Hypertension (JNC-8) Southern California University of Health Sciences Physician Assistant Program Management and Treatment of Hypertension April 17, 2018, presented by Ezra Levy, Pharm.D.!
The 8 th Joint National Committee Guidelines (2013) A. Joint National Committee-6 (1997) Classification of Blood Pressure for Adults Aged 18 Years & Older Category Systolic (mm Hg) Diastolic (mm Hg) rmal < 130 < 85 High rmal 130-139 85-89 Hypertension Stage 1 (mild) 140-159 90-99 Stage 2 (moderate) 160-179 100-109 Stage 3 (severe) 180-209 110-119 Stage 4 (very severe) > 210 > 120 B. Joint National Committee-7 (2003) Table 2. Changes in blood pressure classification JNC 6 Category SBP/DBP Optimal <120/80 rmal 120 129/80 84 Borderline 130 139/85 89 Hypertension >140/90 STAGE 1 140 159/90 99 JNC 7 Category rmal Prehypertension Hypertension STAGE 1 STAGE 2 STAGE 3 160 179/100 109 >180/110 STAGE 2 C. Joint National Committee-8 (2013) Patients > 60 years old, initiate pharm. tx at SBP > 150 OR DBP > 90 Patients < 60 years old, initiate pharm. tx SBP > 140 OR DBP > 90. Patients > 18 years with diabetes or CKD, initiate pharm. tx at SBP > 140 OR DBP > 90 General non-black population, including those with diabetes, initial pharm. tx should include a thiazide diuretic, CCB, ACE-I or ARB. (te: BB are omitted) General black population, initial treatment should include a thiazide diuretic or a CCB. (te: BB, ACE-I & ARB are omitted) All patients with CKD and HTN, initial treatment should include an ACE-I or an ARB to improve kidney outcomes. In all hypertensive patients, if goal BP is not reached within a month of initiating treatment, increase the dose of the initial drug OR add a second drug from one of these four classes. o If goal BP cannot be reached with two drugs, add and titrate a third drug from the list provided.
Figure 1. 2014 Hypertension Guideline Management Algorithm Adult aged 18 years with hypertension Implement lifestyle interventions (continue throughout management). Set blood pressure goal and initiate blood pressure lowering-medication based on age, diabetes, and chronic kidney disease (CKD). General population (no diabetes or CKD) Diabetes or CKD present Age 60 years Age <60 years All ages Diabetes present CKD All ages CKD present with or without diabetes SBP <150 mm Hg SBP <140 mm Hg SBP <140 mm Hg SBP <140 mm Hg nblack Black All races Initiate thiazide-type diuretic or ACEI or ARB or CCB, alone or in combination. a Initiate thiazide-type diuretic or CCB, alone or in combination. Initiate ACEI or ARB, alone or in combination with other drug class. a Select a drug treatment titration strategy A. Maximize first medication before adding second or B. Add second medication before reaching maximum dose of first medication or C. Start with 2 medication classes separately or as fixed-dose combination. Reinforce medication and lifestyle adherence. For strategies A and B, add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB). For strategy C, titrate doses of initial medications to maximum. Reinforce medication and lifestyle adherence. Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB). Reinforce medication and lifestyle adherence. Add additional medication class (eg, β-blocker, aldosterone antagonist, or others) and/or refer to physician with expertise in hypertension management. Continue current treatment and monitoring. b SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker. a ACEIs and ARBs should not be used in combination. b If blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual therapeutic plan. 33 Downloaded From: on 09/13/2018
Adult aged 18 years with HTN Implement lifestyle modifications Set BP goal, initiate BP-lowering medication based on algorithm General Population (no diabetes or CKD) Black JNC 8 Hypertension Guideline Algorithm Diabetes or CKD present Age 60 years Age < 60 years All Ages Diabetes present CKD < 150/90 nblack Initiate thiazide, ACEI, ARB, or CCB, alone or in combo < 140/90 Initiate thiazide or CCB, alone or combo At blood pressure goal? < 140/90 All Ages and Races CKD present with or without diabetes < 140/90 Initiate ACEI or ARB, alone or combo w/another class Reinforce lifestyle and adherence Titrate medications to maximum doses or consider adding another medication (ACEI, ARB, CCB, Thiazide) At blood pressure goal? Reinforce lifestyle and adherence Add a medication class not already selected (i.e. beta blocker, aldosterone antagonist, others) and titrate above medications to max (see back of card) Initial Drugs of Choice for Hypertension ACE inhibitor (ACEI) Angiotensin receptor blocker (ARB) Thiazide diuretic Calcium channel blocker (CCB) Strategy A B C Description Start one drug, titrate to maximum dose, and then add a second drug. Start one drug, then add a second drug before achieving max dose of first Begin 2 drugs at same time, as separate pills or combination pill. Initial combination therapy is recommended if BP is greater than 20/10mm Hg above goal Lifestyle changes: Smoking Cessation Control blood glucose and lipids Diet Eat healthy (i.e., DASH diet) Moderate alcohol consumption Reduce sodium intake to no more than 2,400 mg/day Physical activity Moderate-to-vigorous activity 3-4 days a week averaging 40 min per session. At blood pressure goal? Reinforce lifestyle and adherence Titrate meds to maximum doses, add another med and/or refer to hypertension specialist Continue tx and monitoring Reference: James PA, Ortiz E, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: (JNC8). JAMA. 2014 Feb 5;311(5):507-20 Card developed by Cole Glenn, Pharm.D. & James L Taylor, Pharm.D.
Indication Heart Failure Post MI/Clinical CAD CAD Diabetes CKD Recurrent stroke prevention Pregnancy Compelling Indications Treatment Choice ACEI/ARB + BB + diuretic + spironolactone ACEI/ARB AND BB ACEI, BB, diuretic, CCB ACEI/ARB, CCB, diuretic ACEI/ARB ACEI, diuretic labetolol (first line), nifedipine, methyldopa Hypertension Treatment Beta-1 Selective Beta-blockers possibly safer in patients with COPD, asthma, diabetes, and peripheral vascular disease: metoprolol bisoprolol betaxolol acebutolol Drug Class Agents of Choice Comments Diuretics HCTZ 12.5-50mg, chlorthalidone 12.5-25mg, indapamide 1.25-2.5mg triamterene 100mg K+ sparing spironolactone 25-50mg, amiloride 5-10mg, triamterene 100mg furosemide 20-80mg twice daily, torsemide 10-40mg ACEI/ARB ACEI: lisinopril, benazapril, fosinopril and quinapril 10-40mg, ramipril 5-10mg, trandolapril 2-8mg ARB: candesartan 8-32mg, valsartan 80-320mg, losartan 50-100mg, olmesartan 20-40mg, telmisartan 20-80mg Beta-Blockers Calcium channel blockers Vasodilators metoprolol succinate 50-100mg and tartrate 50-100mg twice daily, nebivolol 5-10mg, propranolol 40-120mg twice daily, carvedilol 6.25-25mg twice daily, bisoprolol 5-10mg, labetalol 100-300mg twice daily, Dihydropyridines: amlodipine 5-10mg, nifedipine ER 30-90mg, n-dihydropyridines: diltiazem ER 180-360 mg, verapamil 80-120mg 3 times daily or ER 240-480mg hydralazine 25-100mg twice daily, minoxidil 5-10mg Monitor for hypokalemia Most SE are metabolic in nature Most effective when combined w/ ACEI Stronger clinical evidence w/chlorthalidone Spironolactone - gynecomastia and hyperkalemia Loop diuretics may be needed when GFR <40mL/min SE: Cough (ACEI only), angioedema (more with ACEI), hyperkalemia Losartan lowers uric acid levels; candesartan may prevent migraine headaches t first line agents reserve for post-mi/chf Cause fatigue and decreased heart rate Adversely affect glucose; mask hypoglycemic awareness Cause edema; dihydropyridines may be safely combined w/ B-blocker n-dihydropyridines reduce heart rate and proteinuria Hydralazine and minoxidil may cause reflex tachycardia and fluid retention usually require diuretic + B-blocker Centrally-acting Agents terazosin 1-5mg, doxazosin 1-4mg given at bedtime clonidine 0.1-0.2mg twice daily, methyldopa 250-500mg twice daily guanfacine 1-3mg Alpha-blockers may cause orthostatic hypotension Clonidine available in weekly patch formulation for resistant hypertension
Considerations for individualizing antihypertensive therapy Indication Antihypertensive drugs Compelling indications (major improvement in outcome independent of blood pressure) Systolic heart failure Post myocardial infarction Proteinuric chronic kidney disease Angina pectoris Atrial fibrillation rate control Atrial flutter rate control ACE inhibitor or ARB, beta blocker, diuretic, aldosterone antagonist* ACE inhibitor, beta blocker, ARB, aldosterone antagonist ACE inhibitor and/or ARB Beta blocker, calcium channel blocker Beta blocker, nondihydropyridine calcium channel blocker Beta blocker, nondihydropyridine calcium channel blocker Likely to have a favorable effect on symptoms in comorbid conditions Benign prostatic hyperplasia Essential tremor Hyperthyroidism Migraine Osteoporosis Raynaud's syndrome Alpha blocker Beta blocker (noncardioselective) Beta blocker Beta blocker, calcium channel blocker Thiazide diuretic Dihydropyridine calcium channel blocker Contraindications Angioedema Bronchospastic disease Depression Liver disease Pregnancy (or at risk for) Second or third degree heart block ACE inhibitor Beta blocker Reserpine Methyldopa ACE inhibitor, ARB, renin inhibitor Beta blocker, nondihydropyridine calcium channel blocker May have adverse effect on comorbid conditions Depression Gout Hyperkalemia Hyponatremia Renovascular disease Beta blocker, central alpha 2 agonist Diuretic Aldosterone antagonist, ACE inhibitor, ARB, renin inhibitor Thiazide diuretic ACE inhibitor, ARB, or renin inhibitor * A benefit from an aldosterone antagonist has been demonstrated in patients with NYHA class III IV heart failure, or decreased left ventricular ejection fraction after a myocardial infarction Adapted from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, JAMA 2003; 289:2560.
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