Presentation on theme: "Review of the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults – JNC 8 Eighth National Joint Committee Amanda Birnschein,"— Presentation transcript:
1Review of the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults – JNC 8Eighth National Joint CommitteeAmanda Birnschein, PharmD candidate 2015APPE 1: Magee RehabPreceptor: Donna Peterson, PharmD
2In the Past……JNC 7 Treatment Goals: 1st line agent – thiazide diureticOther agents can be added on as needed for blood pressure controlTreatment Goals:<140/80 for all patients without compelling indications<130/80 for patients with diabetes and CKDHobanian AV, Bakris GL, Black HR, et al. JAMA. 2003;289(19):
3JNC 7 – Compelling Indications Hobanian AV, Bakris GL, Black HR, et al. JAMA. 2003;289(19):
42014 Guidelines – JNC 8Answered 3 main Questions about adults with hypertension:Does initiating antihypertensive pharmacologic therapy at specific blood pressure thresholds improve health outcomes?Does treatment with anithypertensive pharmacologic therapy to a specified blood pressure goal lead to improvements in health outcomes?Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?The JNC 8 panel focused on when to begin treatment, how low to aim for, and which antihypertensive medications to use.James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
52014 Guidelines – JNC 8 Based on 9 recommendations: Recommendations 1 – 5 address thresholds and goals for blood pressure treatmentRecommendations 6 – 8 address selection of antihypertensive drugsRecommendation 9 is a summary of strategies based on expert opinion for starting and adding antihypertensive drugsThe panel made nine recommendations andone corollary recommendation based on areview of the evidence. Of the 10 total recommendations,five are based on expert opinion.Another two were rated as “moderate” instrength, one was “weak,” and only two wererated as “strong” (ie, based on high-qualityevidence).James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
6Recommendation 1 – Threshold and Goals General population > 60 years old:Initiate pharmacologic treatment of SBP > 150 mm Hg or DBP > 90 mm HgReduces stroke, heart failure, and coronary heart disease (CHG)Setting a goal <140 mm Hg provides no additional benefitThough, 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 HgMore research needed to identify optimal goals of SBPStrong recommendation (Grade A).Considered to have the greatest impact of all of the recommendations.The age cutoff of 60 years old for this recommendation is debatable. JATOS trial and VALISH trial both included patients > 60, with a mean age of 74 and 76.1 respectively. They found no difference in outcomes comparing a SBP of <140 orOther guidelines:American Society of Hypertension and the International Society of Hypertension recommend a SBP <150 in patients > 80 years old, not 60 years oldJames PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
7Recommendation 2 – Threshold and Goals General population < 60 years old:Initiate pharmacologic treatment for DBP > 90 mm HgFor ages 30 – 59 yearsStrong recommendation from 5 trialsDecreasing DBP to < 90 mm Hg reduces cerebrovascular events, heart failure, and overall mortalityFor ages 18 – 29 yearsExpert Opinion, no good- or fair-quality RCTsStrength of Recommendation strong (grade A) for ages & expert opinion (grade E) for ages 18-295 trials: HDFP, Hypertension-Stroke Cooperative, MRC, ANBP, and VA CooperativeThese all demonstrated improvements in health outcomes among adults aged years with elevated BPHOT trial:No benefit in treating patients to a goal of either 80 mm Hg or lower or 85 mm HG or lower compared with 90 mm Hg or lowerPatients randomized to these 3 goals wihtout statisitically significant differences between treatment goups in the primary or secondary outcomesReasonable to aim for the same diastolic goal in younger persons (under age 30), given the higher prevalence of diastolic hypertension in younger people.James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
8Recommendation 3 – Threshold and Goals General population < 60 years oldInitiate pharmacologic treatment for SBP > 140 mm HgAbsence 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 changeMany trials for DBP also achieved a SBP lower than 140 mm HgSimilar recommendation for CKD and diabetic patientsStrength of recommendation: Expert opinionKeep the same systolic goal for people younger than 60 as I the JNC 7 recommendations:Many study participants who achieved a diastolic pressure < 90 mm Hg, also achieved a systolic pressure < 140 mm Hg. Not possible to identify whether the outcome benefits were due to lower SBP or lower DBP or to both.Guidelines would just be simpler if the SBP were the same in the general population as in those with CKD and diabetes.James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
9Recommendation 4 – Threshold and Goals Patients > 18 years old with CKD:Initiate pharmacologic treatment for SBP > 140 orDPB > 90 mm HgCKD as defined by GFR < 60 mL/min/1.73 m2 in patients up to age 70 years oldORAlbuminuria as defined as > 30 mg/g of creatinine at any GFR at any ageNeed to weigh the benefits vs risks for individuals > 70 years old and a GFR < 60 mL/min/1.73 m2Consider factors such as frailty, comorbidities, and albuminuriaBased on the inclusion criteria used in the RCTs reviewed by the panel, this recommendation applies to individuals younger than 70 years with an estimated GFR or measured GFR less than 60 mL/min/1.73 m2 and in people of any age with albuminuria defined as greater than 30 mg of albumin/g of creatinine at any level of GFR.James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
10Recommendation 5 – Threshold and Goals Patients > 18 years old with diabetesInitiate pharmacologic treatment for SBP > 140 mm Hg or DBP > 90 mm HgModerate-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 trialGoal not supported of SBP < 130 mm Hg orDBP < 80 mm HgStrength of recommendation: Expert opinion (Grade E)Not based on RCTsThe ACCORD-BP trial: The control group had a goal SBP < 140 mm Hg and had similar outcomes compared with a lower goal.No evidence to support a lower blood pressure goal <130/80 as in JNC 7.Showed no differences in outcomes with a systolic goal <140 vs <120 EXCEPT for a small reduction in stroke. They stated that the risks of trying to achieve intensive lowering of blood pressure may outweight the benefit of a small reduction in stroke.James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
11Recommendation 6 - Treatment 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 outcomesOne exception: heart failureIn order of efficacy (top to bottom):Thiazide-typeACEICCBPatients needing more than 1 agent:Any of the 4 classes would be good choices as add-on agentsStrength of recommendation: moderate (grade B)The panel did not recommend β-blockers for the initial treatment of hypertension because no differences in outcomes:in one study use of β-blockers resulted in a higher rate of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke compared to use of an ARB, a finding that was driven largely by an increase in strokeThough in other studies, outcomes the same as the other 4 classesThe panel did not address preferential use of chlorthalidone as opposed to HCTZ, or the use of spironolactone in resistant hypertension α-Blockers were not recommended as first-line therapy because in one study initial treatment with an α-blocker resulted in worse cerebrovascular, heart failure, and combined cardiovascular outcomes than initial treatment with a diureticThere were no RCTs of good or fair qualitycomparing the following drug classes to the 4 recommended classes:dual α1- + β-blocking agents (eg, carvedilol), vasodilating β-blockers (eg, nebivolol), central α2 adrenergic agonists (eg, clonidine), direct vasodilators (eg, hydralazine), aldosterone receptor antagonists (eg, spironolactone), peripherally acting adrenergic antagonists (reserpine), and loop diuretics (eg, furosemide) Therefore, these drug classes are not recommended as first-line therapy. In addition, no eligible RCTs were identified that compared a diuretic vs an ARB, or an ACEI vs an ARB. ONTARGET was not eligible because hypertension was not required for inclusion in the study.this recommendation is specific for thiazide-type diuretics, which include thiazide diuretics, chlorthalidone, and indapamide; it does not include loop or potassium-sparing diuretics. Third, it is important that medications be dosed adequately to achieve results similar to those seen in the RCTs. Fourth, RCTs that were limited to specific nonhypertensive populations, such as those with coronary artery disease or heart failure, were not reviewed for this recommendation.JNC 8 did not consider randomized controlled trials in a specific nonhypertensive populations (CAD or HF) beta blockers should be individualized as to use of beta-blocker in these two conditionsJames PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
12Recommendation 7 - Treatment Black population with diabetes – initial antihypertensive treatment should include 1 of the following:Thiazide-type diureticCCBThiazide-type diuretic more effective in improving cerebrovascular, heart failure, and combined cardiovascular outcomes compared to an ACEINo difference in outcomes between CCB and diureticCCB over ACEI51% higher rate of stroke in black patients with the use of an ACEI as initial therapy compared with a CCBACEI less effective in BP reductionConsider using ACEI/ARB on an individual basis, especially for proteinuriaStrength of recommendation: moderate (grade B) for the general black population; weak (grade C) for blacks with diabetesALL—HAT trial: Thiazide-type diuretic (chlorthalidone) better than an ACEI (lisinopril) in terms of cerebrovascular, heart failure, and composite outcomes, but similar for mortality rates and cardiovascular, and kidney outcomes. CCB (amlodipine) better than ACEI for cerebrovascular outcomesThere were no outcome studies meeting our eligibility criteria that compareddiuretics or CCBs vs β-blockers, ARBs, or other renin-angiotensin system inhibitors in black patients.James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
13Recommendation 8 - Treatment Patients > 18 years old with CKD – initial or add-on antihypertensive treatment should include 1 of the following:ACEI or ARBImprove kidney outcomesApplies to all CKD patients with hypertension, regardless of race or diabetes statusNo evidence in patients > 75 years oldCan consider thiazide-type diuretic or CCBNeither ACEIs nor ARBs improve cardiovascular outcomes compared with a CCB or Beta-blockerStrength of recommendation: moderate (grade B)***regardless of race, diabetes, or proteinuria***This recommendation is based primarily on kidney outcomesbecause there is less evidence favoring ACEI or ARB for cardiovascularoutcomes in patients with CKD.The panel noted the potential conflictbetween thisrecommendation to use an ACEI or ARB in those with CKD and hypertension and the recommendation to use a diuretic or CCB (recommendation7) in black persons: what if the person is black and has CKD? To answer this, the panel reliedonexpert opinion. In black patients with CKD and proteinuria, an ACEI or ARB is recommended as initial therapy because of the higher likelihood of progression to ESRD. In black patients with CKD but without proteinuria, the choice for initial therapy is less clear and includes a thiazide-type diuretic, CCB, ACEI, or ARB. If an ACEI or ARB is not used as the initial drug, then an ACEI or ARB can be added as a second-line drug if necessary to achieve goal BP.James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
14Recommendation 9 - Summary Goal BP not reached within 1 month of treatmentIncrease dose of initial drugORAdd 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 patientContinue to assess BP and adjust the regimen until goal BP is reachedIf not reached with 2 drugs, add and titrate a third drugIf goal BP cannot be reached using the recommended classes because of contraindications or the need to use more than 3 drugs to reach goalUse antihypertensives in other classesStrength of recommendation: Expert opinion (grade E)Blood pressure should be monitored and assessed regularly, treatment adjusted as needed, and lifestyle modifications encouraged. The panel did not recommend any monitoring schedule before or after goal blood pressure is achieved, and this should be individualized.Target doses usually can be achieved within 2 – 4 weeks, and generally should not take longer than 2 months.James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
15Strategies to Dose Antihypertensive Drugs StrategyDescriptionAStart one drug, titrate to maximum dose, and then add a second drugBStart one drug and then add a second drug before achieving maximum dose of the initial drugCBegin with 2 drugs at the same time, either as 2 separate pills as a single pill combination3 strategies to dose antihypertensive drugs:These strategies were not compared with each other, nor is it known if one is better than the others in terms of health outcomes. In all cases, avoid combining an ACE inhibitor and an ARB.Some committee members recommend starting therapy with ≥2 drugs when SBP is >160 mm Hg and/or DBP is >100 mm Hg, or if SBP is >20 mm Hg above goal and/or DBP is >10 mm Hg above goal. If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose.James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
16Recommendation Summary Patients > 60 years old, initiate pharmacologic treatment to lower SBP > 150 mm Hg or DBP > 90 mm HgTreat to a goal < 150/90 mm HgPatients < 60 years old, initiate pharmacologic treatment to lower SBP > 140 mm Hg or DPB > 90 mm HgTreat to a goal < 140/90 mm HgPatients > 18 years old with diabetes or CKD initiate pharmacologic treatment to lower SBP > 140 or DBP > 90Treat to a goal < 140/90James PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:
17Hypertension Guidelines Table Thomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine ;81(3):
18Lifestyle Modification DietDietary Approaches to Stop Hypertension (DASH) diet and reduction of sodium intake (< 2,400 mg/day)Greater blood-pressure-lowering effect when the both are combinedPhysical activityModerate to vigorous physical activity for 160 minutes/week4 sessions/week, ~40 minutes in lengthWeight lossNo review of blood-pressure-lowering effect of weight lossMaintain a healthy weight in controlling blood pressureAlcohol intakeNo specific recommendationSodium:noting that limiting intake to 1,500 mg can result in even greater reduction in blood pressure, and that even without achieving these goals, reducing sodium intake by at least 1,000 mg per day lowers blood pressure.Thomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine ;81(3):
19Strengths and Limitations of JNC 8 Simplified algorithm of when to treat and treatment goalsOnly RCT data was includedUtilized information with different age groupsRelaxed blood pressure goals in elderly patientsBased recommendations on clinically significant endpoints instead of surrogate markers for blood pressureTreatment adherence and medication costs were thought to be beyond the scope of reviewOnly RCT data was includedThe review was not designed to determine risk-benefit of therapy-associated adverse effects and harmsBlood pressure targets in some subgroups not clearly addressedHistory of strokeSimplifedThe studies had to be randomized controlled trials. NO observational studies, systematic reviews, or meta-analyses were allowed in the JNC 8 guidelines. Though, these were allowed in JNC 7.Clinical significant endpoint: cerebrovascular events compared to surrogate marker of just blood pressureJames PA, Oparil S, Carter BL, et al. JAMA ;doi: /jama:Thomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine ;81(3):
20What are the differences from JNC 7? Focused on evidenced based recommendationHigher target SBP for patients > 60 years oldLimited data support either SBP 150 mm Hg or 140 mm HgRemoved special lower target BP for those with CKD or diabetesLiberalized initial drug treatment choicesThiazide-type diuretics no longer recommended as the only first line therapyACEI/ARBs do not have cardiovascular benefitsThomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine ;81(3):
21Using the Guidelines – Patient Case #1 AC is a 64 year old female with a PMH of HTN, DM, and hyperlipidemiaMedications: amlodipine 10 mg PO daily, atorvastatin 20 mg PO daily, lisinopril 10 mg PO daily (same medications for last 3 months)BP on exam:136/82Repeat – 138/82According 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?
22Using the Guidelines – Patient Case #2 LZ is an 82 year old man with a PMH of GERD, HTN, and COPDCurrent 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 SOBBP on exam:148/86Repeat-148/84According 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?
23Therapy Overview Patient Population Initial Drug Therapy General nonblack population, including comorbid conditionsThiazide-type diureticACEI/ARBCCBHypertension with CKD, regardless of race or diabetes statusACEIARBBlack patients with HTN + DiabetesBlack patients with comorbid CKDWith proteinuria:ACEI or ARBWithout proteinuria:***Use ACEI or ARB as add-on agent if not already present as initial therapy***Wojtaszek D, Dang DK. Drug Topics ;158(5):33-42.
25In Conclusion Guidelines are not rules Only provide frameworkFormulate antihypertensive plan on the basis of individual patient characteristicsCo-morbiditiesLifestyle factorsMedication side effectsPatient preferencesCost issuesAdherenceThomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine ;81(3):
26ReferencesHobanian 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 ;doi: /jama:Thomas G, Shishehbor MH, Brill D, et al. New hypertension guidelines: one size fits most? Cleveland Clinic Journal of Medicine ;81(3):Wojtaszek D, Dang DK. MTM essentials for hypertension management, Part 2: drug therapy considerations. Drug Topics ;158(5):33-42.