抗高血压药的用药禁忌,临床医生须谨记

2017-10-13 沈云婕 潘雁/上海市胸科医院药剂科 上海药讯

高血压病是中老年人常见的一种慢性疾病,除了改善患者的饮食习惯及生活方式外,应使用抗高血压药物进行长期或终生治疗。抗高血压药物种类较多,如应用不当不仅达不到治疗目的,更有可能引起多种副作用或不良反应。下面就来介绍下临床上常用的一线降压药的用药禁忌及注意事项。敲黑板,划重点!一、利尿剂其降压机制是利钠排水,使高血容量负荷降低而发挥降压作用。包括袢利尿剂、噻嗪类利尿剂以及保钾利尿剂。代表药物有氢氯噻嗪、

高血压病是中老年人常见的一种慢性疾病,除了改善患者的饮食习惯及生活方式外,应使用抗高血压药物进行长期或终生治疗。抗高血压药物种类较多,如应用不当不仅达不到治疗目的,更有可能引起多种副作用或不良反应。下面就来介绍下临床上常用的一线降压药的用药禁忌及注意事项。敲黑板,划重点!

一、利尿剂

其降压机制是利钠排水,使高血容量负荷降低而发挥降压作用。包括袢利尿剂、噻嗪类利尿剂以及保钾利尿剂。代表药物有氢氯噻嗪、呋塞米、螺内酯等。

此类药物的不良反应通常与使用剂量密切相关,故应小剂量联合用药。长期应用噻嗪类利尿剂可能引起低血钾,应对患者定期进行血钾监测,适量补钾;噻嗪类利尿剂痛风患者应禁用,对于肾功能不全及高尿酸血症者应慎用。高血钾与肾衰竭患者禁用醛固酮受体拮抗剂。

二、钙通道阻滞剂

此类药物的降压机制是通过阻断血管平滑肌细胞中的钙离子通道而扩张血管,降低血压。包括二氢吡啶类与非二氢吡啶类。代表药物有硝苯地平、氨氯地平(为二氢吡啶类),及维拉帕米、地尔硫卓(为非二氢吡啶类)。

钙通道阻滞剂常见不良反应为:面部潮红、脚踝水肿、由反射性交感神经激活而导致的心跳加快、牙龈增生等。二氢吡啶类没有绝对的禁忌证,但因其明确的血管扩张作用,短中效制剂降压的同时会出现反射性心率加快,相对禁用于高血压合并快速性心律失常患者。由于非二氢吡啶类钙通道阻滞剂的心脏亲和性及其对心肌、窦房结功能、房室传导的负性肌力和负性传导作用,禁用于二至三度房室传导阻滞患者,并相对禁用于心力衰竭患者。

三、血管紧张素转换酶抑制剂(ACEI)

此类药物的作用机理为使血管紧张素转化酶受到抑制从而减少血管紧张素Ⅱ的生成和缓激肽的水解,发挥降压作用。ACEI对糖、脂代谢无不良影响,单用此药降压作用明确。代表药物有福辛普利、卡托普利和赖诺普利等。

此类药物常见的不良反应为干咳呈持续性,用药初期多见,其他不良反应有皮疹、低血压,偶见味觉障碍及血管神经性水肿。长期应用血钾可能会升高,应定期对血钾和血肌酐水平进行监测。禁忌证为:妊娠、血管神经性水肿、高钾血症(>6.0mmol/L)及双侧肾动脉狭窄。

四、血管紧张素受体阻滞剂(ARB)

此类药物作用机理为使血管紧张素Ⅰ型受体受到阻断进而发挥降压作用。ARB除降压外,还具有心血管、肾脏保护及改善糖代谢的作用。代表药物有氯沙坦、缬沙坦、厄贝沙坦等。

此类药物不良反应少,偶会发生腹泻,长期应用血钾可能会升高,应对血钾及肌酐水平变化注意监测。妊娠、双侧肾动脉狭窄及高血钾症者禁用此类药物。

五、β-受体阻滞剂

此类药物主要通过对过度激活的交感神经活性和心肌收缩力进行抑制以及使心率减慢而发挥降压作用。代表药物有普萘洛尔、美托洛尔、卡维地洛等。

此类药物不良反应包括:激动、肢体寒冷感、疲劳乏困、胃肠不适等症状,会对糖、脂代谢产生影响。长期使用者若突然停止用药能够发生反跳现象。支气管哮喘、二度及以上房室传导阻滞、严重心动过缓的患者为其使用禁忌证。不适宜首选β-受体阻滞剂的人群包括老年人、肥胖者、糖代谢异常者、卒中、间歇跛行、严重慢性阻塞性疾病患者。

六、α-受体阻滞剂

此类药物可以选择性地与α-受体结合,并不激动或减弱激动肾上腺素受体,产生抗肾上腺素作用。α-受体阻滞剂一般不作为首选抗高血压药物,常在一线降压药物应用后血压仍然不达标时联合应用。代表药物有酚妥拉明、哌唑嗪等。

α-受体阻滞剂静脉注射过快可引起心动过速、心律失常,诱发或加剧心绞痛,故冠心病患者慎用。其他不良反应常见体位性低血压、心悸、鼻塞等,也可有恶心、呕吐症状,及嗜睡、乏力等中枢抑制症状,故体位性低血压患者禁用,胃炎、胃溃疡、肾功能不全或心力衰竭患者慎用。

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