**7. Conclusion**

The need of multiple drugs simultaneously used is common in the intensive care environment and contribute to the occurrence of drug interactions. The clinical consequences of these interactions should be considered in order not to endanger ICU inpatients health once this population is under unfavorable conditions.

The presence of drug interactions is a permanent risk in the ICU and not all DDI can be prevented. The use of software is mentioned in the literature as an important toll in reviewing prescriptions to identify interactions and reduce adverse events. Also, the continuing education of professionals involved in the processes of prescribing, dispensing and administering medicines as the main risk factors for drug interactions, the dissemination of information regarding the more frequent and important in clinical practice about drug interactions are instruments in the prevention of drug interactions.

## **8. References**

128 Antihypertensive Drugs

Glucocorticoids may increase blood pressure by increasing the concentration of sodiumpotassium adenosine triphosphate in the cell membrane which could increase the concentration of extracellular sodium and therefore expand the plasma volume. Cortisol also stimulates the synthesis of mineralocorticoid aldosterone leading to sodium and water retention and, consequently, increased blood volume and cardiac output (Ortega et al., 1996; Brown, 2005). It also increases the sensitivity of the myocardium to endogenous catecholamine and increases the vascular response to endogenous vasopressors such as angiotensin II and norepinephrine (Ortega et al., 1996). In addition, glucocorticoids induce hepatic production of angiotensinogen resulting in an exacerbated response of the renin-

The use of beta-blockers and hypoglycemic may result in hypoglycemia, hyperglycemia or hypertension. If the use of a beta blocker is required in a diabetic patient, glucose should be carefully monitored. Cardioselective beta blockers (atenolol, metoprolol) cause less disturbance of glucose metabolism and less masking of hypoglycemic effects. Propranolol accounts for the majority of positive reports of interactions and should clearly be avoided.

Hyperglycemia occurs frequently in critically ill patients and it is a marker of poor prognosis (Pitrowsky et al., 2009). The main complication of insulin therapy is hypoglycemia which is considered a potentially serious adverse event in these patients (Diener et al., 2006). The combination of a beta-blocker and insulin may impose a higher risk of blood glucose changes and lead to the development of hypoglycemia, hyperglycemia and

Beta-blockers may inhibit some of the normal physiologic response to hypoglycemia. Symptoms of hypoglycemia such as tremors and tachycardia may be absent, making it more difficult for patients to recognize an oncoming episode. In addition, multiple effects on glucose metabolism have been reported, usually with the noncardioselective beta-blockers (e.g., propranolol, pindolol, timolol) but occasionally also with relatively beta-1 selective agents (e.g., metoprolol). Specifically, inhibition of catecholamine-mediated glycogenolysis and glucose mobilization in association with beta-blockade can potentiate insulin-induced hypoglycemia in diabetics and delay the recovery of normal blood glucose levels. Prolonged and severe hypoglycemia may occur, although these events have rarely been reported. Significant increases in blood pressure and bradycardia can also occur during hypoglycemia in diabetics treated with insulin and beta-blockers due to antagonism of epinephrine's effect on beta-2 adrenergic receptors, which leads to unopposed alpha-adrenergic effects including vasoconstriction. Other effects reported with various beta-blockers include decreased glucose tolerance and decreased glucose-induced insulin secretion (Goodman & Gilman,

The need of multiple drugs simultaneously used is common in the intensive care environment and contribute to the occurrence of drug interactions. The clinical

**5.2 Steroidal antiinflammatory agents** 

angiotensin-aldosterone system (Dukes, 1992).

hypertension.

2010).

**7. Conclusion** 

**6. Beta-blockers and hypoglycemic drugs** 


**8** 

*Belgium* 

**The Use of Antihypertensive Medicines** 

Marc Twagirumukiza1,2, Jan De Maeseneer2, Thierry Christiaens1,2,

*2Department of Family Medicine and Primary Health Care, Ghent University, Ghent,* 

This chapter is drawing out the patterns and evidences for the use of antihypertensive medicines in general and in primary health care settings in particular. It presents the overview of the recent advances in clinical effectiveness of the antihypertensive medicines, but also document the implication for management of hypertension in low level health facilities. The discussions are based on the new evidences from clinical practice, reviews and

The chapter as whole is written from a comprehensive health care system development rather than from a purely medicines description perspective. Finally the authors do not intend to substitute the students or prescribers vademecum or medicines' handbooks but providing an update in their daily questions when comes the issue of whom, what (and with what) to treat –

Hypertension, also known as "high blood pressure" is currently the major risk factor for coronary heart disease (Roger VL. and others 2011) and cerebrovascular disease (stroke) (Roger VL. and others 2011; Twagirumukiza and others 2011). Already known as significant public health problem worldwide particularly in western societies (Kearney and others 2005), hypertension has been documented recently as real health threat in developing countries as well (Kearney and others 2005; Twagirumukiza and others 2011). Hypertension remains the leading reason for office visits in primary care (Pittrow and others 2004) in some western countries in contrast with developing countries where awareness is still low and where hypertensive patients reach health facilities rather for complications. This situation in developing countries, emphasizes the need of other approaches and strategies to avert the Non Communicable Diseases (NCDs) in general and the arterial hypertension morbidity and mortality in particular by targeting the lower level of the health system chain (De

On the other side, despite the availability of a wide range of antihypertensive drugs (Van Bortel and others 2011), blood pressure has remained poorly controlled in a majority of health

as far as arterial hypertension is concerned, in primary health care settings.

**1. Introduction** 

meta-analysis studies.

**2. Rationale, objectives and methods** 

Maeseneer J. and others 2011).

**in Primary Health Care Settings** 

*1Heymans Institute of Pharmacology, Ghent University, Ghent,* 

Robert Vander Stichele1 and Luc Van Bortel1

