High Blood Pressure in Adults – JNC 8 Review

Report
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.
2014 Guidelines – JNC 8
 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?
James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi:10.1001/jama:284-427.
2014 Guidelines – JNC 8
 Based 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.
Recommendation 2 – Threshold
and Goals
 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
James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi:10.1001/jama:284-427.
Recommendation 3 – Threshold
and Goals
 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
James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi:10.1001/jama:284-427.
Recommendation 4 – Threshold
and Goals
 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
James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi:10.1001/jama:284-427.
Recommendation 5 – Threshold
and Goals
 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
James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi:10.1001/jama:284-427.
Recommendation 6 - Treatment
 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
James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi:10.1001/jama:284-427.
Recommendation 7 - Treatment
 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
James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi:10.1001/jama:284-427.
Recommendation 8 - Treatment
 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
James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi:10.1001/jama:284-427.
Recommendation 9 - Summary
 Goal BP not reached within 1 month of treatment
 Increase dose of initial drug
OR
 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
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.
Recommendation Summary
 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
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 and Limitations of JNC 8
Strengths
 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
Limitations
 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.
What are the differences from JNC 7?
 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
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?
Using the Guidelines – Patient
Case #2
 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?
Therapy Overview
Patient Population
General nonblack population,
including comorbid conditions
Initial Drug Therapy
• Thiazide-type diuretic
• ACEI/ARB
• CCB
Hypertension with CKD, regardless of • ACEI
race or diabetes status
• 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
ACEI
• Captopril
• Enalapril
• Lisinopril
ARB
• Losartan
• Valsartan
• Irbesartan
CCB
• Amlodipine
• Diltiazem ER
Thiazide-type diuretics
• Chlorthalidone
• Hydrochlorothiazide
• Indapamide
Beta-Blockers
• Atenolol
• Metoprolol
Initial
Daily
Dose
(mg)
50
5
10
50
40-80
75
Target Dose in
RCTs
Reviewed (mg)
150-200
20
40
5100
160-320
300
2.5
120-180
12.5
12.5-25
1.25
25-50
50
10
360
12.5-25
25-100
1.25-2.5
100
100-200
Wojtaszek D, Dang DK. Drug Topics. 2014;158(5):33-42.
Number
of
doses/da
y
2
1-2
1
1-2
1
1
1
1
1
1-2
1
1
1-2
Common and/or Major
Adverse Effects
Hyperkalmia, angioedema,
acute kidney failure, SCr, dry
cough
Hyperkalmia, angioedema,
acute kidney failure, SCr
• Dihydropyridines
Reflex tachy, peripheral edema,
dizziness, HA, flushing, 
cardiac contractility
• Nondihydropyridines
Bradycardia, heart block, 
cardiac contractility,
constipation, gingival
hyperplasia
Electrolyte abnormalities,
hyperuricemia, hyperglycemia,
hypercalcemia, hyperlipidemia
Bradycardia, heart block,
rebound HTN, masking
hypoglycemia, transient 
chol, bronchospasm
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.
References
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):25602572.
2. James PA, Oparil S, Carter BL, et al. 2014 Evidencedbased 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.

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