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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: Magee Rehab
Preceptor: Donna Peterson, PharmD
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):2560-2572.
JNC 7 – Compelling Indications
Hobanian AV, Bakris GL, Black HR, et al. JAMA. 2003;289(19):2560-2572.
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:10.1001/jama:284-427.
2014 Guidelines – JNC 8Based 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:10.1001/jama:284-427.
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:10.1001/jama:284-427.
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:10.1001/jama:284-427.
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:10.1001/jama:284-427.
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:10.1001/jama:284-427.
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:10.1001/jama:284-427.
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:10.1001/jama:284-427.
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:10.1001/jama:284-427.
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:10.1001/jama:284-427.
Goal BP not reached within 1 month of treatment Increase dose of initial drugOR 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:10.1001/jama:284-427.
Strategies to Dose Antihypertensive Drugs
Strategy Description
A Start one drug, titrate to maximum dose, and then add a second drug
B Start one drug and then add a second drug before achieving maximum dose of the initial drug
C Begin 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:10.1001/jama:284-427.
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 < 60 years old, initiate pharmacologic treatment to lower SBP > 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:10.1001/jama:284-427.
Hypertension Guidelines Table
Thomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine. 2014;81(3):178-188.
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):178-188.
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:10.1001/jama:284-427.Thomas G, Shishehbor MH, Brill D, et al. Cleveland Clinic Journal of Medicine. 2014;81(3):178-188.
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):178-188.
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?
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
Therapy OverviewPatient Population Initial 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 + Diabetes • Thiazide-type diuretic• CCB
Black patients with comorbid CKD With 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.
Antihypertensive Medications
Initial Daily Dose (mg)
Target Dose in RCTs
Reviewed (mg)
Number of
doses/day
Common and/or Major Adverse Effects
ACEI• Captopril• Enalapril• Lisinopril
505
10
150-2002040
21-21
Hyperkalmia, angioedema, acute kidney failure, SCr, dry cough
ARB• Losartan• Valsartan• Irbesartan
5040-80
75
5100160-320
300
1-211
Hyperkalmia, angioedema, acute kidney failure, SCr
CCB• Amlodipine• Diltiazem ER
2.5120-180
10360
11
• DihydropyridinesReflex tachy, peripheral edema, dizziness, HA, flushing, cardiac contractility• NondihydropyridinesBradycardia, heart block, cardiac contractility, constipation, gingival hyperplasia
Thiazide-type diuretics• Chlorthalidone• Hydrochlorothiazide• Indapamide
12.512.5-25
1.25
12.5-2525-100
1.25-2.5
11-21
Electrolyte abnormalities, hyperuricemia, hyperglycemia, hypercalcemia, hyperlipidemia
Beta-Blockers• Atenolol• Metoprolol
25-5050
100100-200
11-2
Bradycardia, heart block, rebound HTN, masking hypoglycemia, transient chol, bronchospasm
Wojtaszek D, Dang DK. Drug Topics. 2014;158(5):33-42.
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):178-188.
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):2560-2572.
2. James PA, Oparil S, Carter BL, et al. 2014 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:10.1001/jama:284-427.
3. Thomas G, Shishehbor MH, Brill D, et al. New hypertension guidelines: one size fits most? Cleveland Clinic Journal of Medicine. 2014;81(3):178-188.
4. Wojtaszek D, Dang DK. MTM essentials for hypertension management, Part 2: drug therapy considerations. Drug Topics. 2014;158(5):33-42.
References