Medication Management in General Practice

Introduction to Common Medications

• The American College of Cardiology recommends metformin, lisinopril, amlodipine, atorvastatin, and GLP-1 receptor agonists as first-line therapies for various conditions, which have demonstrated significant benefits for morbidity and mortality outcomes 1
• GLP-1 Receptor Agonists have strong cardiovascular and weight benefits, with primary side effects being transient gastrointestinal symptoms 1
• SGLT2 Inhibitors provide cardiovascular and renal protection, but are contraindicated in dialysis patients and may cause genital mycotic infections 1
• DPP-4 Inhibitors have modest efficacy and are weight neutral, but caution is advised due to possible increased heart failure hospitalizations with saxagliptin and alogliptin 1
• Sulfonylureas are inexpensive but associated with hypoglycemia risk and weight gain 1

Hypertension Management

• Calcium Channel Blockers, such as amlodipine, are among the top prescribed medications globally, with amlodipine typically started at 2.5-5mg daily 2
• Beta-Blockers, such as metoprolol, are particularly useful in patients with heart failure or post-MI, and metoprolol is among the top 3 most prescribed medications in the US 2
• ACE inhibitors, such as lisinopril, ramipril, and enalapril, are typically started at doses ranging from 2.5-10mg daily, with target doses of 20-40mg daily 3
• Angiotensin Receptor Blockers (ARBs), including losartan, candesartan, and valsartan, are particularly useful when ACE inhibitors cause cough 4
• Thiazide/Thiazide-like Diuretics, including hydrochlorothiazide, chlorthalidone, and indapamide, are usually dosed at 12.5-25mg daily 5
• Aldosterone Antagonists, including spironolactone and eplerenone, can be used in addition to other agents 3
• Alpha Blockers, such as doxazosin and terazosin, can be used in certain cases 6
• The target blood pressure should be <130/80 mmHg for most patients, and <140/90 mmHg for elderly patients (≥75 years) 6, 7

Hypercholesterolemia Management

• Statins, such as atorvastatin, are first-line for hypercholesterolemia, with benefits including reduced cardiovascular morbidity and mortality, but may cause myopathy and rarely rhabdomyolysis 8

Neuropathic Pain Management

• Gabapentin is recommended at 300-1200mg three times daily for diabetic peripheral neuropathy 9
• Pregabalin is recommended at 100mg three times daily for neuropathic pain 9
• Duloxetine is recommended at 60-120mg daily for diabetic neuropathy 9
• Tricyclic Antidepressants, such as amitriptyline, are recommended at 10-75mg at bedtime for neuropathic pain 9

Weight Management

• GLP-1 Receptor Agonists are the most effective for weight reduction, with demonstrated cardiovascular benefits beyond weight loss 1
• Phentermine/Topiramate has less robust weight reduction than GLP-1 RAs, with side effects including increased heart rate, mood disorders, and cognitive effects 1

Medication Selection and Monitoring

• The American Heart Association recommends considering comorbidities, such as diabetes and hypertension, when selecting medications, and checking for contraindications, such as renal function and history of angioedema 1
• The European Society of Cardiology advises starting low and going slow with dosing, especially in elderly patients, and monitoring appropriately for side effects and efficacy 8
• Medication interactions to be cautious of include NSAIDs, which can reduce the effectiveness of ACE inhibitors, ARBs, and diuretics, as well as potassium supplements, which can increase the risk of hyperkalemia with ACE inhibitors, ARBs, and aldosterone antagonists 10
• Monitoring requirements include checking renal function and potassium within 1-2 weeks of initiation for ACE inhibitors and ARBs, and monitoring electrolytes, particularly potassium, for diuretics 6
• For patients with diabetes and chronic kidney disease, the first choice is an ACE inhibitor or ARB, with additional agents such as diuretics, beta-blockers, or calcium channel blockers used to reach a target blood pressure of <130/80 mmHg 4
• For heart failure with reduced ejection fraction, ACE inhibitors, beta-blockers, aldosterone antagonists, and ARBs are recommended 3
• For non-Black patients, the recommended treatment approach is to start with a low-dose ACE inhibitor or ARB, add a dihydropyridine calcium channel blocker, and then add a thiazide/thiazide-like diuretic, with the option to add spironolactone or other agents as needed 6
• For Black patients, the recommended approach is to start with a low-dose ARB plus a calcium channel blocker, or a calcium channel blocker plus a thiazide diuretic, and then increase to full dose, with the option to add a diuretic or ACE inhibitor/ARB as needed 6