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:

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.

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?

2014 Guidelines – JNC 8

James PA, Oparil S, Carter BL, et al. JAMA. 2013;doi:10.1001/jama:284-427.

2014 Guidelines – JNC 8Based 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


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


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



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



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



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



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

Recommendation 6 - 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



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



Goal BP not reached within 1 month of treatment Increase dose of initial drugOR 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

Recommendation 9 - Summary


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


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

Recommendation Summary


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


Strengths Limitations

Strengths and Limitations of JNC 8

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

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.

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

What are the differences from JNC 7?


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?

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?

Using the Guidelines – Patient Case #2

Therapy OverviewPatient Population Initial Drug Therapy

General nonblack population, including comorbid conditions

• Thiazide-type diuretic• ACEI/ARB• CCB

Hypertension with CKD, regardless of race or diabetes status

• ACEI• 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

Initial Daily Dose (mg)

Target Dose in RCTs

Reviewed (mg)

Number of

doses/day

Common and/or Major Adverse Effects

ACEI• Captopril• Enalapril• Lisinopril

505

10

150-2002040

21-21

Hyperkalmia, angioedema, acute kidney failure, SCr, dry cough

ARB• Losartan• Valsartan• Irbesartan

5040-80

75

5100160-320

300

1-211

Hyperkalmia, angioedema, acute kidney failure, SCr

CCB• Amlodipine• Diltiazem ER

2.5120-180

10360

11

• DihydropyridinesReflex tachy, peripheral edema, dizziness, HA, flushing, cardiac contractility• NondihydropyridinesBradycardia, heart block, cardiac contractility, constipation, gingival hyperplasia

Thiazide-type diuretics• Chlorthalidone• Hydrochlorothiazide• Indapamide

12.512.5-25

1.25

12.5-2525-100

1.25-2.5

11-21

Electrolyte abnormalities, hyperuricemia, hyperglycemia, hypercalcemia, hyperlipidemia

Beta-Blockers• Atenolol• Metoprolol

25-5050

100100-200

11-2

Bradycardia, heart block, rebound HTN, masking hypoglycemia, transient chol, bronchospasm

Wojtaszek D, Dang DK. Drug Topics. 2014;158(5):33-42.

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


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):2560-2572.

2. James PA, Oparil S, Carter BL, et al. 2014 Evidenced-based 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.

References

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:

Documents

pharmacologic treatment

treatment goals

hg ckd

hg similar recommendation

years strong recommendation

goals james pa

pharmd slide

oparil s