First-Line Meds for Hypertension

Special guest Luke Laffin, MD, FACC, the Co-Director, Center for Blood Pressure Disorders with the Department of Cardiovascular Medicine at the Cleveland Clinic joins us to talkabout first-line meds for hypertension.

Listen in as they discuss nuances regarding selection of a first-line medication for the treatment of hypertension.

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Andrea Darby Stewart, MD, Associate Director, Honor Health Family Medicine Residency Program and Clinical Professor of Family, Community & Occupational Medicine at the University of Arizona College of Medicine - Phoenix
• Douglas S. Paauw, MD, MACP, Professor of Medicine at the University of Washington School of Medicine

For the purposes of disclosure, Dr. Luke Laffin reports relevant financial relationships with CRISPR Therapeutics [hyperlipidemia], Eli Lilly [obesity], Medtronic [hypertension] (honorarium); Arrowhead [hyperlipidemia], AstraZeneca [hyperlipidemia], Mineralys Therapeutics [hypertension] (grants/research support).

The other speakers have nothing to disclose. All relevant financial relationships have been mitigated.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter and Prescriber Insights: 

• Chart: Treatment of Hypertension
• Chart: Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors
• Chart: Comparison of Calcium Channel Blockers
• Chart: Comparison of Commonly Used Diuretics

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The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

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Transcript

Narrator 0:05

Welcome to Medication Talk, the official podcast of TRC Healthcare, Homo pharmacist letter, prescriber insights, RX Advanced, and the most trusted clinical resources. On today's episode, we'll listen in as our expert panel discusses nuances regarding selection of a first-line medication for the treatment of hypertension. Our guest today is Dr. Luke Laffin from the Cleveland Clinic. You'll also hear practical advice from panelists on TRC's editorial advisory board. Dr. Andrea Darby Stewart from the University of Arizona College of Medicine Phoenix. And Dr. Douglas Pow from the University of Washington School of Medicine. This podcast is an extract from TRC's Emerging Recommendations panel webinar. Each month, experts and frontline providers discuss current medication therapy topics and practical recommendations to include in TRC's letter articles. The full webinar originally aired on November 13th, 2023.

CE Narrator 1:01

And now, the CE information.

Narrator 1:05

This podcast offers continuing education credit for pharmacists, physicians, and nurses. Please log into your pharmacist letter or prescriber insights account and look for the title of this podcast in the list of available CE courses. For the purposes of disclosure, Dr. Laffin reports a relevant financial relationship by receiving honoraria from CRISPR Therapeutics Eli Lilly Medtronic and grants or research support from Arrowhead, AstraZeneca, and Mineralis Therapeutics. The other speakers you'll hear have nothing to disclose. All relevant financial relationships have been mitigated. Now, let's join TRC editors, Dr. Jeff Linkford and Sarah Clockers, and start our discussion.

Jeff Langford 1:47

Well, let's get started with our discussion on hypertension. And we're talking about this now because questions do continue to pop up about choosing blood pressure meds for initial treatment of uncomplicated hypertension. It's partially driven by the fact that hypertension is so common and the impact that it has on our patients' health. And Luke, I wondered if you could help us get this conversation going by discussing briefly the prevalence of hypertension and some of the ways that it does impact the health of our patients.

Luke Laffin 2:16

Yeah, happy to. And then thank you for the invitation to join the panel, Sarah and Jeff. It's great to be here. So as I'm sure everyone that's listening to this knows, hypertension is just rampant within the United States. It depends a little bit when we think about prevalence about what we use as our cut points, 130 over 80 or 140 over 90. But really, if we use 130 over 80, we're looking at almost half the US population having hypertension. And probably the most important thing to note about that is that less than a quarter of those have their blood pressure under control. And that's been the case year over year. And unfortunately, control rates are getting worse in the US. They were getting better over the early 2000s, got a little worse in the mid-2010s, right around the JNCA recommendations. And then obviously COVID impacted everything as well, and blood pressure started to go up. So you know, obviously a big problem, not just in the US, but worldwide, and one of those most modifiable risk factors when we think about preventing strokes, heart attacks, heart disease.

Jeff Langford 3:21

Excellent. Well, I think as we consider that, Luke, that just tees it up very nicely. We we have a problem that is, as you said, rampant. We also have a problem controlling it. So as we turn to what kind of medications we should use to manage hypertension, I think that makes a very compelling case for this discussion. And we're going to start really with looking at first line options for uncomplicated hypertension. And the treatment options are familiar in terms of the med classes. We're talking about ACEs or ARBs, calcium channel blockers, thiazide type diuretics. So I think that's common ground for our audience today as we consider those med classes. But where I want us to go is to kind of dig a little deeper and dive into some of the nuances in selecting either among those medication classes or even choosing specific agents within the classes. And the first kind of point of debate or discussion that I want us to look at is tackling the question of ACEs versus ARBs. And Andrea, I'd love to get your insight as you work with residents and trainees and students, and even your colleagues' perception as well. Do you find that clinicians have a perception that ACEs are preferred over ARBs? And what might be kind of behind that perception if you if you run across that in your practice?

Andrea Darty Stewart 4:40

What a great question. It actually caused me to reflect on my clinical practice and my duration of time in practice. And so I think a lot of what you see in preference of ACEs over ARBs is just clinical inertia. ACE inhibitors have been present for about two close to three decades available, if I'm remembering correctly. They are effective, they have been less expensive traditionally than our ARB alternatives. And so what we've traditionally taught is start with an ACE inhibitor because they work. They lower people's risk for stroke and heart disease, those outcomes that us and our patients are very keen to prevent. And if they cause side effects, then go ahead and switch over to an ARB. At this point, I, you know, I don't see any barrier to starting with an ARB versus an ACE. It just happens to be that, you know, how I was trained and how we perceive the cost of care in medicine still leads, at least in my clinical practice, for us to start with ACE inhibitors.

Jeff Langford 5:43

I think that's a great response, Andrea. And I think that probably resonates with a lot of people tonight as you walk through that kind of pathway that we are used to considering these drugs and, or perhaps we're trained to consider them in that order. And as we develop this article, what we what we have in the text of our article now says that ACEs are not necessarily preferred over ARBs. And want to dig into that just a little bit, Luke. And I wonder if you could kind of talk about uh the evidence for these classes. Is it fair to say that both classes seem to improve cardiovascular outcomes roughly comparably?

Luke Laffin 6:18

Yes, it is fair to say that. I agree with everything that Andrea said there in terms of, you know, uh traditionally the ACEs have been thought of as cheaper, and we had early cardiovascular outcomes data. But when you look at meta-analyses, and someone does this every few years, right? They look at ARBs versus ACEs and cardiovascular outcomes. Now, no one's going to do a head-to-head trial now since they're all generic, but consistently we see that really high quality evidence shows that they're pretty equivalent in terms of their overall outcomes. And then it comes down to this idea of really side effects, et cetera. And we all know angioedema rare, but more possible with ACEs. And then we come down to this idea of a chronic cough, which can get up to 10% of people. Um, and so I I would argue that there's no reason at all to prescribe an ACE inhibitor for uncomplicated hypertension at this stage, um, because ARBs are cheap too, right? You can get them $4. You can get the fixed dose combinations for very inexpensive as well, unless you're on a very restrictive formulary.

Jeff Langford 7:25

Okay, that's great. And and our bottom line that we really give in this section of the article is echoes what you just said, Luke, and that suggests choosing an ARB over an ACE if starting one of these medications for uncomplicated hypertension. Um, would there be any scenarios outside of that kind of very specific indication where you would consider an ACE inhibitor preferred for a patient with hypertension?

Luke Laffin 7:48

You know, some people would say, you know, in the setting of heart failure with reduced ejection fraction, if you're not putting them on saccuitral valsartin, that there's a little bit better data for ACE inhibitors there. But otherwise, I would say no in this scenario. You know, I think we're gonna talk about it later, is is sort of the choice of ARB, because obviously they're not all created equal to. But the last time I prescribed an ACE inhibitor, gosh, I'd have to, I'd have to look back, maybe even a year ago. It's just I just don't do it commonly. Now, that doesn't mean if someone's well controlled, I take them off of it and they're they're doing fine. We can titrade it up or down. But um, but if you're starting from scratch, ARB no question.

Jeff Langford 8:30

Awesome. Well, that's that's a great point. And I'd like to turn to Sarah to look a little bit at some of the audience questions we have coming through. I imagine as as we talk through this, this does challenge perceptions. Andrea helped us set that stage. And I imagine our audience has a lot of questions on this topic. Sarah, what are some of the things that you're seeing?

Sara Klockars 8:49

Should patients be on both an ACE and an ARB?

Luke Laffin 8:52

That answer is easy. No, but they've done those trials, you know, increased incidence of kidney disease, no improvement in outcomes. So, no, they definitely should not be on that combination.

Sara Klockars 9:06

Excellent. And then we did have an audience member ask about beta blockers and why we aren't talking about beta blockers this evening. So, do you just want to comment on why they aren't first line for most patients?

Luke Laffin 9:19

Yes. So, for most patients in the American blood pressure guidelines, it's an ACD as first line. So ARB or ACE, dihydroperidine calcium channel blocker, andor a diuretic. Beta blockers used to be, but we really only use them now if someone else has a compelling indication. So they have heart failure with reduced ejection fraction and they still have uncontrolled hypertension. You know, they have an aortic aneurysm, they have an arrhythmia, then we can use beta blockers there. Interestingly, Europeans just put beta blockers back in as one of the first drugs you can use in their most recent guidelines. And their argument was that there's a lot of patients that have a compelling indication for a beta blocker, but there's been a lot of pushback for that. So I don't practice that way. I don't think a lot of my colleagues practice that way. And it's still that ACD is the base of the pyramid in terms of cardiovascular risk reduction and the treatment of hypertension up front.

Jeff Langford 10:20

I do want to turn back to a point that you raised briefly, Luke, and that would be around selecting a specific ARB. And I would be interested in your thoughts in that regard because we do have like seven ARBs to choose from, all except for one are available generically. Which one would you favor in your practice or which ones? And what would be a little bit of a background on on the why there?

Luke Laffin 10:46

You know, if if I'm choosing an ARB, I avoid Lozartan like the plague, because it's as it doesn't clinically doesn't work as well, it doesn't last as long, etc. But sometimes that's all the patients can afford, and that's okay. We we will start with that at least in a stepwise fashion. The first thing I look at is is that ARB available in a fixed-dose combination pill? Because most of my patients are gonna have to be on something like that, multiple medicines. If money's not an object, azul sartin, which the brand name is a Darby, but it's not generic, that's far and away the best choice. Um, it also comes in combination with clarthaladone, but it's hypertension. You know, we don't want patients paying an arm and a leg for their medicines. So typically I'll stick with thalmasartin, ulmasartin, or herbosartin. And the vast, vast majority of patients' insurance plan covers one of those, and they're long-acting and effective.

Jeff Langford 11:40

I do want to emphasize something, and you did mention this, but I think it would be helpful just to return to this point as well. I think you said you would not switch from an ace to an orb for a patient who's tolerating it well and doing well with that. You'd prefer an orb first line if we're starting from scratch, but you wouldn't necessarily make a change for a patient who's well managed.

Luke Laffin 12:01

Yeah, that's exactly right, Jeff. And that's similar for really most classes of blood pressure medicine. We're gonna talk about it later too, in terms of diuretics, probably. But if someone's you know well controlled on hydrochlorothiazide, although it's less potent than endapamine or chlorothalidone, I uh, you know, if they're controlled, I'll continue it. And the same is true for ACE inhibitors here as well.

Jeff Langford 12:22

Well, let's jump over to our calcium channel blocker class. And just to kind of open this section up, we can really think about these drugs being in two large buckets, our dihydropyridine, calcium channel blockers like enlodapine, philodopine, or niphetopine. These are potent vasodilators, particularly the peripheral arteries. We might get some reflex tachycardia or a bump in the heart rate if we're using a shorter acting one of these drugs. And then our non-dihydropyridines like deltazin and verapamil are also vasodilating, but slow the heart rate down. So we've got a very broad and diverse class here, Luke, and uh would be interested as you consider a calcium channel blocker if you're going with that option for initial therapy for a patient. Which agent do you consider, or do you have a go-to agent for initial selection in these patients?

Luke Laffin 13:14

Generally, I'll go with amyloidine. Well tolerated, aside from you know the edema issue, which we can talk about. A little bit less tachycardia. You know, we know that it comes in multiple fixed-dose combination pills. Um, and so that's generally my go-to in these scenarios. There's some prevailing myth that niphetopene tends to get a little bit better blood pressure lowering. I've never really seen that or believe in that, particularly when we think about it in the outpatient setting. And niphetopene, you tend to get more tachycardia and more sympathetic activation, particularly the shorter acting niphetopine. So if you have a choice, amyloodopene is generally my go-to. Now, of course, much like a beta blocker, if there is a compelling indication, like a supraventricular tachycardia, like uncontrolled atrial fibrillation, a little bit of deltiaism C D is going to be something that you may end up substituting for that. But you got to choose the right dose there. So, as the as the you know, legend George Bacchus sort of used to tell me, you know, the 180 of deltiism CD, you know, that's the angina dose. That was never really shown to be beneficial in blood pressure. You've got to be 240 or above to really see that. So if there's a compelling indication there to slow down the heart rate, I'll do deltaism, but most of the time it's amylodipine.

Jeff Langford 14:36

Okay. Amlodipine to start, thinking about a non-dihydroperidine, especially deltiazine if needed for rate control, along with blood pressure. But let's talk about managing the side effect that you mentioned. That's probably the elephant in the room for many clinicians if they're thinking about amlodipine or any dihydropyridine calcium channel blocker, and that's peripheral edema. So walk us through your approach to managing that and what we should keep in mind, some caveats and around management there.

Luke Laffin 15:06

Gotcha, gotcha. So we'll pause for a second and everyone think about it for five seconds. That was a smart group. So, but do you treat it with a diuretic or do you treat it with something else? And hopefully you don't are not treating it with diuretic, because that's the wrong answer, okay? So, and we'll talk about how we can manage it with other medicines. But the big thing I tell people is you know, about a third of people on the five milligram dose of amylotopene get a lower extremity edema. On the 10 milligram dose, it's two-thirds, okay? So it's going to be there. But I also tell them it's not your kidneys failing or your liver failing. It's cosmetically displeasing, there's no question. But I give them ways to get around it, first from a lifestyle, and then, you know, and then potentially pairing it with other medicines. So the big things that I've seen have been helpful are number one, take the amlodipine in the evening, because although it lasts over the 24 hours, we tend to see the peak effects sort of earlier in that cycle. But so if you're sleeping, you know, who cares? Then understanding that if you have more sodium, you're gonna have more edema as well. So really stressing that if you have swelling on amlodipine that comes and goes, it's probably because you're just overdosing on salt. Um, and then third is think about, you know, maybe compression stockings, particularly if you're gonna be on your feet for long periods of time, particularly if you live in a hot weather or visiting a hot weather climate. Those things are what we really sort of try to educate patients on. And unfortunately, we have to educate like even our fellows about that to understand it. So it's not sodium or water retention. The other thing that's important to understand is that what the best sort of counteract to this, and you might be asking that other uh as another question, Jeff, but it's it's some type of rasp blocker, so an ACE or an A or B. Um, because you'll get preferential dilation on each side of the capillary bed. And so that tends to counteract the edema. Um, uh and so that's again why those fixed those combinations are so helpful in these scenarios. And then I I'm also not opposed to not maximizing the dose of mlodipine. The dose response curve after about five milligrams isn't particularly high. So if you if you're taking the five and you don't have edema, you're not getting that much more blood pressure lowering going to 10. That's my take on it.

Jeff Langford 17:25

I like that, Luke. And I've seen this so many times in practice, and it does, if we're not careful, it pushes us toward making a wrong choice or seeing another clinician perhaps making choices that aren't ideal. And so I really like those practical tips that you walked us through. Sarah, I want to see if you have any questions from the audience in this section about calcium channel blockers.

Sara Klockars 17:47

We did have one question come through, and that was would you ever put a patient on a non-dihydropyridine and a dihydropyridine calcium channel blocker at the same time?

Luke Laffin 17:59

That's a great question. I was actually going to throw that in at the end. And the answer is yes. Now there's select scenarios. There was some studies, I think they were sort of early 2000s, looking at that combination in resistant hypertension. Um, and the whole idea behind that is you get your more vasodilatory effect better blood pressure lowering with something like amylodipine, but then you have this heart rate that's persistently high, and some of this blood pressure elevation is being driven by excess sympathetic activation. And so, in those scenarios, you can combine it and you can get additional blood pressure lowering. But I will tell you, that is not well known. And there's been more than one time when either a pharmacy has called me and said, What are you doing? You can't prescribe both. I've had my heart failure colleagues tell me, what are you doing? Why are you prescribing both? They're already on it. And so then I have to direct them to the data that there is some in resistant hypertension.

Sara Klockars 18:55

We can go ahead and move on to thiazide diuretics.

Jeff Langford 19:00

Awesome. That sounds good, Sarah. Thank you. I think we're gonna, as we look at this topic, we have some headliner names that are very familiar here within this thiazide type class, like our chlorthalodone, hydrochlorothiazide, and endapamide. And Luke, I'd I'd like to start. I think many of us have seen data suggesting that chlorthalodone has better cardiovascular outcomes. Some of our guidelines give a nod to or a preference to clorthalodone for management of hypertension. And I wondered if you could walk us through that kind of historical perspective and what the what some of the older data are and why we had that uh baked into some of the practice guidelines.

Luke Laffin 19:40

Yeah, so I mean, you're right, and some of our older studies really preferred chlorothalodone because it essentially lowers blood pressure better and there's more cardiovascular outcome data. I want to talk about one more recent study in a little bit more detail, the diuretic comparison project in a second. But you know, when I think about diuretics, obviously, the thiazide type diuretics, obviously the vast majority of patients are prescribed hydrochlorothiazide. You know, then we have some, you know, the informed prescriber will choose chlorothalidone, and then much less so endapamide. Um, but I actually use a lot of endapamide for a couple reasons. One, it's better than hydrochlorothiazide, and number two, it's not associated with quite the degree of hypokalemia that we see and hyponatremia as chlorothalidone, just because it's not quite as potent in this scenario. So that's just something to keep in mind there. Um there was a lot, so the diuretic comparison project was presented, I think it's within the past year, and published in New England Journal. Uh and so that what this did was this tried to show this question, at least in a more contemporary population, that chlorothalidone is better than hydrochlorothiazide in terms of reducing cardiovascular outcomes. The the primary endpoint or the take-home message from the trial was that there's no difference in terms of cardiovascular outcomes. But there are a lot of caveats to that, which which we can definitely talk about. And that's that's really the most contemporary data we have. Because there used to be a thought that maybe there's even a pleotropic effect of chlorphalinum, you know, similar to statin's pleotropic effects, that, you know, maybe it helps with platelet aggregation, things like that. But the diuretic comparison project trial didn't really show that. So I don't know, Jeff, if you want me to go into more detail on that or have a discussion about that trial, because I think there's a lot of misinformation or misinterpretation about it.

Jeff Langford 21:35

Yeah, we'll continue to move through a little bit of that selection and how we can apply that data in just a moment. But I'll pause here for just to kind of recap what we've gotten so far. So we had chlorphalodone as the diuretic of choice in some landmark studies like Alhat that showed cardiovascular benefit. So we've had that data out there for a long time, and I think as you explained very Very nicely. Despite that data, there's been kind of this practice gap where we've got chlorphalodone data, but hydrochlorithiazide is overwhelmingly chosen in practice. And I did want to pull our other panelists in just for a minute and ask Andrea and Doug, do you do you see that gap in your practice as well? Is that reflective of what you see with a with many colleagues choosing hydrochlorothiazide for a variety of reasons?

Douglas S. Paauw 22:29

I you know, I've seen, you know, certainly historically, I think this had been pointed out in in uh the draft that you know clorthalidome was in the earlier studies was used a lot, and then in the late 80s, because of hypokelemia fears, it sort of fell out of favor. Hydrochlorothiazide was then used forever, and then more information came back and and sort of reinvigorated chlorothalodone. I've really seen them pretty equally used. And you know, I do think there's a little more hypokelemia with clothalodone because of its its long half-life.

Jeff Langford 23:06

That's helpful, Doug. And I think, yes, so hearing reasons why clinicians are making that choice is really helpful. Andrea, what the things look like on your front, especially as you're working residents through this important choice.

Andrea Darty Stewart 23:19

You know, I would um I would say Doug's comments. I mean, we've gone back and forth about this. I've made several forays into trying to add chlorophthaladone as my my thiazide of choice. A lot of times it's hard, it has been hard for my patients to find it consistently, and have definitely had some challenges with electrolyte abnormalities that we don't see quite as much of with the hydrochlorothiazide, but I do find that as an opportunity for teaching and learning when we talk about sodium intake in their diet and how that might be impacting the results of their BMP when they're taking chlorothalidone. So right now we stick mostly with hydrochlorothiazide because I think that the most recent data hasn't been enough to force me to type out something.

Jeff Langford 24:06

Right. So the some of the data that Luke mentioned confirming or supporting that hydrochlorid there's not perhaps the benefit with chlorothalidone over hydrochlorothiazide, giving us more information to make that statement. And supporting as well that chlorphalodone seems to cause more hypokelemia when we when we directly compare them. So look in our article. I'm sorry, Andrea, go ahead.

Andrea Darty Stewart 24:32

One of the things I was thinking about as I read this is we're talking a lot about the different types of medications that we can give to people for their hypertension, but we're still not necessarily talking about the things that can actually help them. We skirt around it. You know, what's the sodium intake uh in your diet? Are you exercising? Are you smoking? How much alcohol are you drinking? And how frequently are we bringing those patients back in when we do start the amount of blood pressure medicine to actually see if it's working and they're adherent to therapy. So I'm hoping at some point we can have that part of that conversation as well, because we can prescribe as many medications as we want. And if our patients aren't also working the other angles that we know will help them, we're probably not going to achieve the control that we would like.

Jeff Langford 25:18

What a great point, Andrea. Our article goes on to really try to answer this question that we we've been beating around the bush a little bit about is is there a best thiazide? And based on the data that you helped us unpack, looking at the historical data as well as this more recent observational data, we go on to say that there's not a clear winner among thiazides. And our further advice is that some experts do support the idea that any thiazide will have cardiovascular benefit as long as it controls blood pressure, especially when used in combination with other blood pressure meds. And would you agree with that bottom line?

Luke Laffin 25:53

If you're controlled on your thiazide, then yes, I wouldn't change it. Okay. You know, that is the big caveat to that chlorothaladone versus hydrochlorothiazide diuretic comparison project. So it was a pragmatic trial run within the VA system. The majority of individuals were on 12 and a half of chlorothaladone, okay? So really not the dose that we would typically think about prescribing. And the achieved blood pressure was 139 millimeters of mercury in a contemporary trial. And so, you know, people there was all these headlines saying, oh yeah, win for the general clinician because you know the hydrochlorothiazide isn't worse than chlorothalanone. Well, yeah, if you're only aiming for 139 millimeters of mercury, yeah, that's fine. But if you actually want to get people to sort of target, particularly in a higher risk population under 130, then you better be using chlorphalidone and gapamine because you're really just not going to get there with hydrochlorothiazide. So that's my takeaway from that. And then interestingly, it's subgroup analysis, so all the caveats that go along with that, it's exploratory, et cetera. But people with a history of cardiovascular disease or stroke, there was a pretty clear benefit to them being on chlorothaladone rather than hydrochlorothiazide. So I still do prefer the longer acting thiazide type diuretics. But if someone's doing okay on hydrochlorothiazide, then I typically don't take them off.

Jeff Langford 27:20

Okay. And you touched on something there I would like to circle back to for a moment, and that was the dosing of these agents. And could you just give us kind of a snapshot of comparable dosing, say across HCTZ, chlorthalodone, or endapamide, if we wanted to be able to compare kind of equipotent dosing?

Luke Laffin 27:39

Yeah, so most people obviously are going to start with 12, uh 25 of hydrochlorothiazide, which is good 12.5 of chlorothalidone, 1.25 of endapamide. Those are all pretty similar.

Jeff Langford 27:52

Well, Andrea, I'd like to pull you back in for a minute, and we talk about factoring in practicality when making this choice, and gave us some very good considerations for clorthalodone. We may often be using hydrochlorothiazide out of practicality, and wondering what some of those factors are. We talked about electrolyte disturbances earlier, but on the just very practically meeting your patient's needs where they are, what are some things that come to mind or maybe things that would tip the scales in favor of hydrochlorized in your practice?

Andrea Darty Stewart 28:27

Well, I think the availability of the combinations can be helpful at ease of in my area, just finding consistently hydrochlorothiazide, much easier than finding chlorothalidone from a dosing perspective. If the dose of chlorothalidone needs to be reduced for whatever reason for electrolyte abnormalities or other indications, it's harder to cut those tablets in half than it is to go with a lower dose of hydrochlorothiazide. So, you know, on the other hand, I realized many a couple years ago when I was helping my grandma take care of her pills that hydrochlorithiazide is a very tiny little small is a problem for some of our seniors who have a hard time handling their pills. So, you know, sometimes just knowing those types of things can be helpful as well.

Luke Laffin 29:13

Other things about diuretics, just I don't I don't necessarily know that we touched on them, just want to make sure we get them in. I I always make sure that I ask patients when they're taking their diuretic because surprisingly, not unsurprisingly, a lot of these folks are taking it at night, and that doesn't help in you know, the 65-year-old who also has BPH and things like that and is disrupting their sleep. So I asked them that as well, and that's important. And then also when we think about as our fourth line therapy, adding an MRA like spiralactone, also explaining that although we think of it as a potassium-sparing diuretic and it has some diuretic effect, although not a ton at the lowest dose, they oftentimes will get scared off by that and say, Oh, why are you putting on me on two diuretics doc? So just making sure that communication is clear with the patient and telling them that the MRAs are a very specific mechanism of action that helps with volume, but that's not the only reason.

Narrator 30:12

We hope you enjoyed and gained practical insights from listening into this discussion. Now that you've listened, pharmacists, physicians, and nurses can receive CE credit. Just log in to your pharmacist letter or prescriber insights account and look for the title of this podcast in the list of available CE courses. You'll also be able to access and print out additional materials on this topic, like charts and other quick reference tools from the Pharmacist Letter and Prescriber Insights websites. If you're not yet a pharmacist letter or prescriber insights subscriber, find out more about our product offerings at TRCHealthcare.com. Be sure to follow or subscribe, rate, and review this show in your favorite podcast app. It helps spread the word about our show and is a great way for you to let us know how we're doing. You can also reach out to provide feedback or make suggestions by emailing us at contact us at trchealthcare.com. Thanks for listening to Medication Talk.