, kidney artery stenosis) Compelling indications include: CKD with albuminuria (refer to VA/DoD CKD ); HFrEF; recent MI Long-Acting Calcium Channel Blockers (CCB) DHP CCBs Amlodipineb Felodipine Nifedipine sustained releaseb Non-DHP CCBs Verapamil sustained releaseb Diltiazem sustained releaseb 2.5-10 mg daily 2.5-10 mg daily 30-120 mg daily 120-480 mg divided daily- bid 120-540 mg daily Monitor AEs (DHP CCBs may cause ankle edema, dizziness, flushing, headache, constipation) Use with caution in patients with hepatic (CCBs) or kidney (non-DHP CCBs) dysfunction Non-DHP CCBs may be considered for rate control in supraventricular tachycardia or atrial fibrillation/flutter Verapamil may cause constipation; verapamil is contraindicated 2nd or 3rd degree AV block, severe LV dysfunction Diltiazem may decrease sinus rate; diltiazem is contraindicated in 2nd degree AV block; use with caution in LV dysfunction Verapamil or diltiazem should not usually be used with a beta-blocker due to risk of severe bradycardia or heart block 2 See the VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease. Available at: https://www.healthquality.va.gov/guidelines/CD/CKD/ Drug Usual Dose Range Commentsa Aldosterone/ Mineralocorticoid Receptor Antagonists Eplerenoned Spironolactoneb 50-100 mg/day (daily or divided bid) Avoid use if hyperkalemia or severe kidney dysfunction Monitor K+ and kidney function; consider risk vs. benefit if combined with ACEI, ARB, K+ sparing diuretic, or K+ supplement Higher risk of gynecomastia with spironolactone (9%) than eplerenone Compelling indications include: HFrEF Effective in resistant hypertension Other Potassium- Sparing Diuretics Amiloride 5-10 mg/daily Avoid use if hyperkalemia or severe kidney dysfunction Helpful in reducing hypokalemia caused by thiazide diuretics Effective in resistant hypertension Alpha-Adrenergic Blockers Doxazosin Prazosin Terazosinb 2-20 mg/day (divided bid or tid) 1-20 mg daily Initiate at low doses (1 mg) Administer 1st dose at bedtime to avoid syncope Avoid use as monotherapy May be considered for use in patients with symptomatic BPH Beta-Adrenergic Blockers Noncardioselective Propranolol Cardioselective Atenololb Metoprolol tartrateb Metoprolol succinate (XL)b Combined alpha- beta adrenergic blockers Carvedilol Labetalold Immediate release: 80-160 mg/day (divided bid) Sustained release: 80-160 mg daily 25-100 mg daily (adjust dose in CKD) Immediate release: 50-300 mg/day (daily or divided bid) Sustained release: Immediate releaseb : 12.5-50 mg/day (divided bid) Sustained released : 200-800 mg/day (divided bid) Discontinue with slow taper over one week Avoid combination with non-DHP CCB due to increased risk of bradycardia or heart attack As doses increase, cardioselectivity decreases Beta-blockers should be used cautiously in asthma Compelling indications include: HFrEF (evidence available for reduction in morbidity and mortality with bisoprolol, carvedilol, metoprolol succinate in HFrEF); recent MI; angina; rate control in atrial fibrillation/flutter; data available for select beta-blockers for migraine prevention Drug Usual Dose Range Commentsa Direct Acting Vasodilators Minoxidil Hydralazineb 2.5-100 mg/day (daily or divided bid) 50-200 mg/day (divided bid) Monitor for hypertrichosis, volume retention, and pericardial effusions with minoxidil Monitor for headache and SLE (dose- related) with hydralazine Direct acting vasodilators often require concomitant use of diuretic and beta- blocker to reduce edema and reflex tachycardia Centrally Acting Antiadrenergic Drugs Clonidine Tabletb Clonidine Patch Methyldopa 0.1-0.8 mg/day (divided bid) mg patch weekly (divided bid) Monitor for bradycardia, somnolence, and dry mouth. 