hyper-tension clinic. 27:37.690 --> 27:44.413 [SPEAKER_01]: I'm curious of any patient stories come to mind that could be helpful to empower us to make us feel like we can also do some all-ins in our own ways. 27:46.028 --> 27:52.196 [SPEAKER_00]: One of the most common consults I've had is the patient who cannot tolerate any medication that's been tried. 27:52.376 --> 28:03.589 [SPEAKER_00]: I see patients like that probably once a week in my complex hypertension clinic, they come in and they're frustrated, they're primary care clinician is frustrated, they feel like they can't take any pain. 28:04.290 --> 28:09.414 [SPEAKER_00]: And so, I very systematically go through what they've tried, what the side effects were. 28:09.434 --> 28:12.116 [SPEAKER_00]: I look for those class killers in a void dose. 28:12.616 --> 28:22.983 [SPEAKER_00]: And then my strategy is to try to get them to start with a different agent in the class of agents that bothered them the least. 28:23.404 --> 28:30.489 [SPEAKER_00]: I usually don't try something that a patient has already taken in failed unless it's, for instance, like I said, 10 milligrams of 28:33.117 --> 28:51.846 [SPEAKER_00]: then I will explain to them, we may be able to use a lower dose, we may be able to use this if you're already on something like a brass blockade, but if you take a different agent in the same category that they tolerated the best, and then I'll start, essentially a homeopathic dose of that medication. 28:51.866 --> 28:57.549 [SPEAKER_00]: And so as an example and load a peen, I had a patient who I prescribed 2.5 milligrams of 29:02.791 --> 29:15.134 [SPEAKER_00]: Yeah, I have a little bit to point from I've had them take that for a few weeks and they tolerated it then after that time, you can say all right, let's go up to 2.5 milligrams. 29:15.354 --> 29:22.356 [SPEAKER_00]: I describe it to them in the context of infant toddler adolescent doses of medications. 29:22.416 --> 29:24.957 [SPEAKER_00]: And sorry, so we're going to start you on an infant dose of this. 29:24.997 --> 29:29.658 [SPEAKER_00]: And if you can tolerate the infant dose, we're going to get you up to the toddler dose or the adolescent or teenage 29:31.122 --> 29:39.990 [SPEAKER_00]: And if you would explain to people the side effects or lower lower doses and give your body some time to become adjusted to the medication. 29:40.070 --> 29:50.959 [SPEAKER_00]: Remember that patients who've had higher very high blood pressures for a long time, they may need some autonomic regulation to be able to tolerate the blood pressure lowering and part of the reason why. 29:51.780 --> 29:59.586 [SPEAKER_00]: They may have side effects from medications, particularly things like dizziness or lightheadedness is that somebody's trying to lower their blood pressure too fast, too soon. 29:59.746 --> 30:03.549 [SPEAKER_00]: So there are some patients who just do better with this strategy. 30:04.009 --> 30:09.373 [SPEAKER_00]: I want to be clear, this is a strategy to use only for patients who have these medication and tolerances for them. 30:09.453 --> 30:14.356 [SPEAKER_00]: Fast majority of people they're going to do just fine with trying to get their blood pressure to go all more quickly. 30:14.917 --> 30:18.719 [SPEAKER_00]: For patients who have this sort of multiple medication and tolerance, that's a strategy. 30:19.620 --> 30:35.987 [SPEAKER_00]: In patients who really can't tolerate first-line agents, I'll go more deliberately to those second-line agents, and, you know, sometimes you strategies like quantity and patches, things that provide nice, long, even coverage and may have fewer side effects in some specific patients. 30:37.246 --> 30:41.949 [SPEAKER_02]: It does sound like you do favor trying to get people on first line as much as possible. 30:42.149 --> 30:47.613 [SPEAKER_02]: Even if it had side effects before, it's going down to the lower doses, it's not just possible. 30:47.713 --> 30:49.674 [SPEAKER_02]: It's trying to uptite tree it really slowly. 30:49.815 --> 30:52.717 [SPEAKER_02]: Instead, I feel like I do this myself, which is this not didn't work. 30:52.777 --> 30:54.218 [SPEAKER_02]: I'm reaching for a baitable. 30:54.238 --> 31:00.162 [SPEAKER_02]: I'm reaching for a curbed all, I'm reaching for something else instead of really trying to focus on how do we minimize side effects? 31:01.255 --> 31:15.114 [SPEAKER_00]: I will really, really try hard to get people on first line agents and unless it's one of those class killer side of facts, I'll just shift to a different agent in the same category of first line medications. 31:16.516 --> 31:26.778 [SPEAKER_00]: part of what I enjoy doing hypertension consults is I have the luxury to spend 30 minutes and is a busy primary care clinician even when I'm doing my primary care practice. 31:26.798 --> 31:41.842 [SPEAKER_00]: I'm a worse hypertension doctor in my own primary care practice because it takes a lot of time reporting trust and frequent touch points to be able to really get these patients on board and get them up to doses of the medications that are going to be therapeutic for them. 31:51.944 --> 31:56.126 [SPEAKER_01]: Okay, what a great refresher, crash course, or a hyper-tension expert. 31:56.746 --> 32:02.890 [SPEAKER_01]: I think something's always changing in my practice, or things that I have actually changes at instead of refluxing maximizing one medication. 32:03.370 --> 32:20.819 [SPEAKER_01]: To really think earlier about lower dose commos, and this is actually happening other days, someone came in with hypertense of urgency, and the overnight person had increased their low-sart in from 50 to 100 milligrams instead of thinking about, okay, is there another lower dose commo, or we can get the most bang for their buck and prevent some of these admissions for hypertense of urgency. 32:21.539 --> 32:34.591 [SPEAKER_01]: Second, when a patient saw an amuletopine and gets a demon, it's a really pause before maybe reaching for a diuretic and actually think about the pathophysiology underlying and either lower that amuletopine dose or add an orb to help with some of that dilatation. 32:34.611 --> 32:43.379 [SPEAKER_01]: And third, I have definitely felt like an ulcer when I recommended can't assort in patients with hypertension that also have migraines and happy to see that it actually helped in some patients. 32:44.060 --> 32:45.864 [SPEAKER_01]: Thank you so much for joining us today. 32:45.884 --> 32:47.667 [SPEAKER_01]: I hope you got something out of this episode. 32:47.687 --> 32:48.409 [SPEAKER_01]: I know I did. 32:48.890 --> 32:52.236 [SPEAKER_01]: Our ask is that you send this to someone else who could also use some of these winds. 32:52.677 --> 32:55.823 [SPEAKER_01]: Please check out our show notes for more of Kansai summary on the teaching points. 32:55.863 --> 32:58.909 [SPEAKER_01]: Thank you so much for listening and we'll see you next time on Korayam.