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Review of the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults – JNC 8 Amanda Birnschein, PharmD candidate 2015 APPE 1:

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Presentation on theme: "Review of the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults – JNC 8 Amanda Birnschein, PharmD candidate 2015 APPE 1:"— Presentation transcript:

1 Review of the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults – JNC 8 Amanda Birnschein, PharmD candidate 2015 APPE 1: Magee Rehab Preceptor: Donna Peterson, PharmD

2 In the Past……JNC 7 Treatment Goals: <140/80 for all patients without compelling indications <130/80 for patients with diabetes and CKD Hobanian AV, Bakris GL, Black HR, et al. JAMA. 2003;289(19):

3 JNC 7 – Compelling Indications Hobanian AV, Bakris GL, Black HR, et al. JAMA. 2003;289(19):

4  Answered 3 main Questions about adults with hypertension: 1.Does initiating antihypertensive pharmacologic therapy at specific blood pressure thresholds improve health outcomes? 2.Does treatment with anithypertensive pharmacologic therapy to a specified blood pressure goal lead to improvements in health outcomes? 3.Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? 2014 Guidelines – JNC 8 James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

5 2014 Guidelines – JNC 8  Based on 9 recommendations:  Recommendations 1 – 5 address thresholds and goals for blood pressure treatment  Recommendations 6 – 8 address selection of antihypertensive drugs  Recommendation 9 is a summary of strategies based on expert opinion for starting and adding antihypertensive drugs James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

6 Recommendation 1 – Threshold and Goals  General population > 60 years old:  Initiate pharmacologic treatment of SBP > 150 mm Hg or DBP > 90 mm Hg  Reduces stroke, heart failure, and coronary heart disease (CHG)  Setting a goal <140 mm Hg provides no additional benefit  Though, if treatment was <140 mm Hg and not associated with adverse effects  no adjustments made (corollary recommendation)  High-risk groups (black persons, CVD including stroke, and multiple risk factors) insufficient evidence to raise the SBP target from <140 mm Hg to <150 mm Hg  More research needed to identify optimal goals of SBP James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

7  General population < 60 years old:  Initiate pharmacologic treatment for DBP > 90 mm Hg  For ages 30 – 59 years  Strong recommendation from 5 trials  Decreasing DBP to < 90 mm Hg reduces cerebrovascular events, heart failure, and overall mortality  For ages 18 – 29 years  Expert Opinion, no good- or fair-quality RCTs Recommendation 2 – Threshold and Goals James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

8  General population < 60 years old  Initiate pharmacologic treatment for SBP > 140 mm Hg  Absence of RCTs that compared the current SBP standard of 140 mm Hg with another higher or lower standard in age group – no compelling reason to change  Many trials for DBP also achieved a SBP lower than 140 mm Hg  Similar recommendation for CKD and diabetic patients Recommendation 3 – Threshold and Goals James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

9  Patients > 18 years old with CKD:  Initiate pharmacologic treatment for SBP > 140 or DPB > 90 mm Hg  CKD as defined by GFR < 60 mL/min/1.73 m2 in patients up to age 70 years old OR  Albuminuria as defined as > 30 mg/g of creatinine at any GFR at any age  Need to weigh the benefits vs risks for individuals > 70 years old and a GFR < 60 mL/min/1.73 m2  Consider factors such as frailty, comorbidities, and albuminuria Recommendation 4 – Threshold and Goals James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

10  Patients > 18 years old with diabetes  Initiate pharmacologic treatment for SBP > 140 mm Hg or DBP > 90 mm Hg  Moderate-quality evidence that treatment to an SBP < 150 mm Hg improves cardiovascular and cerebrovascular health outcomes and lowers mortality  < 140 based on expert opinion from ACCORD-BP trial  Goal not supported of SBP < 130 mm Hg or DBP < 80 mm Hg Recommendation 5 – Threshold and Goals James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

11  Nonblack population with diabetes – initial antihypertensive treatment should include 1 of the following:  Thiazide-type diuretic (hydrochlorothiazide, chlorthalidone, and indapamide)  Calcium channel blocker (CCB)  Angiotensin-converting enzyme inhibitor (ACEI)  Angiotensin receptor blocker (ARB)  Each of the 4 drug classes yielded comparable effects on overall mortality and cardiovascular, cerebrovascular, and kidney outcomes  One exception: heart failure  In order of efficacy (top to bottom):  Thiazide-type  ACEI  CCB  Patients needing more than 1 agent:  Any of the 4 classes would be good choices as add-on agents Recommendation 6 - Treatment James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

12  Black population with diabetes – initial antihypertensive treatment should include 1 of the following:  Thiazide-type diuretic  CCB  Thiazide-type diuretic more effective in improving cerebrovascular, heart failure, and combined cardiovascular outcomes compared to an ACEI  No difference in outcomes between CCB and diuretic  CCB over ACEI  51% higher rate of stroke in black patients with the use of an ACEI as initial therapy compared with a CCB  ACEI less effective in BP reduction  Consider using ACEI/ARB on an individual basis, especially for proteinuria Recommendation 7 - Treatment James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

13  Patients > 18 years old with CKD – initial or add-on antihypertensive treatment should include 1 of the following:  ACEI or ARB  Improve kidney outcomes  Applies to all CKD patients with hypertension, regardless of race or diabetes status  No evidence in patients > 75 years old  Can consider thiazide-type diuretic or CCB  Neither ACEIs nor ARBs improve cardiovascular outcomes compared with a CCB or Beta-blocker Recommendation 8 - Treatment James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

14  Goal BP not reached within 1 month of treatment  Increase dose of initial drug OR  Add a second drug from one of the 4 recommended classes (thiazide-type diuretic, CCB, ACEI, or ARB)  Do not use an ACEI and an ARB together in the same patient  Continue to assess BP and adjust the regimen until goal BP is reached  If not reached with 2 drugs, add and titrate a third drug  If goal BP cannot be reached using the recommended classes because of contraindications or the need to use more than 3 drugs to reach goal  Use antihypertensives in other classes Recommendation 9 - Summary James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

15 Strategies to Dose Antihypertensive Drugs StrategyDescription AStart one drug, titrate to maximum dose, and then add a second drug BStart one drug and then add a second drug before achieving maximum dose of the initial drug CBegin with 2 drugs at the same time, either as 2 separate pills as a single pill combination James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

16  Patients > 60 years old, initiate pharmacologic treatment to lower SBP > 150 mm Hg or DBP > 90 mm Hg  Treat to a goal < 150/90 mm Hg  Patients 140 mm Hg or DPB > 90 mm Hg  Treat to a goal < 140/90 mm Hg  Patients > 18 years old with diabetes or CKD initiate pharmacologic treatment to lower SBP > 140 or DBP > 90  Treat to a goal < 140/90 Recommendation Summary James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama:

17 Hypertension Guidelines Table Thomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine. 2014;81(3):

18 Lifestyle Modification  Diet  Dietary Approaches to Stop Hypertension (DASH) diet and reduction of sodium intake (< 2,400 mg/day)  Greater blood-pressure-lowering effect when the both are combined  Physical activity  Moderate to vigorous physical activity for 160 minutes/week  4 sessions/week, ~40 minutes in length  Weight loss  No review of blood-pressure-lowering effect of weight loss  Maintain a healthy weight in controlling blood pressure  Alcohol intake  No specific recommendation Thomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine. 2014;81(3):

19 Strengths Limitations Strengths and Limitations of JNC 8  Simplified algorithm of when to treat and treatment goals  Only RCT data was included  Utilized information with different age groups  Relaxed blood pressure goals in elderly patients  Based recommendations on clinically significant endpoints instead of surrogate markers for blood pressure  Treatment adherence and medication costs were thought to be beyond the scope of review  Only RCT data was included  The review was not designed to determine risk-benefit of therapy-associated adverse effects and harms  Blood pressure targets in some subgroups not clearly addressed  History of stroke James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi: /jama: Thomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine. 2014;81(3):

20  Focused on evidenced based recommendation  Higher target SBP for patients > 60 years old  Limited data support either SBP 150 mm Hg or 140 mm Hg  Removed special lower target BP for those with CKD or diabetes  Liberalized initial drug treatment choices  Thiazide-type diuretics no longer recommended as the only first line therapy  ACEI/ARBs do not have cardiovascular benefits What are the differences from JNC 7? Thomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine. 2014;81(3):

21 Using the Guidelines – Patient Case #1  AC is a 64 year old female with a PMH of HTN, DM, and hyperlipidemia  Medications: amlodipine 10 mg PO daily, atorvastatin 20 mg PO daily, lisinopril 10 mg PO daily (same medications for last 3 months)  BP on exam:  136/82  Repeat – 138/82  According to JNC 7, what would you do in terms of AC’s antihypertensive therapy?  According to JNC 8, what would you do in terms of AC’s antihypertensive therapy?

22  LZ is an 82 year old man with a PMH of GERD, HTN, and COPD  Current medications: hydrochlorothiazide 25 mg PO daily, pantoprazole 40 mg po daily, Advair 250/50 PO BID, Spiriva 18 mcg PO daily, and albuterol inhaler PO Q4H PRN SOB  BP on exam:  148/86  Repeat-148/84  According to JNC 7, what would you do in terms LZ’s antihypertensive therapy?  According to JNC 8, what would you do in terms of HN’s antihypertensive therapy? Using the Guidelines – Patient Case #2

23 Therapy Overview Patient PopulationInitial Drug Therapy General nonblack population, including comorbid conditions Thiazide-type diuretic ACEI/ARB CCB Hypertension with CKD, regardless of race or diabetes status ACEI ARB Black patients with HTN + DiabetesThiazide-type diuretic CCB Black patients with comorbid CKDWith proteinuria: ACEI or ARB Without proteinuria: Thiazide-type diuretic ACEI/ARB CCB ***Use ACEI or ARB as add-on agent if not already present as initial therapy*** Wojtaszek D, Dang DK. Drug Topics. 2014;158(5):33-42.

24 Antihypertensive Medications Initial Daily Dose (mg) Target Dose in RCTs Reviewed (mg) Number of doses/da y Common and/or Major Adverse Effects ACEI Captopril Enalapril Lisinopril Hyperkalmia, angioedema, acute kidney failure,  SCr, dry cough ARB Losartan Valsartan Irbesartan Hyperkalmia, angioedema, acute kidney failure,  SCr CCB Amlodipine Diltiazem ER Dihydropyridines Reflex tachy, peripheral edema, dizziness, HA, flushing,  cardiac contractility Nondihydropyridines Bradycardia, heart block,  cardiac contractility, constipation, gingival hyperplasia Thiazide-type diuretics Chlorthalidone Hydrochlorothiazide Indapamide Electrolyte abnormalities, hyperuricemia, hyperglycemia, hypercalcemia, hyperlipidemia Beta-Blockers Atenolol Metoprolol Bradycardia, heart block, rebound HTN, masking hypoglycemia, transient  chol, bronchospasm Wojtaszek D, Dang DK. Drug Topics. 2014;158(5):33-42.

25 In Conclusion  Guidelines are not rules  Only provide framework  Formulate antihypertensive plan on the basis of individual patient characteristics  Co-morbidities  Lifestyle factors  Medication side effects  Patient preferences  Cost issues  Adherence Thomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine. 2014;81(3):

26 1.Hobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19): James PA, Oparil S, Carter BL, et al Evidenced- 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). JAMA. 2013;doi: /jama: Thomas G, Shishehbor MH, Brill D, et al. New hypertension guidelines: one size fits most? Cleveland Clinic Journal of Medicine. 2014;81(3): Wojtaszek D, Dang DK. MTM essentials for hypertension management, Part 2: drug therapy considerations. Drug Topics. 2014;158(5): References


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