Presentation on theme: "Treatment of Hypertension in Pediatrics"— Presentation transcript:
1Treatment of Hypertension in Pediatrics Kelsey R. Green, Pharm.D.Pediatric Clinical PharmacistLSU-HSC in Shreveport, LA
2Objectives Define hypertension in children Identify when blood pressure should be takenPractice determining BP percentile and interpreting how to use this information to best treat the patientDiscuss treatment options used in pediatrics to treat hypertension
3Definitions2Hypertension: average SBP and/or DBP >95th percentile for gender, age, and height on > 3 occasionsPrehypertension: average SBP or DBP >90th percentile but <the 95th percentileAdolescents with BP levels >120/80 mm Hg should be considered prehypertensive
4Measurement of Blood Pressure2 Children >3 years old should have their BP measured when seen in a medical settingPreferred method: AuscultationRequires a cuff that is appropriate for the child’s armRight arm preferred-Elevated BP must be confirmed on repeated visits.-Ideally, the child should have avoided stimulant drugs or foods, have been sitting quietly for 5 minutes, and seated with his or her back supported, feet on the floor and right arm supported at heart level.
5Blood Pressure Cuff2Equipment needed to measure BP in children (3-adolescents):Child cuffs of different sizesStandard adult cuffLarge adult cuffThigh cuff
6Measurement of BP in children < 3 years old2 History of prematurity, VLBW, or other neonatal complicationsCongenital heart diseaseRecurrent UTI, hematuria, or proteinuriaKnown renal disease or urologic malformationsFamily history of congenital renal diseaseSolid-organ transplantMalignancy or bone marrow transplantTreatment with drugs known to raise BPSystemic illnesses associated with hypertensionEvidence of elevated ICP (intracranial pressure)
7Using the Blood Pressure Tables2 Use the standard height charts to determine the height percentile.Measure and record the child’s 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 50th, 90th, 95th, and 99th percentiles for SBP in the left columns and for DBP in the right columns.
8Let’s PracticeAMF is a 5 yo female weighing 25 kg in the 75th 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 do we do with this information?BP percentile – 95th
9What does this percentile mean?2 Normal<90thPrehypertension90-<95th or if >120-80Stage 1 hypertension95th-99th plus 5 mm HgStage 2 hypertension>99th plus 5 mm Hg> Than 95th percentile should be staged. If stage 1 (95-99th). BP should be repeated on 2 more occasions. If hypertension is confirmed – proceed with evaluation. If stage 2 (>99th) prompt referral – if symptomatic – immediate referral.
10Classification of Hypertension & Therapy Recommendations2 NormalEncourage healthy diet, sleep, & physical activityPrehypertensionPhysical activity & diet management; No medication unless compelling indications such as chronic kidney disease, DM, HF or LVH existStage 1 HypertensionPhysical activity & diet management; Initiate therapyStage 2 HypertensionPhysical activity & diet management; Initiate therapy (more than 1 drug may be required)-Prehypertension – start medication within months if indicated-Stage 1 hypertension – start medication within 1 month of diagnosis-Stage 2 hypertension – start medication within 1 week or immediately if symptomatic
16Indications for Antihypertensive Drug Therapy2 Symptomatic hypertensionSecondary hypertensionHypertensive target-organ damageDiabetes (types 1 and 2)Persistent hypertension despite nonpharmacologic measures
17Step-wise Approach to Therapy2 Start with a small dose of a single anti-hypertensive drugIncrease dose of single anti-hypertensive drug (to max dose if tolerated)Add a small dose of a second drugIncrease dose of second anti-hypertensive medication
19Drug Options for Initial Therapy1 Class of DrugsPatients’ CharacteristicsACE-Is/ARBsFirst-line therapyCCBsDiureticsAdjunct second-line drugβ–BlockerAvoid in athletes (controversial) and people with diabetes
20ACE-I1-3, 5Angiotensin Converting Enzyme InhibitorsBenazepril*, Captopril, Enalapril*, Fosinopril*, Lisinopril*, QuinaprilMechanism 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
22ACE-I Patient’s Characteristics: High plasma renin activity Renal insufficiency (unilateral renovascular hypertension, renal parenchymal disease, renal proteinuria)Congestive heart failureDiabetesHyperlipidemiaCI in pregnancy – females of childbearing age should use reliable contraceptionThe risk of angioedema is higher within the first 30 days of use, for African Americans, for lisinopril or enalapril (compared to captopril) and for patients previously hospitalized.
23ACE-I Comments: Contraindicated in pregnancy Monitor serum potassium and SCrCough and angioedemaMay require a dosing adjustment in renal impairmentFosinopril in children >50 kgGood data on compounding Captopril into a suspension
24ARB1-3, 5 Angiotensin Receptor Blockers Irbesartan*, Losartan* Mechanism of Action: angiotensin II receptor antagonist; blocks the vasoconstrictor and aldosterone-secreting effects of anigotensin IIARB – very similar to ACE-I; there main benefit is less side effects (such as cough and angioedema)
26ARB Patient’s Characteristics: same as ACE-I Comments: Less studied than ACE-IDosing not available in Neofax or Pediatric Dosing HandbookAll are contraindicated in pregnancyCheck serum potassium and SCrNot available currently on formulary
27CCB1-3, 5 Calcium Channel Blocker Amlodipine*, Felodipine, Isradipine, Extended-release NifedipineMechanism 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 vasodilationMOA: decrease intracellular calcium concentrations and results in dilation of peripheral arterioles
30CCBComments:ADR: edema, arrhythmias, headache, fatigue, dizziness, flushingNo adjustment in renal impairmentMay need adjustment in hepatic impairmentGood data for compounding Amlodipine oral suspension
31Diuretics1-3, 5 Mechanisms of Action: Amiloride, Chlorothiazide, Chlorthalidone, Triamterene, Furosemide, HCTZ*, Spironolactone, Metolazone, BumetanideMechanisms 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
32Diuretics 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 ionsK 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 wellMiscellaneous: (Metolazone) Inhibits sodium reabsorption in the cortical diluting site and proximal convoluted tubules
34Diuretics Patient’s Characteristics: Volume dependent, low plasma renin activityBlack raceCongestive heart failureAvoid in athletesWhy do you avoid in athletes?
35Diuretics Comments: ADR: Dizziness, Photosensitivity, Rash, Vomiting Monitor ElectrolytesAdjust in renal impairmentFurosemide and Chlorothiazide available in solutionsGood data to compound Spironolactone, Metolazone and HCTZ into oral suspensions
36BB 1-3, 5Βeta-BlockerAtenolol, Bisoprolol/HCTZ, Metoprolol, Propranolol*Mechanism of Action: Selective inhibitor of beta1-adrenergic receptors at lower doses; also inhibits beta2-receptors at higher doses
38BB Patient’s Characteristics: High plasma renin activity Hyperdynamic circulationAnxietyMigraineHyperthyroidismNeuroadrenergic tumors
39BB Comments: Good data to compound Metoprolol and Atenolol Propranolol available as a solutionWorried about higher doses in asthma patientsContraindicated in sick sinus syndromeAvoid in athletes and people with diabetes
40Goals of Therapy2 Disease State Desired Percentile for Gender, Age, & HeightUncomplicated primary HTN with no target-organ damage<95th PercentileChronic renal disease, diabetes, hypertensive target-organ damage<90th Percentile
41Long-Term Management3Monitor therapy for efficacy and for potential adverse effectsMeasure blood pressure every 2-4 weeks until good controlOnce controlled, monitor every 3-4 months
42Step-Down Therapy2After blood pressure is stable, gradually reduce medicationGoal: Discontinue medicationBest Candidates: Children with uncomplicated HTN due to obesityContinue to follow BP and continue lifestyle changes
43Our Patient AMF – BP was in 95th percentile Repeated BP at 3 office visits (93rd percentile)Recommend Lifestyle ChangesRepeat BP in 6 months (95th percentile)Patient work-up – unilateral renovascular hypertensionStart an ACE-I
44ConclusionsUse patient’s BP Percentile to determine if they have hypertension.First-line agents to treat hypertension are ACE-I/ARB or CCB.Diuretics are usually used as second line therapy.
45References1. Seikaly, Mouin G. Hypertension in children: an update on treatment strategies. Curr Opin Pediatr 2007; 19:2. 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; 114:3. Flynn, JT. Pharmacologic Treatment of Hypertension in Children and Adolescents. J Pediatr 2006; 149:4. McNiece, Karen and Portman R. Ambulatory blood pressure monitoring: what a pediatrician should know. Curr Opin Rediatr 19:5. Pediatric Dosage Handbook, 14th ed. Hudson, OH: Lexi-Com, 2005.6. Luma, GB and Spiotta, RT. Hypertension in Children and Adolescents. AAFP 2006; 73: