Transcript Therapeutic Considerations for Hypertension

Therapeutic Considerations
for Hypertension
presented by Jerad Bailey, Pharm D
Clinician Resource
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Today’s Guest Speaker
Jerad Bailey, Pharm D
Lead Pharmacist,
Cabin Creek Health Systems
BA, Marshall University
Pharm D, West Virginia University
Therapeutic
Considerations for
Hypertension
PRESENTATION BY JERAD BAILEY, PHARM.D.
Presentation Goals
Review of blood pressure and the condition
“hypertension”
Hypertension treatment protocols
Therapeutic classes used for the treatment
of hypertension
Therapeutic effects, side effects, and
considerations to be made in the outpatient
setting
Blood Pressure
“Blood pressure (BP) is the force of blood
against arterial walls as it circulates through
the body.” –Center for Disease Control
Systolic BP: Left ventricle is most contracted
(high pressure)
Diastolic BP: Left ventricle is most relaxed
(low pressure)
The Cardiac Cycle
Blood Pressure
Cardiac Output
◦ Heart Rate
◦ Stroke Volume
Blood Viscosity
Total Peripheral Resistance (TPR)
Blood Pressure
Heart Rate: The faster the
heart beats, the more
blood that flows through
the circulatory system
If each pump moves the
same amount of fluid, then
faster pumping means
greater fluid movement
Blood Pressure
Stroke Volume: A larger stroke volume allows
for more blood to circulate with each
heartbeat
A full bucket is more
effective than a halfempty bucket
Blood Pressure
Blood Viscosity: Blood
that is more viscous
(thick) becomes more
difficult to circulate
A thinner fluid requires
less effort to move and
flows more freely
Blood Pressure
Total Peripheral Resistance (TPR): An amount of
fluid (blood) flowing through a smaller area is under
more pressure than flowing through a larger area
Resistance means
more work and
more pressure
“Normal” Blood Pressure
Thresholds defined by the American Heart Assoc
Blood Pressure
Category
Systolic
mm Hg (upper#)
Diastolic
mm Hg (lower#)
Normal
Less than 120
and
Less than 80
Prehypertension
120-139
or
80-89
High Blood Pressure
(Hypertension) Stage 1
140-159
or
90-99
High Blood Pressure
(Hypertension) Stage 2
160 or higher
or
100 or higher
Hypertension Crisis
(Emergency care needed)
Higher than 180
or
Higher than 110
*Your doctor should evaluate unusually low blood pressure readings.
Complications of Hypertension
Heart and blood vessels must work harder to
overcome pressure
Decreased blood perfusion to heart (angina,
heart failure, MI)
Blockages or burst arteries leading to the
brain (stroke)
Renal Artery Stenosis (kidney failure)
Eighth Joint National Committee
More commonly referred to as “JNC 8”
Best practices for treatment of hypertension
Revised / Revisited 2014
Combination of lifestyle modifications and
pharmacotherapeutic interventions
Lifestyle Modifications
Dietary considerations
(low salt)
◦ Less fluid retention
Physical activity
◦ Stronger heart and
healthier arteries
Weight loss
◦ Less work for the heart
Smoking cessation
◦ Nicotine acts as a
stimulant and can harden
arterial walls
Stress management
Limit use of alcohol
◦ Alcohol weakens cardiac
muscle and can cause
arrhythmias
Starting Pharmacologic Therapy
JNC 8 Guidelines
Varying goals depending on age and
comorbidities
Over 60: < 150/90
Under 60: < 140/90
Over 18 and with CKD: < 140/90
Over 18 and with Diabetes: < 140/90
PLEASE NOTE: Guidelines and recommendations are to be used along with physician/clinician
judgment and treatment and based on individual patient’s unique needs and circumstances.
Therapeutic Options
Over a dozen medication classes are
indicated to treat hypertension
Each class may have more than one
medication
Combination products are available
Where do we begin?
First-Line Therapies
JNC 8 “Starting Lineup”
◦ Thiazide diuretics
◦ Calcium Channel Blockers (CCB)
◦ Angiotensin-Converting Enzyme (ACE) Inhibitors
◦ Angiotensin Receptor Blockers (ARB)
Thiazide Diuretics
Hydrochlorothiazide (HCTZ)
◦ Esidrix, Microzide
Chlorthalidone
◦ Thalitone
Metolazone
◦ Zaroxolyn
Indapamide
◦ Lozol
Thiazide Diuretics
Inhibit sodium and chloride reabsorption in
the kidney
Creates a diuretic effect
Less water in the blood, less work for the
heart
Thiazide Diuretics
Frequent urination
Electrolyte imbalance
◦ Hypokalemia,
Hypomagnesemia,
Hypercalcemia
Hyperuricemia
◦ Gout
Exacerbation of
comorbidities
◦ Hyperglycemia,
Hyperlipidemia
Skin conditions
◦ Photosensitivity, Rash
Renal Failure
Thiazide Diuretics
Rehydrate
Increased sun sensitivity
Baseline / periodic labs
Calcium Channel Blockers
Dihydropyridines
Nondihydropyridines
Amlodipine
Diltiazem
◦ Norvasc
Felodipine
◦ Plendil
Isradipine
◦ DynaCirc
Nicardipine
◦ Cardene
Nifedipine
◦ Procardia XL
Nisoldipine
◦ Sular
◦ Cardizem, Dilacor, Tiazac
Verapamil
◦ Isoptin, Calan, Verelan, Covera
Calcium Channel Blockers
Calcium Channel Blockers inhibit movement
of calcium ions in muscle tissue, aiding in
muscle relaxation
Dihydropyridines mainly target muscles in
arteries, reducing TPR
Nondihydropyridines mainly target cardiac
muscle, reducing heart rate and contractility
Calcium Channel Blockers
Fatigue
Edema
Dizziness
Headache
Skin conditions
◦ Rash
Conductivity issues
◦ AV Block
Calcium Channel Blockers
Drug-Drug Interactions
◦ CYP 3A4 Substrates
Electrocardiogram
ACE Inhibitors
Benazepril
◦ Lotensin
Captopril
◦ Capoten
Enalapril
◦ Vasotec
Fosinopril
◦ Monopril
Lisinopril
◦ Prinivil, Zestril
Moexipril
◦ Univasc
Quinapril
◦ Accupril
Ramipril
◦ Altace
Trandolapril
◦ Mavik
ACE Inhibitors
Angiotensin Converting Enzyme is
responsible for converting Angiotensin I to
Angiotensin II
Angiotensin II is an extremely potent
vasodilator
ACE Inhibitors prevent this conversion,
reducing TPR
ACE Inhibitors
Dry Cough
Dizziness
Electrolyte imbalance
◦ Hyperkalemia
Skin conditions
◦ Rash
Renal Artery Stenosis
Angioedema (more common in African-Americans)
ACE Inhibitors
Pregnancy Category
Therapeutic Dosing
◦ Renal Artery Stenosis
Therapeutic Duplication (ARB)
Angiotensin Receptor Blockers
Candesartan
Telmisartan
◦ Atacand
◦ Micardis
Losartan
Eprosartan
◦ Cozaar
Irbesartan
◦ Avapro
Valsartan (first available
January 2015)
◦ Diovan
◦ Teveten
Olmesartan (not available)
◦ Benicar
Angiotensin Receptor Blockers
Blocks the effects of the enzyme Angiotensin
II by preventing binding to its receptor
Similar end result as patient taking ACE
Inhibitor (reduction of TPR), but reduced
instances of coughing
Angiotensin Receptor Blockers
Dry Cough (less often
than ACE Inhibitors)
Dizziness
Electrolyte imbalance
◦ Hyperkalemia
Skin conditions
◦ Rash
Renal Impairment
Upper Respiratory
Infections
Angioedema (more
common in AfricanAmericans)
Angiotensin Receptor Blockers
Pregnancy Category
Therapeutic Duplication (ACE Inhibitors)
Newest of the four classes of medications
◦ Most expensive of the four front-line therapies
Selecting a First-Line Therapy
For the general population, any of these agents
are viable
If severe hypertension, may start with two
therapies
African-American
◦ Preference for CCB or Thiazide diuretic, due to
increased risk of angioedema with ACE or ARB
Chronic Kidney Disease
◦ Preference for ACE or ARB, due to renal protective
properties
Escalation of Therapy
Option 1: Max-out current therapy before adding
additional agents
Option 2: Add additional agent before maxing-out current
therapy
If a third therapy is necessary, use the remaining frontline
option unless there is a compelling contraindication
Once patient has a thiazide diuretic, a CCB, and either an
ACE/ARB, resort to secondary therapies to help patient
reach goal
Backup Therapies
Beta-Blockers
Loop Diuretics
Potassium Sparing Diuretics
Alpha-Adrenergic Blockers
Vasodilators/Nitrates
Alpha Agonists
Renin Inhibitor(s)
Beta-Blockers
Examples include atenolol
(Tenormin), carvedilol
(Coreg), labetalol
(Normodyne), metoprolol
(Lopressor, Toprol XL),
nadolol (Corgard), and
propranolol (Inderal)
Blocks central and peripheral
beta receptors, which causes
decreased heart rate and
TPR
Side Effects
◦
◦
◦
◦
◦
Fatigue
Decreased exercise tolerance
GI upset
Hypertriglyceridemia
Can mask hypoglycemia
Considerations
◦ Exercise intolerance a major issue
initially
◦ Pregnancy Category (in 1st
Trimester)
◦ Asthma medications (BetaAgonists)
Loop Diuretics
Includes furosemide (Lasix),
bumetanide (Bumex),
torsemide (Demadex)
Inhibits reabsorption of
sodium and chloride
throughout renal system,
creating a diuretic effect;
less water in the blood, less
work for the heart
Side Effects
◦ Dehydration
◦ Electrolyte imbalance
◦ Hypokalemia
◦ Hyponatremia
◦ Hypomagnesemia
◦ Hyperglycemia
Considerations
◦ Fluid overload or renal failure
◦ Interaction with diabetes
medications
Potassium Sparing Diuretics
Includes spironolactone
(Aldactone), eplerenone
(Inspira), triamterene
(Dyrenium), amiloride
(Midamor)
Side Effects
◦ Dehydration
◦ Cramps
◦ Electrolyte imbalance
◦ Hyperkalemia
◦ GI disturbance
◦ Skin conditions
◦ Rash
◦ Gynecomastia
◦ Sexual dysfunction
Decreases sodium reabsorption
in the kidney, decreasing water Considerations
◦ Avoid in patients with diabetes,
reabsorption and increasing
cholesterol, gout
potassium retention; less water ◦ Caution when combining with
ACE/ARB
in the blood, less work for the
heart
Alpha-Adrenergic Blockers
Includes doxazosin
(Cardura), prazosin
(Minipress), terazosin
(Hytrin)
Side Effects
◦ Edema
◦ Palpitations
◦ Postural / orthostatic hypotension
◦ Syncope
Considerations
Blocks alpha-adrenergic
receptors, preventing
vasoconstriction in arterioles
and veins, decreasing TPR
◦ Combine with a diuretic due to
edema
◦ May be beneficial to men with BPH
◦ Consider giving at bedtime
◦ Avoid in cardiovascular disease
◦ Drug-drug interactions with PDE5
inhibitors
◦ Viagra, Cialis, Levitra
Vasodilators / Nitrates
Includes hydralazine
(Apresoline) and
minoxidil (Loniten)
Side Effects
◦ Fluid retention
◦ Tachycardia
◦ Skin Conditions
◦ Dermatitis
Causes smooth muscle
relaxation in arterioles,
decreasing TPR
◦ Peripheral neuropathy
◦ Minoxidil: Hirsutism
Considerations
◦ Reserved for treatmentresistant patients
◦ Pair with agents that offset fluid
retention and tachycardia
Alpha Agonists
Includes clonidine
(Catapres), guanfacine
(Tenex), methyldopa
(Aldomet), guanabenz
(Wytensin)
Side Effects
◦ Bradycardia
◦ Dry mouth
◦ Sedation
◦ Rebound hypertension
◦ Heart block
Reduces nerve activity in
Considerations
sympathetic nervous
system, decreasing heart ◦ Last-line therapy
◦ Side effect profile
rate and TPR
◦ Adherence
Renin Inhibitor(s)
Only drug in class is
Tekturna (aliskiren)
Side Effects
◦ Electrolyte imbalance
◦ Hyperkalemia
◦ Skin conditions
◦ Rash
Decreases renin activity,
interfering with
conversion of
Angiotensinogen to
Angiotensin I, reducing
TPR
◦ Diarrhea
◦ Renal Failure
Considerations
◦ Pregnancy category
◦ Avoid in diabetes
◦ Therapeutic duplication (ACE/ARB)
References
Agency for Healthcare Research and Quality
American Heart Association
Center for Disease Control
Epocrates
Joint National Committee, Eighth (JNC 8)
National Institute on Alcohol Abuse and Alcoholism
Pearson PLC
Pharmacy Times
HHQI Blood Pressure Resources
 Cardiovascular Health Part 1: Aspirin as
appropriate and Blood pressure control BPIP
 Fundamental Focus: Blood Pressure Control &
Smoking Cessation
 Patient Videos
– Cardiovascular Blood Pressure Control
• Blood Pressure Medication Management
• How to Check My Own Blood Pressure
Thank You!
If you have any questions,
please contact us at [email protected].
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health
Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-061915