PHARMACOLOGY CONSULT
The 2014 hypertension guidelines: Processing the information Randee Gelatic, PharmD
ABSTRACT Recent guidelines on hypertension management offer conflicting recommendations. This article describes the JNC 8 and ASH/ISH guidelines and the four medications recommended for controlling BP in various patient populations. Keywords: hypertension, guidelines, JNC 8, ASH/ISH, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers
A
mong adults who are not pregnant, hypertension is the most common reason for office visits and prescription drug use in the United States.1 About 31% of American adults (some 65 million) have a diagnosis of hypertension.2 Of patients diagnosed, fewer than half (47%) have their BP under control, defined as a level below 140/90 mm Hg.2 Uncontrolled hypertension increases the risk for heart disease and stroke, two leading causes of death.2 In 2009, hypertension was a primary or contributing cause of death for more than 348,000 Americans.2 With 53% of patients at high risk for mortality because their BP is not controlled, treatment guidelines are an increasingly important resource for clinicians managing patients with this often asymptomatic condition. The much anticipated 8th Joint National Committee (JNC 8) hypertension guideline was published late in 2013. One day earlier, the American Society of Hypertension (ASH) and International Society of Hypertension (ISH) released their guidelines. The American Heart Association (AHA), American College of Cardiology (ACC), and CDC also published a scientific advisory intended to support clinical hypertension guidelines. Practitioners had more than 50 pages of new and conflicting information from which to decipher what is most useful in daily practice.
Randee Gelatic is a pharmacist at North Country HealthCare in Flagstaff, Ariz. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000455652.34919.4c Copyright © 2014 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
JNC 8 GUIDELINE The JNC 8 guideline focused on answering three highpriority questions: • when to initiate therapy • what BP goal to reach • which medication to use.3 The panel presented nine recommendations. 3 Recommendations one through five address goal thresholds; recommendations six through nine are specific to medications (Table 1)3. The definition of hypertension from the JNC 7 remains the same, but compelling indications for specific medications are now extinct and nonpharmacologic lifestyle recommendations are discussed separately in support of the 2013 Lifestyle Work Group.3 For patients who need specific lifestyle modifications or have comorbid conditions, clinicians must look beyond the scope of these guidelines. The intent of the appointed panel was to produce guidelines from the best evidence.3 Their recommendations are compiled from a systematic review of original randomized controlled trials, considered to be the gold standard in determining efficacy.3 However, most of their recommendations are classified as Grade E (expert opinion) because evidence was insufficient, unclear, or conflicting.3 Only two recommendations are considered Grade A (strong recommendation), and those come with some discrepancy.3 Recommendation 1 suggests a higher systolic BP target of 150/90 mm Hg for adults over age 60 years.3 Following the release of the guidelines, a minority group of five JNC 8 panel members published a follow-up article stating that this higher target could leave older adults with untreated hypertension at greater risk for complications.4 The debate originates from lack of randomized controlled trial evidence in high-risk older adults with hypertension.3,4 The panel recommends four first-line agents: angiotensinconverting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), thiazide diuretics, and calcium channel blockers.3 ACE inhibitors or ARBs are recommended as initial therapy for patients with chronic kidney disease (CKD), but are never used in combination and no longer specifically recommended for all patients with diabetes.3 Thiazide diuretics or calcium channel blockers are recommended initially for black patients (Table 1).3 www.JAAPA.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
15
PHARMACOLOGY CONSULT
Three titration strategies are indicated to attain goal BP (Table 1).3 If control is not reached on three of these medications, the guidelines recommend referral to a hypertension specialist. Overall, the panel’s recommendations encourage the use of the four most effective medications, titrated to reach the most beneficial BP goals that reduce cardiovascular risks. This simplified evidence-based approach aims to improve adherence and reduce adverse drug events. Corollary Recommendation 1 gives readers the impression that drug therapy does not need to be adjusted if it results (or has previously resulted) in lower achieved systolic BP than recommended, and is well tolerated without adverse effects on patient health or quality of life.3 However, we now have the opportunity to reduce medication burden without increasing cardiovascular risk.
TABLE 1.
JNC 8 hypertension guideline recommendations3,7
Do not combine ACE inhibitors with ARBs. Number
Recommendation
Grade
1
Age ≥60 years: Initiate drug if systolic BP ≥150 or diastolic BP ≥90 with BP goal
The 2014 hypertension guidelines: Processing the information Randee Gelatic, PharmD
ABSTRACT Recent guidelines on hypertension management offer conflicting recommendations. This article describes the JNC 8 and ASH/ISH guidelines and the four medications recommended for controlling BP in various patient populations. Keywords: hypertension, guidelines, JNC 8, ASH/ISH, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers
A
mong adults who are not pregnant, hypertension is the most common reason for office visits and prescription drug use in the United States.1 About 31% of American adults (some 65 million) have a diagnosis of hypertension.2 Of patients diagnosed, fewer than half (47%) have their BP under control, defined as a level below 140/90 mm Hg.2 Uncontrolled hypertension increases the risk for heart disease and stroke, two leading causes of death.2 In 2009, hypertension was a primary or contributing cause of death for more than 348,000 Americans.2 With 53% of patients at high risk for mortality because their BP is not controlled, treatment guidelines are an increasingly important resource for clinicians managing patients with this often asymptomatic condition. The much anticipated 8th Joint National Committee (JNC 8) hypertension guideline was published late in 2013. One day earlier, the American Society of Hypertension (ASH) and International Society of Hypertension (ISH) released their guidelines. The American Heart Association (AHA), American College of Cardiology (ACC), and CDC also published a scientific advisory intended to support clinical hypertension guidelines. Practitioners had more than 50 pages of new and conflicting information from which to decipher what is most useful in daily practice.
Randee Gelatic is a pharmacist at North Country HealthCare in Flagstaff, Ariz. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000455652.34919.4c Copyright © 2014 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
JNC 8 GUIDELINE The JNC 8 guideline focused on answering three highpriority questions: • when to initiate therapy • what BP goal to reach • which medication to use.3 The panel presented nine recommendations. 3 Recommendations one through five address goal thresholds; recommendations six through nine are specific to medications (Table 1)3. The definition of hypertension from the JNC 7 remains the same, but compelling indications for specific medications are now extinct and nonpharmacologic lifestyle recommendations are discussed separately in support of the 2013 Lifestyle Work Group.3 For patients who need specific lifestyle modifications or have comorbid conditions, clinicians must look beyond the scope of these guidelines. The intent of the appointed panel was to produce guidelines from the best evidence.3 Their recommendations are compiled from a systematic review of original randomized controlled trials, considered to be the gold standard in determining efficacy.3 However, most of their recommendations are classified as Grade E (expert opinion) because evidence was insufficient, unclear, or conflicting.3 Only two recommendations are considered Grade A (strong recommendation), and those come with some discrepancy.3 Recommendation 1 suggests a higher systolic BP target of 150/90 mm Hg for adults over age 60 years.3 Following the release of the guidelines, a minority group of five JNC 8 panel members published a follow-up article stating that this higher target could leave older adults with untreated hypertension at greater risk for complications.4 The debate originates from lack of randomized controlled trial evidence in high-risk older adults with hypertension.3,4 The panel recommends four first-line agents: angiotensinconverting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), thiazide diuretics, and calcium channel blockers.3 ACE inhibitors or ARBs are recommended as initial therapy for patients with chronic kidney disease (CKD), but are never used in combination and no longer specifically recommended for all patients with diabetes.3 Thiazide diuretics or calcium channel blockers are recommended initially for black patients (Table 1).3 www.JAAPA.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
15
PHARMACOLOGY CONSULT
Three titration strategies are indicated to attain goal BP (Table 1).3 If control is not reached on three of these medications, the guidelines recommend referral to a hypertension specialist. Overall, the panel’s recommendations encourage the use of the four most effective medications, titrated to reach the most beneficial BP goals that reduce cardiovascular risks. This simplified evidence-based approach aims to improve adherence and reduce adverse drug events. Corollary Recommendation 1 gives readers the impression that drug therapy does not need to be adjusted if it results (or has previously resulted) in lower achieved systolic BP than recommended, and is well tolerated without adverse effects on patient health or quality of life.3 However, we now have the opportunity to reduce medication burden without increasing cardiovascular risk.
TABLE 1.
JNC 8 hypertension guideline recommendations3,7
Do not combine ACE inhibitors with ARBs. Number
Recommendation
Grade
1
Age ≥60 years: Initiate drug if systolic BP ≥150 or diastolic BP ≥90 with BP goal
