North of Tyne and Gateshead Guidelines for Management and Diagnosis of Hypertension Reviewed August 2017

North of Tyne and Gateshead Guidelines for Management and Diagnosis of Hypertension Reviewed August 2017 An electronic version of this document can also be viewed / downloaded from the North of Tyne and Gateshead Area Prescribing Committee Website at: http://www.northoftyneapc.nhs.uk/documents/guidelines-and-statements/ Endorsed for use within North Tyneside, Northumberland, Newcastle and Gateshead by the North of Tyne and Gateshead APC Medicines October Use and 2017 Guideline Group recommended review Review date Membership of the guideline development group date: August 2020 Dr J Skinner, Consultant Community Cardiologist, NuTH guideline co-ordinator Dr S Bennett, Consultant Physician and Diabetologist, NHCT Dr R Curless, Consultant Physician with interest in Stroke Medicine, NHCT Dr A Dixit, Consultant in Stroke Medicine, NuTH Dr P Dorman, Consultant Neurologist, NuTH Dr A Dyker, Consultant in Clinical Pharmacology and Stroke, NuTH Dr S Eaton, Consultant in Diabetes, NDr D Higham, Consultant Cardiologist, NHCT Dr S Kirk, GP, Newcastle and Gateshead CCG. Dr S Little, Consultant in Diabetes, NuTH Mr M Lowery, Formulary Pharmacist, NuTH Prof S Marshall, Consultant in Diabetes, NuTH Dr F Naylor, GP, Northumberland CCG Dr C Runnett, Consultant Cardiologist, NHCT Dr Caroline Sprake, GP, North Tyneside CCG Prof G Stansby, Consultant in Vascular Surgery, NuTH Dr C Tomson, Consultant Nephrologist, NuTH Professor S Thomas, Consultant in Clinical Pharmacology, NuTH Mrs S Turner, Medicines Optimisation, NECS 1

Contents Introduction 3 Diagnosis of hypertension summary 4 Management of hypertension summary 5 Antihypertensive drug treatment summary 6 Additional notes 7 Appendices Examples of drug costs 9 Membership of the guideline group 10 Page 2

Introduction This guidance is for the diagnosis and management of hypertension. In particular it summarises and interprets the NICE guideline for the clinical management of primary hypertension in adults, the two NICE guidelines for Type 1 and Type 2 diabetes, and the NICE guideline for CKD for local implementation. However, it does not rewrite the NICE guidelines with which clinicians should also be familiar. These guidelines are intended for all clinicians in the Newcastle, North Tyneside, Northumberland and Gateshead areas involved in the diagnosis and management of hypertension. Some top tips for managing patients with hypertension Ensure blood pressure is measured correctly on each occasion (see Diagnosis of hypertension flowchart). Consider reducing the dose of a drug, rather than stopping, if there are problems with tolerability. Moderate doses of more than one agent may be more effective than maximum dose of a single agent. Agree a schedule with the patient for monitoring effectiveness and safety of treatment and for titration of medication to optimise management as part of the initial shared decision making about management with the patient. Medication to control blood pressure to target should be titrated every 4 to 6 weeks. Monitoring blood tests (egfr and serum electrolytes) should be checked 2 weeks after initiating or increasing the dose of ACE inhibitors or ARBs. How to use the guidelines The guideline is presented as three summary flow charts: diagnosis of hypertension, management of hypertension and antihypertensive drug treatment, with additional notes thereafter. Hyperlinks are included from the index and the flow charts can also be printed and laminated for easy reference if preferred. The BNF and the North of Tyne Formulary should be referred to as appropriate. Patient information There are a variety of resources available for patients. None are specifically endorsed by the group, but clinicians may find some of the following useful to share with patients. Blood Pressure UK; http://www.bloodpressureuk.org/bloodpressureandyou HBPM; http://www.bloodpressureuk.org/bloodpressureandyou/homemonitoring/howtome asure http://bhsoc.org/files/3014/1088/8029/how_to_instructional_leaflet.pdf http://bhsoc.org/files/8514/1088/8028/home_blood_pressure_diary.pdf http://bhsoc.org/files/6614/1088/8029/home_blood_pressure_monitoring_explaine d.pdf The guideline development group recognise and fully support the importance of shared decision making with patients and will signpost to additional resources as these are identified, but it is beyond the scope of this guideline to include detailed information within this guideline. 3

Diagnosis of hypertension Patient information and education Provide information and education in an appropriate format to support patients to make informed decisions about their treatment for hypertension and to lower cardiovascular risk at each step in the diagnostic and management pathway Patient being assessed for possible hypertension Measure blood pressure in both arms If difference between the 2 arms > 20 mmhg repeat If difference remains > 20 mmhg, record which arm is higher and use thereafter 1 If BP 140/ 90 mmhg Make a second measurement If second measurement substantially different to first, make a third 2 Record lower of last two measurements as clinic blood pressure Notes 1 Consider including on primary care template which to use for subsequent measurements if BP different between arms 2 BP should be measured after 5 minutes rest 2 or 3 times, with 2 minutes between. Consider additional measurements if successive BP measurements are substantially different and BP still falling. 3 ABPM: at least 2 measurements / hour during normal waking hours with average 14. 4 HBPM: person seated, 2 measurements at least 1 minute apart, and BP recorded twice daily (ideally morning and evening), and for at least 4 days, ideally 7 days. Discard measurements on day 1, average all remaining for result of HBPM Refer for same day specialist care if: Accelerated hypertension (papilloedema/ retinal haemorrhage) or Suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, diaphoresis) or Suspected hypertensive encephalopathy (confusion, visual loss, with severe hypertension) Clinic blood pressure < 140/ < 90 mmhg Clinic blood pressure 140/90 180/110 mmhg Clinic blood pressure 180/ 110 mmhg Indication to start antihypertensive treatment same day? No Offer ambulatory blood pressure monitoring (ABPM) 3 If ABPM not tolerated or refused, offer home blood pressure monitoring (HBPM) 4 Arrange investigations for target organ damage (kidney, LVH, consider fundoscopy) Assess 10 year cardiovascular risk Yes Start treatment Severe hypertension ABPM / HBPM < 135/ < 85 mmhg ABPM / HBPM 135/ 85 < 150/ < 95 mmhg Diagnose Stage 1 hypertension ABPM / HBPM 150/ 95 mmhg Diagnose Stage 2 hypertension Normotensive If evidence of target organ damage and or high cardiovascular risk, manage appropriately, otherwise check BP at least every 5 years No diabetes / CKD with ACR 70 mg/mmol/l (at all times) Diagnosis: clinic BP 140/ 90 mmhg, ABPM / HBPM 135/ 85 mmhg Type 2 Diabetes no kidney, eye or cerebrovascular damage Diagnosis: 140/ 80 mmhg, ABPM / HBPM 135/ 75 mmhg Type 1 Diabetes if no renal damage and < 2 features of the metabolic syndrome Diagnosis: 135 / 85 mmhg, ABPM / HBPM 120 / 80 mmhg Others with diabetes, and all patients with CKD and ACR > 70 mg/mmol/l (at any time) Diagnosis: clinic BP 130/ 80 mmhg, ABPM / HBPM 125/ 75 mmhg In some patients, for example those with ACR 70 mg/mmol/l, diabetic retinopathy, lower thresholds may be considered clinically appropriate and management individualised. Management of hypertension 4

Patient information and education Provide information and education in an appropriate format to support patients to make informed decisions about their treatment for hypertension and to lower cardiovascular risk at each step in the diagnostic and management pathway All patients diagnosed with hypertension Assess Cardiovascular risk (refer to FATS) Measure Urine protein quantification (ACR), use reagent strip for haematuria Blood sample: HbA1c, electrolytes, creatinine, egfr, total and HDL cholesterol Consider examining fundi for retinopathy 12 lead ECG for LVH Lifestyle advice (offer appropriate information and interventions to support changes) Healthy eating, including reducing salt Increase physical activity Quit smoking Alcohol within safe limits Discourage excessive coffee / caffeine rich products Review results of ABPM / HBPM Consider specialist referral Patients aged < 40 years, before starting drug treatment Patients with particularly severe hypertension (eg 220/120 but without features of accelerated hypertension) Complicated hypertension (eg with TIA, heart failure) Possible underlying causes: including primary aldosteronidism (hypokalemia +/- high normal plasma sodium), phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, diaphoresis) Suspected renal hypertension (see local CKD guidelines) Sudden worsening / rapidly progressive hypertension Drug resistant hypertension (not controlled by three drugs or more) Therapeutic problems preventing blood pressure control (drug intolerance etc) ABPM / HBPM 135/ 85 < 150/ < 95 mmhg Stage 1 hypertension ABPM / HBPM 150/ 95 mmhg Stage 2 hypertension 1 Offer drug treatment (see drug flow) if aged < 80 years, and Target organ damage Established cardiovascular disease Renal disease Diabetes 10 year cardiovascular disease risk equivalent 20% Offer drug treatment (see drug flow) Target blood pressure on treatment, aged 80 years 2 No diabetes / CKD Clinic BP < 140/ < 90 mmhg, HBPM / daytime av. ABPM < 135/ < 85 mmhg CKD without diabetes / ACR 70 mg/mmol/l Clinic BP < 140/ < 90 mmhg, HBPM / daytime av. ABPM < 135/ < 85 mmhg Type 2 Diabetes no kidney, eye or cerebrovascular damage Clinic BP < 140/ < 80 mmhg, ABPM / HBPM < 135/ < 75 mmhg Type 1 Diabetes if no renal damage and < 2 features of the metabolic syndrome Clinic BP < 135 / 85 mmhg, ABPM / HBPM < 130 / < 80 mmhg All others with diabetes, and all patients with CKD and ACR > 70 mg/mmol/l (at any time) Clinic BP < 130/ < 80 mmhg, HBPM / daytime av. ABPM < 125/ < 75 mmhg (target range systolic BP 120-130 mmhg, HBPM / daytime av. ABPM 115 125 mmhg, unless other comorbidities to consider) Target blood pressure on treatment, aged > 80 years 2 Lower targets can be used, with a target systolic blood pressure 10 mmhg lower in each group above Notes 1 Patients with stage 1 hypertension and no drug treatment should be reviewed annually and offered drug treatment if clinic blood pressure > 160/ > 100 (repeat ABPM / HBPM if uncertainty) and or high risk features (see above) develop 2 Consider repeating ABPM / HBPM on treatment as adjunct to clinic blood pressure measurements to monitor response to treatment if significant white coat effect ie discrepancy > 20/ > 10 mmhg between clinic and average ABPM/HBPM at diagnosis, but not as routine. HBPM may be particularly useful in this circumstance. 3 Patients aged 80 years with previous diagnosis and already treated - do not down-titrate drugs unless postural hypotension is a concern. All patients diagnosed with hypertension should have an annual review to include: Clinic BP (consider HBPM the week before or if the clinic BP > target), ACR, egfr / U&E, review and agree management plan. Refer to other local guidelines for additional monitoring requirements eg FATS, diabetes guidelines, etc Antihypertensive drug treatment 5

Aged < 55 years Aged 55 years or black person of African or Caribbean family origin of any age Step 1 ACE inhibitor ARB only if ACE inhibitor not tolerated Calcium channel blocker eg amlodipine 1 indapamide i/r if CCB not tolerated or evidence of heart failure or high risk of heart failure (providing not already treated with a loop diuretic) Step 2 Step 3 Combine A + C Review concordance Titrate drugs to maximum tolerated If additional drug treatment required add 1 indapamide i/r, if not already started in step 1 ie combine A + C + D Patient information and education Provide information and education in an appropriate format to support patients to make informed decisions about their treatment for hypertension and to lower cardiovascular risk at each step in the diagnostic and management pathway Resistant hypertension Step 4 Review concordance with lifestyle and drug treatment Titrate drugs to maximum tolerated doses Consider additional drug treatment: Spironolactone or eplerenone (consider and monitor for risk of hyperkalaemia) Alpha blocker 2 Beta blocker eg atenolol, bisoprolol Do not combine an ACE inhibitor and ARB for treatment of hypertension Try and avoid the combination of an ACE inhibitor / ARB with spironolactone / eplerenone in the absence of HF-REF, particularly in patients at greatest risk of developing hyperkalaemia Seek specialist advice unless circumstances make this inappropriate / unnecessary Notes 1 Appropriate generic preparations of thiazide-like diuretics are now available. Indapamide is substantially less costly than chlorthalidone (see drug costs in the appendix) and is preferred. Patients already treated with bendroflumethiazide and are stable on that, should continue existing treatment, and not be routinely switched. 2 Beta blockers may be considered as initial treatment if Intolerance to ACE inhibitors / ARB Women of child bearing potential Evidence of increased sympathetic drive If treated with a beta blocker, add a CCB, not a thiazide diuretic if additional treatment required, to reduce risk of developing diabetes particularly in those at risk of developing Type 2 diabetes. If the combination of a beta blocker and a thiazide is used consider combining with a potassium sparing diuretic to avoid cellular potassium depletion The BNF and North of Tyne / Gateshead Formulary should be referred to as appropriate 6

Additional notes It is assumed that healthcare providers will ensure any device used for measuring blood pressure is appropriately maintained and calibrated, and appropriate cuff sizes for the patients arm are available and used. Healthcare professionals who take blood pressure measurements should be adequately trained and be competent to do so, adhering to the recommendations in the NICE guideline. Palpate the pulse before measuring blood pressure. If the pulse is irregular, consider investigating for atrial fibrillation and measure blood pressure manually using direct auscultation over the brachial artery. Automated devices may not be accurate with an irregular pulse. A difference in blood pressure between the two arms of > 20 mmhg, does not require further investigation unless symptomatic and or aged 50 years. The arm with the higher blood pressure should be used to measure blood pressure and cardiovascular risk managed appropriately. In general, patients should be considered to have peripheral arterial disease and be treated with secondary prevention. Ambulatory blood pressure monitoring (ABPM) is recommended in preference to home blood pressure monitoring (HBPM) for the diagnosis of hypertension, consistent with the NICE guideline and recognising that there is evidence which links the results of ABPM monitoring with cardiovascular risk. The local guideline group recognised that there are inadequate resources at present for all patients to have ABPM or HBPM, but that this should be aspired to in the future. If ABPM (or HBPM) is normal and there is no end organ damage or other high risk conditions such as established cardiovascular disease or diabetes, clinic blood pressure need not be routinely repeated for 5 years. In general, clinicians should avoid measuring ABPM (or HBPM) repeatedly in response to clinic blood pressure measurements, if there is no significant change compared to the initial clinic blood pressure when ABPM (or HBPM) was normal. Previously the North of Tyne APC recommended bendroflumethizide, rather than a thiazide-like diuretic pending appropriate generic preparations becoming available. Indapamide and chlorthalidone preparations are now available. Indapamide is far less costly (see appendix for drug costs) and there was a clinical consensus within the guideline group that the local guideline should now be consistent with the NICE guideline for hypertension and recommend indapamide i/r as a thiazide like diuretic, in patients who are starting a diuretic for hypertension. This approach has been discussed and agreed by the APC. The APC also wished to emphasise that patients who are stable and treated with bendroflumethiazide should in general continue that, and not switch (unless there are clinical indications to do otherwise). Reference to diabetes and CKD is made in the summaries. The diagnostic thresholds and therapeutic targets in the different NICE guidelines as well as in Type 2 diabetes the requirements for the National Diabetes Audit and QOF, mean it is not possible to simplify and harmonise these. When the diastolic blood pressure is lower, it is recognised that in the majority of older people, the lower 7

diastolic blood pressure will be easily achieved if the systolic blood pressure target is met. Patients with established cardiovascular disease are high risk and drug treatment of stage 1 hypertension should be considered. Peripheral arterial disease In patients with peripheral arterial disease and claudication, lowering blood pressure may worsen claudication distance and patients should be provided with appropriate information to continue antihypertensive treatment. In patients with critical ischaemia of the leg, the critical ischaemia should be managed initially discuss with vascular surgeons. 8

APPENDICES Examples of drug costs Drug Cost per 28 days ( ) Bendroflumethiazide Tabs 2.5 mg od 0.63 Chlorthalidone Tabs 50 mg od 89.10 Indapamide MR Tabs 1.25 mg od 3.40 Indapamide Tabs 2.5 mg od 1.02 Amlodipine Tabs 5 mg od 0.73 Amlodipine Tabs 10 mg od 0.78 Ramipril Caps 1.25 mg od 1.42 Ramipril Tabs 1.25mg od 1.53 Ramipril Caps 2.5 mg od 1.63 Ramipril Tabs 2.5 mg od 1.13 Ramipril Caps 5 mg od 1.01 Ramipril Tabs 5 mg od 1.00 Ramipril Caps 10 mg od 1.05 Ramipril Tabs 10 mg od 1.16 Lisinopril Tabs 2.5 mg od 0.71 Lisinopril Tabs 5 mg od 0.72 Lisinopril Tabs 10 mg od 0.76 Lisinopril Tabs 20 mg od 0.82 Lisinopril Tabs 40 mg(2x20) od 1.64 Perindopril (erbumine) Tabs 2 mg od 0.98 Perindopril (erbumine) Tabs 4 mg od 1.07 Perindopril (erbumine) Tabs 8 mg od 1.32 Perindopril (arginine) Tabs 2.5mg od 4.43 Perindopril (arginine) Tabs 5 mg od 6.28 Perindopril (arginine) Tabs 10 mg od 10.65 Losartan Tabs 12.5mg od 26.66 Losartan Tabs 25mg od 0.80 Losartan Tabs 50 mg od 0.85 Losartan Tabs 100 mg od 1.02 Atenolol Tabs 25 mg od 0.70 Atenolol Tabs 50 mg od 0.72 Atenolol (angina ) Tabs 100mg od 0.76 Bisoprolol (heart failure) Tabs 1.25 mg od 0.86 Bisoprolol (heart failure) Tabs 2.5 mg od 0.78 Bisoprolol (heart failure) Tabs 3.75 mg od 1.05 Bisoprolol Tabs 5 mg od 0.75 Bisoprolol (heart failure) Tabs 7.5 mg od 1.47 Bisoprolol Tabs 10 mg od 0.80 Accessed from NHSBSA Electronic Drug Tariff April 2017, accessed 11/4/2017 9

Membership of the guideline development group Dr J Skinner, Consultant Community Cardiologist, Newcastle upon Tyne Hospitals NHS guideline co-ordinator Dr S Bennett, Consultant Physician and Diabetologist, Northumbria Healthcare NHS Dr R Curless, Consultant Physician with interest in Stroke Medicine, Northumbria Healthcare NHS Dr A Dixit, Consultant in Stroke Medicine, Newcastle upon Tyne Hospitals NHS Dr P Dorman, Consultant Neurologist, Newcastle upon Tyne Hospitals NHS Dr A Dyker, Consultant in Clinical Pharmacology and Stroke, Newcastle upon Tyne Hospitals NHS Dr S Eaton, Consultant in Diabetes, Northumbria Healthcare NHS Foundation Trust Dr D Higham, Consultant Cardiologist, Northumbria Healthcare NHS Foundation Trust Dr S Kirk, GP, Newcastle and Gateshead CCG. Dr S Little, Consultant in Diabetes, Newcastle upon Tyne Hospitals NHS Mr M Lowery, Formulary Pharmacist, Newcastle upon Tyne Hospitals NHS Prof S Marshall, Consultant in Diabetes, Newcastle upon Tyne Hospitals NHS Dr F Naylor, GP, Northumberland CCG Dr C Runnett, Consultant Cardiologist, Northumbria Healthcare NHS Foundation Trust Dr Caroline Sprake, GP, North Tyneside Prof G Stansby, Consultant in Vascular Surgery, Newcastle upon Tyne Hospitals NHS Dr C Tomson, Consultant Nephrologist, Newcastle upon Tyne Hospitals NHS Professor S Thomas, Consultant in Clinical Pharmacology, Newcastle upon Tyne Hospitals NHS Mrs S Turner, Medicines Management, North of Tyne Declared conflicts of interest None declared Date of guideline August 2017 Date of review August 2020 10