Jenifer Smith, Pharm.D.
Clinical pharmacy specialist, Providence Health Plan
In the last issue of Provider eNews, we focused on how new hypertension guidelines issued by the Eighth Joint National Committee affect diabetes management. This article looks at the guidelines' broader applications.
The committee based its revised guidelines on studies that examined important health outcomes – such as mortality, cardiovascular events, coronary revascularization, renal outcomes and hospitalizations – in various populations. It outlined several major recommendations:
Blood pressure goals
- General, non-elderly population: <140/90 mm Hg.
- General, elderly population (60 or older): <150/90 mm Hg. This differs from the recent American Society of Hypertension/International Society of Hypertension guidelines, which recommend this goal for those 80 or older.
- Patients with diabetes and chronic kidney disease: <140/90 mm Hg. This also is a change from previous guidelines and was based on lack of evidence supporting lower goals.
- First-line options in the general, non-black population (with or without diabetes): Thiazide-type diuretics, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs).
- The authors note that therapy should be individualized based on patient characteristics. For example, heart failure patients may benefit more from a thiazide-type diuretic or an ACEI.
- American Society of Hypertension and International Society of Hypertension guidelines recommend ACEIs or ARBs for patients younger than 60 and thiazide-like or CCB for those 60 or older.
- General, black population (with or without diabetes): Initial treatment should be with a thiazide-type diuretic or a CCB.
- Patients with chronic kidney disease and hypertension (with or without diabetes): Initial or add-on therapy should be with an ACEI or ARB to improve renal outcomes.
The American Diabetes Association continues to recommend ACEIs or ARBs as first-line therapy for patients with diabetes and hypertension.
Monitoring and adjusting therapy
- Assess patients at least monthly during initiation of therapy.
- If blood pressure goals are not met, increase the dose or add a second medication from one of the recommended classes (ACEI, ARB, CCB or thiazide-type). Combining ACEIs and ARBs is not recommended.
- If blood pressure goals are not met after the addition of three medications, other classes of medications can be added. These can include beta-blockers, loop diuretics and aldosterone antagonists. Consider a referral to a hypertension specialist.
- James PA, Oparil S, Carter BL et al. 2014 evidence-based guideline for the management of high blood pressure in adults, JAMA. 2014;311(5):507-20
- Weber MA, Schiffrin EL, White WB et al. Clinical practice guidelines for the management of hypertension in the community, J Clin Hypertens. 2014;16(1):14-26
- American Diabetes Association. Standards of Medical Care in Diabetes – 2014, Diabetes Care. 2014;37 (Supp 1):S14-S80