Without the White Coat
By Florentino P. Alerta II, M.D.

TARKA… preventing microalbuminuria

We have come to a generation where treatment and controlling hypertension comes in combination of two anti-hypertensives enclosed in one preparation. We may call it a combination therapy and there is always that convenience of taking one preparation per day instead of chubbing on two to three medications thrice or twice daily. Convenience does not always entail good control at all. How about the nasty side effects of medications that we never fully understand? As the lay persons are presented with all the treatment options and combination therapy we still gonna ask ourselves the effects or outcome of the medications. Almost everyday we are bombarded with all the newer drugs out there, how can we prove them to be effective? The ultimate goal of controlling blood pressure and at the same time the cardio-reno protective properties of the drug is ever and always will be looked upon.

High blood pressure will always be the milk and honey of every practicing physician, and the ultimate goal is keeping the number down. The first rule of treating hypertension is correcting the secondary cause of hypertension like renovascular disease, pheochromocytoma (tumor-catecholamines) and the rest which have some funny names like Conn's, Cushing's and aldosteronism.

Physicians are good preachers for effectively controlling essential hypertension and will rather counsel an overweight patient to lose weight, reduce sodium intake (less than 2 grams of sodium or less than 6 grams of table salt), stop smoking, reducing the intake of dietary saturated fat and cholesterol, a regular aerobic exercise, limiting intake of alcohol (24oz of beer, 8 oz of wine, 2 oz 100 proof whiskey and lastly maintaining adequate dietary potassium, calcium, and magnesium are just part of what we call lifestyle modification.

The treatment of hypertension as recommended by the JNC 7 dictates that beta blockers (those that end in “olol”) and/or diuretics (those that end in “mide”/or “tone”) are the first line of treatment. Due to hard times the physician will always look at the compliance of patients, for those that have mild to moderate hypertension the use of beta blockers is advocated and/or a low dose diuretics. For those with severe hypertension the use of calcium blockers (those that end in “pine”, for “mil” or “zem”) are well advised. I may call it the ten commandments of treating hypertension, but it is a good guide for those that had just started. For the (1) young hypertensive use beta blockers unless contraindicated,(2) for the elderly patients use diuretics at lower dose, (3) for athletes avoid beta blockers and diuretics, (4) for those dyslipidemic patients avoid beta blockers and diuretics, (5) for those coronary artery disease use beta blockers, calcium antagonist and avoid hydralazine, (6) for heart failure patients the use of ACE inhibitors (those that end in “pril”) and/or diuretics, just avoid using beta blockers and calcium antagonists, (7) for those with broncho-pulmonary disease may use verapamil and other calcium antaogonist, patient should avoid beta blockers, (8) for patients that are diagnosed to have some peripheral vascular disease use of nifedipine (calcium antagonist), vasocontrictors (those that end in “zosin” / or hydralazine) or ACE inhibitors, and should avoid the use of beta blockers, (9) those that have the end stage renal disease the use of calcium antagonist,, diuretics, central acting agents (clonidine/mehtyldopa) are well advocated with caution given to the use of ACE inhibitors, the last category of the commandments (10) is among the diabetics in which the use of ACE inhibitors or angiotensin II antagonist (the famous “zartans”) to delay diabetic nephropathy is well advised, and with the avoidance of the use of diuretics and beta blockers.

The last commandment is given emphasis when a new drug was again introduced to the market, it may sound like some hindu or Indian word or something that you wear in the coldest season like a “parka”, but this drug combination of verapamil (calcium channel blocker) and trandolapril (ACE inhibitor) will surely reduce the risk of microalbuminuria that will later entail to cardiovascular complications. Tarka was shown to have good blood pressure (dropping SBP at -18.1%, and dBP at -11.1%) control with a good ratio at 8/10 (sBP <140mmHg) and 9/10 (dBP<90mmHg), respectively. In summary the level of protection is well emphasized for the pre diabetic and diabetic hypertensive. Available as verapamil at 180 mg and trandolapril at 2 mg is another addition to our armaments in controlling and treating hypertension as we deal with its unforeseen complications.