Long-Term Care Updates

Long-Term Care Updates August 2015 By Darren Hein, PharmD Hypertension is a clinical condition in which the force of blood pushing on the arteries is higher than normal. This increases the risk for heart disease and stroke. 1 Hypertension is the most common chronic health condition seen by primary care providers and affects around 1 in every 3 adults. 2 Additionally, hypertension is prevalent in the geriatric population, affecting approximately 67% of men and 79% of women over the age of 75. Hypertension is harder to control in black patients, as they tend to develop hypertension earlier and more often than white and Hispanic patients. 3 Because residents may have multiple comorbidities, functional disability, and complicated medication regimens, care of the hypertensive patient in the long-term care setting is complex. Goals of treatment include reaching and maintaining blood pressure goals, slowing the progression of organ damage due to uncontrolled hypertension, and preventing myocardial infarction, stroke, renal failure, and death. The article that follows will summarize and synthesize clinical practice guidance on the pharmacologic management of hypertension from the eighth Joint National Committee, American Society of Hypertension, International Society of Hypertension, American Heart Association, American College of Cardiology, and Centers for Disease Control and Prevention (CDC). While these documents provide significant evidence-based guidance on the management of hypertension, patient-specific factors and the clinician s judgement should ultimately dictate an appropriate care plan. www.creighton.edu/pharmerica The panel members of the eighth Joint National Committee published their revised Evidence-Based Guideline for the Management of High Blood Pressure in Adults in 2014. Compared to the JNC7 guideline, which was based on evidence from a range of study designs as well as consensus recommendations, the JNC8 guideline only considered clinical

evidence from randomized controlled trials. Recommendations from the JNC8 focus on the general adult population, with distinct recommendations for patients 60 years of age. The JNC8 guideline suggests that pharmacotherapy for hypertension be initiated in patients 60 years of age when systolic blood pressure (SBP) is 150 mmhg or diastolic blood pressure (DBP) is 90 mmhg, with goal SBP and DBP set at < 150 mmhg and < 90 mmhg, respectively. However, according to the expert panel, if the selected pharmacotherapy leads to a SBP < 140 mmhg and is well-tolerated, there is no need to adjust treatment. In patients < 60 years of age, the threshold for initiating treatment of hypertension is a SBP 140 mmhg or a DBP 90 mmhg. This threshold is also recommended for all adult patients with chronic kidney disease (CKD) and/or diabetes. The previous JNC7 guideline recommended thiazide diuretics as initial pharmacotherapy for most patients, and provided specific treatment approaches for patients with compelling indications (e.g., diabetes, stroke, heart failure). The JNC8 guideline deviates from this and recommends one of the following as initial treatment for hypertension in the general nonblack population with or without diabetes: thiazide diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACE-I), or angiotensin receptor blocker (ARB). This broad recommendation is based on clinical trials showing that each class had similar efficacy to the others for reducing mortality and improving cardiovascular, cerebrovascular, and kidney outcomes. In the general black population, JNC8 recommends initial treatment with a thiazide diuretic or a CCB, based on evidence showing that these drug classes are safer and more effective than ACE-Is in black patients. JNC8 does not recommend beta-blockers as initial therapy in any patient due to evidence of an increased risk of cardiovascular death, myocardial infarction, or stroke with this class of drugs vs. ARBs. The JNC8 panel recognizes that treatment with more than one antihypertensive agent may be required in order to reach and maintain blood pressure goals. If target blood pressure is not reached within one month, the dose of the initial agent should be increased or another agent from another recommended class should be selected. If target blood pressure is not reached with two agents, a third agent may be added. However, JNC8 recommends that patients should not receive both an ACE-I and an ARB. In patients who cannot reach target blood pressure with three agents from the classes recommended above, addition of a beta-blocker, aldosterone antagonist, or other agent may be necessary. While the JNC8 guideline does not include unique recommendations for patients with compelling indications, the panel does suggest that adult patients with CKD receive initial treatment with an, based on evidence that these classes improve kidney outcomes. The American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) jointly published Clinical Practice Guidelines for the Management of Hypertension for the first time in 2014. The ASH/ISH guidelines focus on the general adult population in the community setting. The ASH/ISH guidelines affirm a goal blood pressure of < 140/90 mmhg for most patients. However, a goal blood pressure of < 150/90 mmhg is recommended in patients 80 years of age. Unlike the JNC8 guideline, ASH/ISH provides a treatment algorithm taking into

account patient age, ethnicity/race, concomitant disease states, and hypertension stage. In non-black patients < 60 years of age with stage 1 hypertension (defined as 140-159/90-99 mmhg), an is recommended as initial therapy. In non-black patients 60 years of age with stage 1 hypertension, a is recommended as initial therapy. In black patients with stage 1 hypertension, a CCB or thiazide diuretic is recommended as initial therapy. ASH/ISH recommend increasing doses or adding additional drugs at 2-3 week intervals if goal blood pressures are not achieved. In patients with stage 2 hypertension ( 160/100 mmhg), all patients should start with two antihypertensive agents, a plus an. Unlike JNC8, ASH/ISH provides specific treatment recommendations for patients with concomitant disease states. These recommendations are summarized in table 1 below. (black patients: acceptable to start with CCB or thiazide diuretic) Beta-blocker + (black patients: acceptable to start with CCB or thiazide diuretic) (black patients: add ACE-I or ARB if starting with CCB or thiazide diuretic) + beta-blocker + diuretic + spironolactone for symptomatic heart failure regardless of blood pressure (dihydropyridine CCB may be added for additional blood pressure control) Abbreviations: ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker ASH/ISH further recommends treatment with longer-acting agents vs. shorter-acting agents in the same class because once-daily dosing may improve patient adherence in the community setting. The use of single-formulation combination products is preferred over taking two medications separately for the same reason. The American Heart Association (AHA), American College of Cardiology (ACC), and Centers for Disease Control and Prevention (CDC) published an algorithm entitles An Effective Approach to High Blood Pressure Control in 2014. The AHA/ACC/CDC algorithm focuses on patients with stage 1 and stage 2 hypertension and does not address age-specific blood pressure goals. In patients with stage 1 hypertension, the AHA/ACC/CDC algorithm suggests lifestyle modifications with or without a thiazide diuretic

as initial therapy. If blood pressure is not controlled at a goal of < 140/90 mmhg after 3 months, additional therapy with an ACE-I, ARB, or CCB is suggested. If dose titration and addition of medications from other classes are not sufficient to achieve blood pressure goals, then adherence and secondary causes of hypertension should be addressed. In patients with stage 2 hypertension, the AHA/ACC/CDC algorithm recommends lifestyle modifications plus treatment with a thiazide diuretic with or without an ACE-I, ARB, or CCB. If blood pressure is not at goal (< 140/90 mmhg) after 2-4 weeks, the same process of dose and medication optimization used in stage 1 hypertension should be employed. The AHA/ACC/CDC algorithm also recommends specific antihypertensive medication classes for patients with concomitant disease states. (see table 2 below). Coronary Artery Disease / Post-Myocardial Infarction Diabetes Diastolic Heart Failure Kidney Disease Stroke or Transient Ischemic Event Systolic Heart Failure Beta-blocker, ACE-I, Thiazide Diuretic, Beta-Blocker, CCB, Beta-Blocker, Thiazide Diuretic Thiazide Diuretic, ACE-I, Beta-Blocker, Aldosterone Antagonist, Thiazide Diuretic Abbreviations: ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) published an Expert Consensus Document on Hypertension in the Elderly in 2011. Because clinical evidence on the management of hypertension in elderly patients is limited, most of the recommendations from the ACCF/AHA are based on expert opinion. Like the other guidelines reviewed in this article, ACCF/AHA recommends a goal blood pressure of < 140/90 mmhg for most patients, noting that it is unclear if patients > 80 years of age should target the same SBP as younger patients. Because very few clinical trials have focused on treatment of hypertension in the elderly, selection of antihypertensive therapy is driven mostly by patient-specific factors. However, thiazide diuretics are recommended as initial therapy for most patients. In general, ACCF/AHA recommends that antihypertensive therapy be started at the lowest dose possible and gradually titrated up to desired blood pressure response or until the medication is no longer tolerated. If needed, a second drug from another class may be added. A third drug may be added if additional blood pressure lowering is required. The ACCF/AHA further recommends that patients with

an initial blood pressure > 20 mmhg over SBP goal or > 10 mmhg over DBP goal start with two antihypertensive drugs. As new drugs are initiated, providers should address drug-drug interactions and adherence issues. Further, because polypharmacy is a concern in the elderly population, limiting prescriptions by use of combination products and long-acting vs. short-acting medications is suggested. While the focus of this article has been on the recommended treatment goals and drug therapy for patients with hypertension, all of the guidelines reviewed recommend that patients make lifestyle modifications to improve blood pressure, reduce risk for cardiovascular complications and organ damage, and eliminate or reduce the need for antihypertensive medications. Patients should be encouraged to lose weight, reduce their salt intake, increase physical activity, limit alcohol consumption, and quit smoking. 2,4-6 In general, treatment guidelines for hypertension suggest treating most patients to a goal blood pressure of 140/90 mmhg. 2,4-6 However, some organizations suggest that higher goals (e.g., 150/90 mmhg) for older patients (particularly those aged 80 years) may be appropriate. 4,6 If lifestyle modifications alone are not enough to adequately control blood pressure, the addition of one or more antihypertensive medications is recommended. Some guidelines suggest initial therapy with thiazide diuretics, while others recommend thiazide diuretics, ACE-Is, ARBs, or CCBs as first-line therapy due to similar safety and efficacy among the classes. However, the recommended first-line therapy in black patients is a thiazide diuretic or CCB. Further, patients with chronic kidney disease should receive an ACE-I or an ARB as initial therapy. Beyond these recommendations, patient-specific factors should guide drug selection. 2,4-6 Selection of long-acting agents taken once daily and/or antihypertensive drugs available as combination products may help improve adherence and limit pill burden in elderly patients. 2,4,6

1.) High Blood Pressure Fact Sheet. Division for Heart Disease and Stroke Prevention. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm. Accessed August 11, 2015. 2.) Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community. A statement by the American Society of Hypertension and the International Society of Hypertension. 2014;32(1):14-26. 3.) High Blood Pressure Facts. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/bloodpressure/facts.htm. Accessed August 11, 2015. 4.) James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). 2014;311(5):507-20. 5.) Go AS, Bauman MA, Coleman King SM, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. 2014;63(12):1230-8. 6.) Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. 2011;57(20):2037-114. http://creighton.edu/pharmerica