Presentation is loading. Please wait.

Presentation is loading. Please wait.

Treatment of Hypertension in Pediatrics Kelsey R. Green, Pharm.D. Pediatric Clinical Pharmacist LSU-HSC in Shreveport, LA.

Similar presentations


Presentation on theme: "Treatment of Hypertension in Pediatrics Kelsey R. Green, Pharm.D. Pediatric Clinical Pharmacist LSU-HSC in Shreveport, LA."— Presentation transcript:

1 Treatment of Hypertension in Pediatrics Kelsey R. Green, Pharm.D. Pediatric Clinical Pharmacist LSU-HSC in Shreveport, LA

2 Objectives Define hypertension in children Define hypertension in children Identify when blood pressure should be taken Identify when blood pressure should be taken Practice determining BP percentile and interpreting how to use this information to best treat the patient Practice determining BP percentile and interpreting how to use this information to best treat the patient Discuss treatment options used in pediatrics to treat hypertension Discuss treatment options used in pediatrics to treat hypertension

3 Definitions 2 Hypertension: average SBP and/or DBP >95 th percentile for gender, age, and height on > 3 occasions Hypertension: average SBP and/or DBP >95 th percentile for gender, age, and height on > 3 occasions Prehypertension: average SBP or DBP >90 th percentile but 90 th percentile but 120/80 mm Hg should be considered prehypertensive

4 Measurement of Blood Pressure 2 Children >3 years old should have their BP measured when seen in a medical setting Children >3 years old should have their BP measured when seen in a medical setting Preferred method: Auscultation Preferred method: Auscultation –Requires a cuff that is appropriate for the child’s arm –Right arm preferred

5 Blood Pressure Cuff 2 Equipment needed to measure BP in children (3-adolescents): Equipment needed to measure BP in children (3-adolescents): –Child cuffs of different sizes –Standard adult cuff –Large adult cuff –Thigh cuff

6 Measurement of BP in children < 3 years old 2 History of prematurity, VLBW, or other neonatal complications History of prematurity, VLBW, or other neonatal complications Congenital heart disease Congenital heart disease Recurrent UTI, hematuria, or proteinuria Recurrent UTI, hematuria, or proteinuria Known renal disease or urologic malformations Known renal disease or urologic malformations Family history of congenital renal disease Family history of congenital renal disease Solid-organ transplant Solid-organ transplant Malignancy or bone marrow transplant Malignancy or bone marrow transplant Treatment with drugs known to raise BP Treatment with drugs known to raise BP Systemic illnesses associated with hypertension Systemic illnesses associated with hypertension Evidence of elevated ICP (intracranial pressure) Evidence of elevated ICP (intracranial pressure)

7 Using the Blood Pressure Tables 2 Use the standard height charts to determine the height percentile. Use the standard height charts to determine the height percentile. Measure and record the child’s SBP and DBP. Measure and record the child’s SBP and DBP. Use the correct gender table for SBP and DBP. Use the correct gender table for SBP and DBP. Find the child’s age on the left side of the table. Follow the age row across the table to the intersection of the line for the height percentile. Find the child’s age on the left side of the table. Follow the age row across the table to the intersection of the line for the height percentile. Find the 50 th, 90 th, 95 th, and 99 th percentiles for SBP in the left columns and for DBP in the right columns. Find the 50 th, 90 th, 95 th, and 99 th percentiles for SBP in the left columns and for DBP in the right columns.

8 Let’s Practice AMF is a 5 yo female weighing 25 kg in the 75 th percentile of height. Her BP is taken when she goes to the Dr. for a routine visit. Her BP is 114/73. AMF is a 5 yo female weighing 25 kg in the 75 th percentile of height. Her BP is taken when she goes to the Dr. for a routine visit. Her BP is 114/73. What is her BP percentile? What is her BP percentile? What do we do with this information? What do we do with this information?

9 What does this percentile mean? 2 Normal <90 th Prehypertension 90- 120-80 Stage 1 hypertension 95 th -99 th plus 5 mm Hg Stage 2 hypertension >99 th plus 5 mm Hg

10 Classification of Hypertension & Therapy Recommendations 2 Classification of Hypertension Therapy Recommendations Normal Encourage healthy diet, sleep, & physical activity Prehypertension Physical activity & diet management; No medication unless compelling indications such as chronic kidney disease, DM, HF or LVH exist Stage 1 Hypertension Physical activity & diet management; Initiate therapy Stage 2 Hypertension Physical activity & diet management; Initiate therapy (more than 1 drug may be required)

11 Management Algorithm 2

12 Diagnostic Work-Up 6 Urinalysis Rule out infection, hematuria, proteinuria Protein/Cr Ratio Kidney function Renal Ultrasound Rule out renal scarring, congenital renal anomalies EKGCardiomegaly CBC with differential Rule out anemia, consistent with chronic renal disease Electrolyetes, BUN, Cr Rule out renal disease, pyelonephritis

13 Possible Etiologies Causing Hypertension 2 Chronic Renal Failure Chronic Renal Failure Cushing Syndrome Cushing Syndrome Turner Syndrome Turner Syndrome Hyperthyroidism Hyperthyroidism Systemic Lupus Systemic Lupus Coarctation of the aorta Coarctation of the aorta Wilms tumor Wilms tumor

14 Treatment Strategies Therapeutic lifestyle changes Therapeutic lifestyle changes Drug therapy Drug therapy

15 Lifestyle changes Weight reduction Weight reduction Regular physical activity Regular physical activity Restriction of sedentary activity Restriction of sedentary activity Dietary modification Dietary modification Family-based intervention Family-based intervention

16 Indications for Antihypertensive Drug Therapy 2 Symptomatic hypertension Symptomatic hypertension Secondary hypertension Secondary hypertension Hypertensive target-organ damage Hypertensive target-organ damage Diabetes (types 1 and 2) Diabetes (types 1 and 2) Persistent hypertension despite nonpharmacologic measures Persistent hypertension despite nonpharmacologic measures

17 Step-wise Approach to Therapy 2 1. Start with a small dose of a single anti-hypertensive drug 2. Increase dose of single anti- hypertensive drug (to max dose if tolerated) 3. Add a small dose of a second drug 4. Increase dose of second anti- hypertensive medication

18 Antihypertensive Medication Angiotensin Converting Enzyme- Inhibitors Angiotensin Converting Enzyme- Inhibitors Angiotensin Receptor Blockers Angiotensin Receptor Blockers Calcium Channel Blockers Calcium Channel Blockers Diuretics Diuretics Beta-Blockers Beta-Blockers Central alpha-agonists Central alpha-agonists Peripheral alpha-antagonist Peripheral alpha-antagonist Vasodilators Vasodilators

19 Drug Options for Initial Therapy 1 Class of Drugs Patients’ Characteristics ACE-Is/ARBs First-line therapy CCBs Diuretics Adjunct second-line drug β–Blocker Avoid in athletes (controversial) and people with diabetes

20 ACE-I 1-3, 5 Angiotensin Converting Enzyme Inhibitors Angiotensin Converting Enzyme Inhibitors Benazepril*, Captopril, Enalapril *, Fosinopril*, Lisinopril*, Quinapril Benazepril*, Captopril, Enalapril *, Fosinopril*, Lisinopril*, Quinapril Mechanism of Action: prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; results in lower levels of angiotensin II which causes an increase in plasma renin activity and a reduction in aldosterone secretion Mechanism of Action: prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor; results in lower levels of angiotensin II which causes an increase in plasma renin activity and a reduction in aldosterone secretion

21 www.medscape.com ACE-I

22 ACE-I Patient’s Characteristics: Patient’s Characteristics: –High plasma renin activity –Renal insufficiency (unilateral renovascular hypertension, renal parenchymal disease, renal proteinuria) –Congestive heart failure –Diabetes –Hyperlipidemia

23 ACE-I Comments: Comments: –Contraindicated in pregnancy –Monitor serum potassium and SCr –Cough and angioedema –May require a dosing adjustment in renal impairment –Fosinopril in children >50 kg –Good data on compounding Captopril into a suspension

24 ARB 1-3, 5 Angiotensin Receptor Blockers Angiotensin Receptor Blockers Irbesartan*, Losartan* Irbesartan*, Losartan* Mechanism of Action: angiotensin II receptor antagonist; blocks the vasoconstrictor and aldosterone- secreting effects of anigotensin II Mechanism of Action: angiotensin II receptor antagonist; blocks the vasoconstrictor and aldosterone- secreting effects of anigotensin II

25 www.medscape.com ARB

26 ARB Patient’s Characteristics: same as ACE-I Patient’s Characteristics: same as ACE-I Comments: Comments: –Less studied than ACE-I –Dosing not available in Neofax or Pediatric Dosing Handbook –All are contraindicated in pregnancy –Check serum potassium and SCr –Not available currently on formulary

27 CCB 1-3, 5 Calcium Channel Blocker Calcium Channel Blocker Amlodipine*, Felodipine, Isradipine, Extended-release Nifedipine Amlodipine*, Felodipine, Isradipine, Extended-release Nifedipine Mechanism of Action: inhibits calcium ions from entering the “slow channels” or select voltage-sensitive areas of vascular smooth muscle and myocardium during depolarization; produces a relaxation of coronary vascular smooth muscle and coronary vasodilation Mechanism of Action: inhibits calcium ions from entering the “slow channels” or select voltage-sensitive areas of vascular smooth muscle and myocardium during depolarization; produces a relaxation of coronary vascular smooth muscle and coronary vasodilation

28 http://calcium.ion.ucl.ac.uk/images/contraction- smc.gif CCB

29 CCB Patient’s Characteristics: Patient’s Characteristics: –Emergency hypertension (nifedipine) –Black race –Diabetes –Chronic obstructive lung disease –Broncho-pulmonary dysplasia –Gout –Hyperlipidemia –Peripheral Vascular Disease –Renal Transplant (cyclosporine-induced)

30 CCB Comments: Comments: –ADR: edema, arrhythmias, headache, fatigue, dizziness, flushing –No adjustment in renal impairment –May need adjustment in hepatic impairment –Good data for compounding Amlodipine oral suspension

31 Diuretics 1-3, 5 Amiloride, Chlorothiazide, Chlorthalidone, Triamterene, Furosemide, HCTZ*, Spironolactone, Metolazone, Bumetanide Amiloride, Chlorothiazide, Chlorthalidone, Triamterene, Furosemide, HCTZ*, Spironolactone, Metolazone, Bumetanide Mechanisms of Action: Mechanisms of Action: –Loop Diuretic: (Furosemide, Bumetanide) Inhibits reabsorption of Na and Cl in the ascending loop of Henle and distal tubule – causing increased excretion of water, K, Na, Cl, Mg, & Ca

32 Diuretics Mechanism of Action: continued Mechanism of Action: continued –Thiazide Diuretic: (HCTZ, Chlorothiazide) Inhibits Na reabsorption in the distal tubules causing increased excretion of Na and water as well as K, Mg, Ca, hydrogen, phosphate, & bicarb ions –K Sparing Diuretic: (Spironolactone) Competes with aldosterone for receptor sites in the distal renal tubules, increasing NaCl and water excretion while conserving K and hydrogen ions; may block the effect of aldosterone on arteriolar smooth muscle as well –Miscellaneous: (Metolazone) Inhibits sodium reabsorption in the cortical diluting site and proximal convoluted tubules

33 http://sprojects.mmi.mcgill.ca/nephrology/prese ntation/images/86no2.gif Diuretics

34 Diuretics Patient’s Characteristics: Patient’s Characteristics: –Volume dependent, low plasma renin activity –Black race –Congestive heart failure –Avoid in athletes

35 Diuretics Comments: Comments: –ADR: Dizziness, Photosensitivity, Rash, Vomiting –Monitor Electrolytes –Adjust in renal impairment –Furosemide and Chlorothiazide available in solutions –Good data to compound Spironolactone, Metolazone and HCTZ into oral suspensions

36 BB 1-3, 5 Βeta-Blocker Βeta-Blocker Atenolol, Bisoprolol/HCTZ, Metoprolol, Propranolol* Atenolol, Bisoprolol/HCTZ, Metoprolol, Propranolol* Mechanism of Action: Selective inhibitor of beta 1 -adrenergic receptors at lower doses; also inhibits beta 2 - receptors at higher doses Mechanism of Action: Selective inhibitor of beta 1 -adrenergic receptors at lower doses; also inhibits beta 2 - receptors at higher doses

37 http://www.eaa- knowledge.com/ojni/ni/602/strate1.jpg BB

38 BB Patient’s Characteristics: Patient’s Characteristics: –High plasma renin activity –Hyperdynamic circulation –Anxiety –Migraine –Hyperthyroidism –Neuroadrenergic tumors

39 BB Comments: Comments: –Good data to compound Metoprolol and Atenolol –Propranolol available as a solution –Worried about higher doses in asthma patients –Contraindicated in sick sinus syndrome –Avoid in athletes and people with diabetes

40 Goals of Therapy 2 Disease State Desired Percentile for Gender, Age, & Height Uncomplicated primary HTN with no target-organ damage <95 th Percentile Chronic renal disease, diabetes, hypertensive target-organ damage <90 th Percentile

41 Long-Term Management 3 Monitor therapy for efficacy and for potential adverse effects Monitor therapy for efficacy and for potential adverse effects Measure blood pressure every 2-4 weeks until good control Measure blood pressure every 2-4 weeks until good control Once controlled, monitor every 3-4 months Once controlled, monitor every 3-4 months

42 Step-Down Therapy 2 After blood pressure is stable, gradually reduce medication After blood pressure is stable, gradually reduce medication Goal: Discontinue medication Goal: Discontinue medication Best Candidates: Children with uncomplicated HTN due to obesity Best Candidates: Children with uncomplicated HTN due to obesity Continue to follow BP and continue lifestyle changes Continue to follow BP and continue lifestyle changes

43 Our Patient AMF – BP was in 95 th percentile AMF – BP was in 95 th percentile Repeated BP at 3 office visits (93 rd percentile) Repeated BP at 3 office visits (93 rd percentile) Recommend Lifestyle Changes Recommend Lifestyle Changes Repeat BP in 6 months (95 th percentile) Repeat BP in 6 months (95 th percentile) Patient work-up – unilateral renovascular hypertension Patient work-up – unilateral renovascular hypertension Start an ACE-I Start an ACE-I

44 Conclusions Use patient’s BP Percentile to determine if they have hypertension. Use patient’s BP Percentile to determine if they have hypertension. First-line agents to treat hypertension are ACE-I/ARB or CCB. First-line agents to treat hypertension are ACE-I/ARB or CCB. Diuretics are usually used as second line therapy. Diuretics are usually used as second line therapy.

45 References 1. Seikaly, Mouin G. Hypertension in children: an update on treatment strategies. Curr Opin Pediatr 2007; 19:170-177. 2. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004; 114:555- 576. 3. Flynn, JT. Pharmacologic Treatment of Hypertension in Children and Adolescents. J Pediatr 2006; 149:746-54. 4. McNiece, Karen and Portman R. Ambulatory blood pressure monitoring: what a pediatrician should know. Curr Opin Rediatr 19:178-182. 5. Pediatric Dosage Handbook, 14 th ed. Hudson, OH: Lexi-Com, 2005. 6. Luma, GB and Spiotta, RT. Hypertension in Children and Adolescents. AAFP 2006; 73: 1158-68.

46 Questions


Download ppt "Treatment of Hypertension in Pediatrics Kelsey R. Green, Pharm.D. Pediatric Clinical Pharmacist LSU-HSC in Shreveport, LA."

Similar presentations


Ads by Google