European Strategies for Blood Pressure Control

Prepared for RCI by

Helen Ann Halpin, PhD

October 1, 2010

Professor, SPH, UC BerkeleyDeputy Editor, Public Health Reviews, Sorbonne, Paris

Introduction

Evidence-based hypertension treatment guidelines

• E.U. every 2 years; 7 year gap in U.S.

1. Compare E.U. to U.S.

2. Compare A.L.L. to E.U.

3. Role of community pharmacists in E.U.

Major Hypertension Drugs

Major Hypertensions Drugs

Most Prescribed: generic (Brand)

Thiazide-diuretics (TD) hydrochlorothiazide (Tagamet)

Beta Blockers (BB) propanolol (Inderal), atenolol (Tenormin),

metoprolol (Lopressor, Toprol-XL, Inderal)

Ace Inhibitors (ACEI) captopril (Capoten), lisinopril (Prinivel, Zestril), enalapril (Vasotec), benzapril(Lotesnin)

Calcium Channel Blockers (CCB)

nifedipine (Procardia), diltiazem (Cardizem), verapamil (Calan, Isoptin)

Angiotension receptor blockers (ARB)

losartan (Cozaar), losartan HCTZ (Hyzaar

Hypertension Guidelines: U.S. vs E.U.

Recommendations US DHHS EU

Last Update 2004 2009 (2007)

Next Update 2011 (Fall ) 2011

Treatment by Stage Yes No

Initial Treatment Thiazide-diuretic (T-D) Two-combination drugs

Drug Combinations Silent T-D with ACEI, ARB or CCB

OR

ACEI with CCB

Or ARB with CCB

If 3rd: add T-D, ARB or CCB

Hypertension Guidelines: U.S. vs E.U.Recommendations US DHHS EU

Treatments to Avoid

None specified Beta Blockers (BB)

BB/T-D combinations

ACEI/ARB combinations

Fix-dose/single pill Recommended Recommended

Low does aspirin As an adjunct only after BP is controlled

Only for patients with a previous cardiovascular

event

Polypill Silent Not supported

Lifestyle risks Weight, sodium, activity, alcohol,

smoking, fat, blood glucose

Weight, sodium, activity, alcohol,

smoking, fat, blood glucose

BP RCTs Published Since 2004 (40)

2005 2006 2007 2008 2009ACTION

ALLHAT

ASCOT

BBLTTC

EDIC

FEVER

IDNT

LIFE

MOSES

PROGRESS

SCOPE

SHEP

VALUE

CAFÉ

DREAM

ELSA

FEVER

HYVET

INVEST

MOSES

PHARAO

STAR

Steno 2

TROPHY

UKPDS

VALUE

ACCORD

ACTION

ADVANCE

CAPRAF

COMET

INVEST

JIKEY HEART

LIFE

PROGRESS

SENIORS

ACCOMPLISH

ACCORD

ADVANCE

DIRECT

HYVET

I-PRESERVE

JUPITER

LIFE

ONTARGET

PROFESS

TRANSCEND

ADVANCE

CHHIPS

ELSA

FEVER

GISSI-AF

ONTARGET

PAMELA

UADT

VALUE

A.L.L. Protocol* vs E.U. Guidelines**Kaiser A.L.L. Protocol

E.U. Blood Pressure Guidelines

aspirin Recommended only following first cardiovascular event. (Serious side effects include serious bleeding from the stomach/intestine and increased risk of hemorrhagic stroke)

lisinopril

(ace inhibitor)

Recommended in combination with Thiazide-Diuretic or CCB only

Lovastatin

(statin)

Not recommended unless lipids are elevated. (Serious side effects include rhabdomylysis and kidney failure, peripheral neuopathy, memory loss, and delirium)

3 pills/day 1 pill/day

Fixed doses for all Medicate based on individual risk

*for diabetic patients at risk of cvd mortality** for treatment of high blood pressure

Community Pharmacists in E.U.• Use of pharmacists as part of primary care team

– Primary prevention– Detection– Management

• Advantages– Access– Evidence of increased compliance and improved BP control

• Challenges– Education and training (beyond Rx filling)– Legal duty to perform (Denmark, Spain, Belgium, France)– Contractual relationship with and payment by insurers (FFS;

little evaluation)– Cooperation between physicians and pharmacists– Lack of time

Recent Policy Innovation

• France has established a national pharmaceutical electronic record– All community pharmacists must

participate– Goal: to prevent adverse drug reactions

and redundant treatments