Hypertension Medications Selections based on Race and Co-Morbid Conditions

Daniel LeUNMC College of Pharmacy

Overview• Why important to control hypertension• Life Style modification• Medication Classes• Most patients response• Goals from JNC 7• JNC 8 general question prior to treatment &

methods of dosing• Treatment for different Races and co-morbidity • Resistant Hypertension

Important to control hypertension

• One of the major risk factors for cardiovascular disease

• 67 million adults in the US (31%), 1 in 3 Americans• Associated with developing other co-morbid disease• On average the U.S spend about $131 billion per

year• Untreated can lead to heart failure, heart attack,

damage arteries which can prevent blood from getting to the vital organs

Lifestyle modification

• JNC 8 really focuses on lifestyle changes

• Diet changes with limiting salt to 2.4g a day

• Limit Alcohol intake• Increase in vegetable,

fruits and whole grain• Also stresses on regular

physical activity

Life Style Modifications results• Aerobic Physical Activity at

least 30 minutes/day for most days of the week – 4-9 mm Hg

• Weight Reduction- 5-20 mm Hg per 10 kg weight loss

• DASH Diet( more potassium and less sodium) – 11-12 mm HG

• Moderation of Alcohol( 2 drinks/day in men, 1 drink/day in women) – 2-4 mm Hg

Medication Classes• ACE inhibitors ( Captopril, enalapril, lisinopril)• Angiotensin Receptor Blockers (Losartan, valsartan)• Beta-Blockers (Propranolol, metoprolol, nadolol)• Combined alpha & beta-blockers (labetalol, carvedilol)• Calcium channel blockers (diltiazem, verapamil & Nifedipine)• Thiazide diuretics (hydrochlorothiazide)• Potassium Sparing Diuretic (Spironolactone)

Rare Hypertension Medications

• Direct vasodilators (hydralazine, minoxidil, nitroprusside)

• Alpha-2 agonists (clonidine, methyldopa)• Alpha blockers (doxazosin, prazosin, terazosin)• Renin inhibitor (aliskiren)

Side Effects of Medications

• ACEI = dry cough, higher potassium levels• Thiazide= lower potassium levels• Alpha Blockers = dizziness• Beta Blockers = Bradycardia, dizziness • Aldosterone Antagonist = higher potassium

levels• Calcium channel blockers = constipation

Most Patients

• Most antihypertensive drugs will have the same cardiovascular protection for the same level of blood pressure control

• Most patients will require 2 medications to reach goals, and about 40% will need 3 medications

• Many patients will get hypokalemia• Many medications will deplete Potassium and

should be counter-balance with potassium sparing diuretic to increase the low level of potassium

Goals from JNC 7• JNC 7 guidelines can still be

useful in setting goals• <140/90 mmHg Primary

Prevention• <130/80 mmHg• - Diabetes • - Chronic Kidney Disease• - Coronary Artery Disease• - CAD Risk Equivalent• < 120/80 mmHg Left

Ventricular Dysfunction

JNC 8 have 3 general questions• At what BP should

treatment be initiated to improve outcomes?

• What should the target BP be for those undergoing treatment?

• What medications are best?• JNC 8 moved away from

Goals of JNC 7, and looked at recommendation based on the three questions

3 Distinct methods of dosing by JNC 8

1. Start with one medication at initial dose, titrate to max dose and if not effective add 2nd drug

2. Start with one medication, then add 2nd medication, titrate both to max dose

3. Initiate 2 medication from 2 different classes

Race and health conditions

• Diabetes• Pregnancy• African Americans• Chronic Kidney Disease• Elderly

Diabetes• Mortality is decreased when the

SBP is kept below 150 mm Hg• Also there will be improvement

on both cardiovascular and cerebrovascular outcomes

• ACEI/ARB are the first-line therapy as a single agent (renal protective)

• Always avoid ACEI and ARB combo

• If not a target another agent such as thiazide can be added

Pregnancy

Hemodynamic Changes in normal pregnancy = causes hypertension

• Changes in cardiac output and systemic vascular resistance (SVR)

• Hormones such as estrogen, progesterone and prolactin causes systemic vasodilation

• Decrease response to pressor hormones such as angiotensin II and vasopressin also causes vasodilation

• Also increase in cardiac output• All this leads to increase in BP

Pregnancy hypertensive meds• Methyldopa continues to be

the first-line drug• It has been shown to have

the no adverse effect on children

• Also hydralazine has been use

• Somnolence common side effect for methyldopa, and hydralazine multi-dose daily regimens which will often time lead to non-adherence

African American• Higher percentage of

hypertension compared to the general population

• Thiazides diuretics and CCB are consider first-line

• Avoid ACEI/ARB unless patient is a diabetic

• African Americans often have low-renin levels so are not affected by the ACEI/ARB

Chronic Kidney Disease• Define as GFR <60 mL/min• ACEI and ARB are the first-

line agents to prevention the progression to end-stage renal disease.

• 2nd- line would be CCB, non-dihydropyridines (diltiazem, verapamil) has been shown to reduce proteinuria

Elderly

Elderly Population physical changes and risks for Hypertension

• Body weight and % of body fat usually increases with age which will elevate blood pressure

• Sodium sensitivity increased in the elderly

• Arthritis develops with age which will limit exercise

• Dementia overtime can also cause a problem with medication compliance

Elderly Population Medication• Thiazides are first-line• Often advise to add

spironolactone to prevent hypokalemia

• ACEI would be a good alternative to thiazides

• Beta-Blockers should be use with caution because it can drop heart heart

• Short-acting CCB like Nifedipine has shown to increase mortality and should be avoided

Help Elderly Stay Organize !• Keep pill box • Family members can help

keep out• Pharmacist and doctors can

help patient with questions and signs of side effects

• Both over-taking and forgetting to take meds can be dangerous esp. to older patients

Monitor• Document blood pressure

readings• Talk to doctor about blood

pressure goals• Follow up with doctor

appointments to look at lab values especially for potassium

• Any serious side effects that started after initiation of drugs

Treatment-Resistant Hypertension• Elevated BP that cannot be

controlled with 3 drug regiment at max doses

• Ask patient about compliance, sometimes patients get confused and forget

• Any OTC & herbals that could have caused elevation?

• Patient might not be able to afford the drug cost?

Treatment-resistant hypertension

• IF no such issues are identified…..

• Refer to specialist• Further evaluation and

look at other possible disorders

• Such as CKD, renal artery stenosis, hyperaldosteronemia, and sleep apnea

Conclusion• It is important in the

selection of hypertensive meds that we are aware of what co-morbid as well as racial background of patients

• Understanding when a 2nd medication should be added

• What side effects are common in the medications

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of the role of multimorbidity in blood pressure control. BMC Family Practice • Flack J.M., Levy P.D., Nasser S.A. (2011). Therapy of Hypertension in African Americans . American Journal of Cardiovascular

Drugs, 11(2) 83-92• Scantelbury D.C., Schwartz G.L., Acquah L.A., White, W.M., Moser M., Garovic V.D.,(2013). The Treatment of Hypertension

During Pregnancy: When Should Blood Pressure Medications be Started? National Institutes of Health, 15 (11).• Stokes G.S. (2009). Management of hypertension in the elderly patient. Clinical Interventions in Aging, 4, 379-389