MTM Essentials for Hypertension Management, Part 2: Drug Therapy Considerations

By Wojtaszek, Danielle; Dang, Devra K. | Drug Topics, May 2014 | Go to article overview

MTM Essentials for Hypertension Management, Part 2: Drug Therapy Considerations


Wojtaszek, Danielle, Dang, Devra K., Drug Topics


Abstract

Antihypertensive drug therapy to control blood pressure can decrease rates of morbidity and mortality associated with hypertension. These drugs are associated with various adverse effects and drug-drug interactions that must be taken into consideration when choosing an appropriate agent to treat patients with hypertension. The "2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults" from the JNC 8 provides guidance on place in therapy of the various antihypertensive drug classes and is reviewed in this article. Pharmacists must also be aware of the use of herbal supplements that can affect blood pressure and potentially interact with prescribed antihypertensives.

Hypertension is a major risk factor for adverse cardiovascular, cerebrovascular, and renal outcomes and is strongly correlated with cardiovascular morbidity and mortality. Studies have shown that therapy to control blood pressure reduces the increased rates of cardiovascular events and that antihypertensive drug therapy can decrease rates of death associated with hypertension.1 The various antihypertensive drug classes have specific places in therapy based on patient-specific factors, such as race and comorbid conditions, due to evidence that supports benefit of use in those populations. Despite the benefits of antihypertensive medications, these agents are not without risk of adverse effects and drug-drug interactions that may affect choice of therapy. Additionally, the use of herbal products must be taken into consideration due to potential effects on blood pressure and concomitant prescribed medications. Pharmacists can play an important role in identifying and resolving medication-related problems in the treatment of patients with hypertension.

Place in therapy of antihypertensive medications in adults

In December 2013 an updated guideline for the management of hypertension in adults was published by the Eighth Joint National Committee appointed by the National Heart, Lung, and Blood Institute. This guideline is titled the "2014 EvidenceBased Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee'' and is commonly referred to as the JNC-8 guideline.2 Unlike the previous version, the JNC7 7 published in 2003, the JNC 8 does not provide a comprehensive review of hypertension management.1'2 Instead, the JNC-8 guideline provides updated recommendations on blood pressure goals and pharmacologic treatment recommendations based on the expert panel's systematic review of randomized, controlled trials with 100 or more study participants and follow-up periods of 1 year or longer only.2 The expert panel also had other stringent study selection criteria in their systematic review of the literature of studies published between January 1, 1966 and August 2013. Additionally, the expert panel assessed the quality of the studies (eg, low, fair, or good quality). Thus, the JNC-8 guideline was developed in a manner more closely matching the Institute of Medicine's report on quality standards for practice guidelines called Clinical Guidelines We Can Trust.3

The JNC-8 guideline provides recommendations on the systolic and diastolic blood pressures at which to initiate drug therapy, as well as the goal pressures to achieve in various patient populations. A full discussion of the recommended blood pressure goals and their rationale was provided in the April 2014 article of this Drug Topics-UConn Cardiovascular Disease (CVD) Medication Therapy Management (MTM) series.4 Briefly, according to JNC 8, in the nonpregnant adult general population with hypertension who are younger than age 60 years and in patients age 18 years or older with chronic kidney disease (CKD) or diabetes mellitus, antihypertensive drug therapy should be started when the systolic blood pressure is 140 mm Hg or higher and when the diastolic blood pressure is 90 mm Hg or higher. …

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