Pharmaceutical Care Hypertension

1
Pharmaceutical CareHypertension

• Fiona Reid
• NHS Lothian

2
Plan

• Definition and clinical risks
• Prevalence and aims of treatment
• Guidelines for management
• lifestyle /
  medicines
• Delivering pharmaceutical care to patients

3
Diagnosis of hypertension

• ? BP ? 160/100mmHg
• ? SBP 140-159mmHg OR DBP 90-99mmHg
• target organ damage
• established cardiovascular disease
  
• diabetes
• 10 year CVD risk ? 20

4
10-year cardiovascular risk

• Based on Framingham data
• ? Age
• ? Gender
• ? Smoking status
• ? Blood pressure
• ? Ratio of TC/HDL cholesterol
• ? Family history of CVD
• ? Diabetic status - treated as established
  cardiovascular disease

5
(No Transcript)
6
Definitions

• Essential hypertension 95
• Secondary hypertension - 5
• eg phaeochromoctyoma, renal artery stenosis
• Isolated systolic hypertension
• in elderly - normal DBP elevated SBP
• ? eg 190/80mmHg
• White coat hypertension
• 24 hour ambulatory monitoring / home
  monitoring
• ? elderly, female, non smokers

7
Clinical effects of hypertension

• Major risk factor for
• ? Stroke (62)
• ? Coronary heart disease (52)
• ? Heart failure
• ? Renal failure (2-5)
• ? Retinopathy

8
Ethnicity, hypertension and clinical risk

• ? British African Caribbean
• ? mortality x 3.5 cf white caucasian
• CVA / renal failure
• ? British South Asians
• ? mortality x 1.5 cf white caucasian
• MI / CVA

9
Prevalence

• ? Major public health issue
• Scotland - 45 (2000) / England - 33 (2004)
• ? Increases with age
• 76 in patients ? 75 years
• ? Most common condition for GP consultation
• males ? 45 years
• females ? 65 years
• ? 15 of drug budget in UK (pre GMS)

10
What does a hypertensive patient look like?

• Asymptomatic
• ? education re disease complications
• ? compliance / concordance
• Wide age range
• Lifelong
• ? lifestyle changes effected

11
British Hypertension Society 2004Treatment goals
12
Other UK guidelinesTreatment goals
13
Control of hypertension

• ? Rule of halves
• 50 of population have diagnosis
• 50 of those diagnosed at target BP
• ? BP lt140/90mmHg
• England 1994 - 6 ? 2003 - 23
• Scotland 1999 - 18
• ? GMS contract 2005
• BP lt150/90mmHg
• National 70-100!?
• ?exclusion criteria / prevalence on register

14
Public health risk and blood pressure

• ? Mortality /morbidity risk starts at SBP 115mmHg
• ? Reduction of 5mmHg in population
• ? decrease stroke by 14
• ? heart disease by 9

15
Lifestyle Management

• Weight
• ? aim BMI 20-25??
• ? low calorie healthy eating diet reduces
• BP by 5-6mmHg (fruit and vegetables)
• Exercise
• ? 30-60mins aerobic exercise 3-5 x weekly
  reduces
• BP by 2-3mmHg
• Salt intake
• ? cutting sodium intake to lt6g/day reduces
• BP by 3-4 mmHg (average intake 12g)

16
Lifestyle Management (cont)

• Alcohol
• ? 14u - 21u / week - no binging
• ? reduces BP by 3-4mmHg
• Smoking
• reduces overall cardiovascular risk
• Environmental stress
• ? relaxation therapies reduces BP by 3-4mmHg
• Caffeine
• ? gt5 cups / day increases BP by 1-2mmHg

17
Choice of treatment

• ? ACEI/ A2A - decrease renin release
• ? Beta blockers - reduce cardiac output,
  decrease renin release
• ? Calcium Channel blockers - block Ca influx
  to smooth muscle, decrease peripheral resistance
• ? Diuretics (thiazides) - reduce cardiac
  output and decrease peripheral resistance
• ? Alpha blockers - block alpha 1 receptors,
  decrease peripheral resistance

18
ACE inhibitors

• Indications
• Heart failure, post MI ,type 1 diabetic
  nephropathy
• Contraindications
• Bilateral renal artery stenosis
• Adverse effects / monitoring
• Cough, fatigue, angiooedema, renal
  impairment, hyperkalaemia, rhinitis.

19
Angiotensin 2 Antagonists

• Indications
• ACE intolerance, type 2 diabetic nephropathy,
  left ventricular hypertrophy
• Contraindications
• Bilateral renal artery stenosis
• Adverse effects / monitoring
• Renal impairment, hyperkalaemia, rhinitis.

20
Beta Blockers

• Indications
• Post MI, angina,heart failure
• Contraindications
• Asthma, severe COPD, heart block, PVD
• Adverse effects / monitoring
• Wheeze, cold extremities, fatigue,bradycardia,
  impotence.

21
Calcium Channel BlockersDihydropyridines

• Indications
• ISH, angina
• Contraindications
• Aortic stenosis
• Adverse effects / monitoring
• Ankle oedema, headache, flushing,gum
  hypertrophy, constipation.

22
Calcium Channel BlockersRate limiting

• Indications
• Angina
• Contraindications
• Heart block, heart failure.
• Adverse effects / monitoring
• Ankle oedema, headache, bradycardia.

23
Thiazide Diuretics

• Indications
• ISH, heart failure
• Contraindications
• Gout
• Adverse effects / monitoring
• Gout, electrolyte imbalance,postural
  hypotension

24
Alpha Blockers

• Indications
• Benign prostatic hypertrophy
• Contraindications
• Urinary incontinence
• Adverse effects / monitoring
• Postural hypotension, dry mouth, headache

25
Role of combination therapy

• ? Dual therapy LIFE
• 90 required ? 2drugs (?145/81mmHg)
• ? Triple therapy UKPDS
• 60 required ? 2 drugs
• 33 required ? 3 drugs
• 
  (?150/85mmHg)
• CONSIDER USE OF FIXED DOSE COMBINATION
  PRODUCTS!!!
• (eg ACEI / thiazide)

26
(No Transcript)
27
NICE algorithm
28
NICE

• In patients lt 55 years consider BB
• Recognition of different effects dependant on age
  / ethnicity
• All classes similar effects mortality
• (alpha
  blockers)
• AB / CD
• ? no evidence of better CV outcomes
• ? no evidence of cost effectiveness

29

• However most important
• factor
• morbidity / mortality
• ? BP target level achieved

30
Medicines ? BP

• NSAIDs / COX2
• OCP
• Steroids
• Sympathomimetics (phenylpropanolamine)
• Liquorice
• Salt content eg soluble tablets

31
Pharmaceutical Care Plan

• Social and psychological make up
• EDUCATION
• What does X/YmmHg mean?
• Why is it necessary to treat - asymptomatic?
• What is target and why?
• Why more than one drug?
• Can I stop taking when target reached?
• What happens if I miss doses?

32
Pharmaceutical care plan (cont)

• Effectiveness
• Compliance / concordance
• Lifestyle management
• ADR / concurrent medication
• Choice of agent with co-morbidities
• BUT
• hypertension only 1 risk factor in overall CV
  risk to the patient
• dont treat in isolation!!