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Drugs In Hypertension
Source: Disturbances Of The Heart
The drugs that are mostly used to lower blood pressure are nitrites
or drugs which are like nitrites, and these are nitroglycerin,
sodium nitrite, erythroltetra nitrate and amyl nitrite, and the
frequency of their use is in the order named. Other drugs used to
lower blood pressure are iodids, thyroid, alkalies, chloral, bromids
and aconite, the latter rarely.
Amyl nitrite is required only when a sudden immediate effect is
desired in angina pectoris or in some other serious spasmodic
condition. Sodium nitrite is more likely to upset the stomach than
is nitroglycerin. It acts, however, a little longer, but not enough
to warrant its frequent selection. The dose of sodium nitrite is
from 0.03 to 0.06 gm. (1/2 grain to a grain), best in tablet form
and given with plenty of water. The tablet should of course be
dissolved or crushed with the teeth. It should not be given on an
empty stomach, as it may cause considerable irritation and pain. It
more or less actively lowers the blood pressure for about an hour.
Erythrol tetranitrate is preferred by some clinicians who find that
its effect lasts somewhat longer. There is probably, however, no
better nitrite or nitrate than nitroglycerin. While it acts but a
short time, it acts effectively, and although no nitrite has
vasodilating effects for any length of time from one dose, when the
doses are given repeatedly and for days at a time, the blood
pressure will generally be more or less reduced. The dose is from
1/500 to 1/100 grain, three or four times a day, or every three
hours, as desired. The best form in which to use it is in a very
soluble tablet, and the tablet should not be dissolved unless
intense immediate action is desired. It acts when absorbed from the
tongue almost as rapidly as when given hypodermically; it acts in
two or three minutes, and the blood pressure may drop from 20 to 30
mm. In experimental tests the action does not last more than from
fifteen minutes to half an hour, but clinically the effect of
repeated doses is much more satisfactory. Spirit of glyceryl
trinitrate or spirit of Nitroglycerin, dose 1 minim, keeps well if
care is taken to guard against evaporation of alcohol; tablets if
well made and kept in bottles properly corked, will retain their
activity for months.
The closer a physician is to the laboratory, the less he believes in
the value of nitroglycerin in hypertension. The nearer he is to
clinical work the more he believes in it. It is a fact that in some
instances, even with a dose as small as 1/200 grain of
nitroglycerin, three or four times in twenty-four hours, the blood
pressure will be lower, whatever the diet is and whatever the other
treatments are, than if the patient does not take the nitroglycerin.
Also the value of these short relaxation periods from the standpoint
of a strained and tired heart should not be underestimated, the same
as the value of a night's rest, or the value of a recreation period
of an hour or two. If a patient has hypotension and a systolic
pressure of 110, and is given nitroglycerin, the very unpleasant
results from its administration will be immediately noticed. Hence
nitroglycerin is one of the most valuable drugs that we possess for
the treatment of hypertension, and some patients are even benefited
by as small a dose as l/500 grain. Lawrence [Footnote: Lawrence, C.
H.: The Effect of Pressure-Lowering Drugs and Therapeutic Measures
on Systolic and Diastolic Pressure in Man, Arch. Int. Med., April,
1912, p. 409.] found that the fall of diastolic pressure from
nitrites was about half of the fall of systolic pressure. When there
is no kidney lesion a very high systolic pressure falls more under
nitroglycerin than does a medium high systolic pressure.
Alkalies, whether potassium or sodium citrate or sodium bicarbonate,
are often of advantage in so changing and aiding metabolism, or
perhaps reducing the irritation from hyperacidity or a mild
condition of acidosis, that their administration causes a lowering
of blood pressure.
While iodids may not be direct vasodilators and do not render the
blood more aplastic or diminish its viscosity, as shown by Capps
[Footnote: Capps, J. A.: Effect of Iodids on the Circulation and
Blood Vessels in Arteriosclerosis, THE JOURNAL A. M. A., Oct. 12,
1912. p. 1350.] still, iodids in small doses, 0.1 to 0.2 gm. (1-1/2
to 3 grains) given from once to three times a day, after meals
(these small doses do not disturb the stomach), will stimulate the
thyroid gland to greater activity, and when this gland secretes
properly, the blood pressure is somewhat lowered. Of course, in
syphilitic sclerosis large doses of iodids are indicated and are
In obese patients with hypertension, in the hypertension of women at
the menopause, and in hypertension with insufficient kidneys,
thyroid medication is often of great value. Sometimes a small dose
of from 0.1 to 0.2 gm. (1 1/12 to 3 grains) once a day is all that
is needed. At other times, especially when there is no marked
arteriosclerosis and no marked kidney or liver lesion, very high
blood pressures are reduced only by very large doses, even as much
as 10 grains a day. Such treatment is often of very great benefit.
Of course, if one of the persons under consideration has symptoms of
hyperthyroidism, or if small doses of thyroid cause palpitation, the
treatment is not indicated, on the one hand, and should be stopped,
on the other. Sometimes when the blood pressure cannot be reduced,
in these cases without apparent organic lesions, and thyroid
treatment is more or less successful, but at the same time causes
great excitation, it may be combined with bromid medication, and
then the benefit is sometimes very great.
A patient who cannot sleep and who has hypertension may receive
bromids if he is very irritable or if there are symptoms of thyroid
irritability; but the most successful sleep and lowering of blood
pressure is caused by chloral. A dose of 0.5 gm. (7 1/2 grains) at
night is generally sufficient and need not be long continued.
Chloral has been frequently given to reduce pressure in 0.2 to 0.25
gm. (3 or 4 grain) doses, three times a day, after meals.
Bromids, of course, will lower the blood pressure, but they depress
all metabolism, interfere with digestion, and are not advisable for
any length of time. However, in some cases they cause a marked
improvement in the patient's condition.
Patients under treatment with chloral, bromids, and thyroid
especially, should be carefully watched and the treatment modified
to meet the varying conditions. Patients under iodid need not be
seen so frequently; those under nitroglycerin or alkalies still less
frequently. But all patients under the active management of
hypertension should be seen at from one to three week intervals, and
the urine should be repeatedly examined and the blood pressure