The Jury is STILL Deliberating

The title of this post comes from one of the education sessions I attended at Midyear this year. So, the JNC-8 was supposed to come out last year or the year before, and is now set to be released next year in 2012 (hopefully!). The session was presented by two pharmacists - the first one was discussing all the major articles published about hypertension in that last few years - papers that the JNC committee cannot ignore when releasing the latest guidelines. The second speaker went over cases. I thought this talk was very interesting, and jotted down the following notes.

*The guidelines used today for hypertension come from the JNC-7 (published in 2003) and the AHA Scientific Statement (published in 2007). 

*BP goals:

• JNC7 states: <140/90, and <130/80 for patients with DM or CKD. 
• AHA states: <140/90, and <130/80 for patients with DM, CKD, and/or an increased CAD risk. 
• The diabetes goal being lower is interesting - because according to the speaker, this isn't really evidence-based medicine. The ACCORD trial (done in DM patients) for example, compared a SBP goal of either <140 or <120. The primary endpoints were stroke and MI. Results - more meds were needed to reach SBP <120 and no difference between primary outcomes (p = 0.20). I believe there was a study that showed that patients with proteinuria of 300-1000mg (probably signifies diabetics) had better outcomes when their blood pressure goals were lower. In the HOT trial, blood pressure goals were also studied. In the diabetic population, there were better outcomes with a DBP <80 rather than <90. However, the latter was a subgroup analysis. This is important to consider in my opinion, because diabetic patients are likely already on a couple medications. Is adding more blood pressure medication to reach a lower goal blood pressure worth it if it's not truly evidence-based?

*Treatment schemes:

• In 2003
• If a patient had compelling indications other than hypertension, then specific BP meds would be prescribed (ex. comorbid disease DM, then ACEI/ARB, or post MI, BB, etc.).
• Non-compelling indication stage 1 HTN: HCTZ first line usually, or ACEI/ARB/CCB/BB
• Non-compelling indication stage 2 HTN: 2-drug combo of any of the above with HCTZ as one of the choices. 
• In 2007 (AHA Scientific Statement) 
• If a patient had compelling indications, then no change to above.
• Changes to non-compelling indications: BB were taken off the list and no preference to HCTZ. 
• The ACCOMPLISH trial was a study that looked at combination HTN medications - CCB/ACEI vs. HCTZ/ACEI. The trial was stopped early because the CCB/ACEI combination was significantly better than the other combination. This may have been one of the reasons to take away the preference for HCTZ. 

*ACEI/ARBS

• How are these two different?
• ACEI: dry cough, more data, less expensive. 
• ARB: no dry cough, less data, more expensive; however, 2 generics are supposed to be coming out in 2012, so the use of ARBs may increase. 
• the ONTARGET trial studied the effects of ACEI alone, ARB alone, and combination ACEI/ARB. The results showed increased renal dysfunction, increased incidences of hyperkalemia, with no added benefit. This is why we don't see the combination used very often (except in severe CHF or proteinuria). 

*Chlorthalidone and HCTZ

• If a patient is on HCTZ, and has resistant HTN (on 3 or more meds not at goal OR on 4 or more meds at goal), then consider switching to chlorthalidone. 
• Also, something that the speaker said about HCTZ caught my attention - I've always thought that 25mg/day of HCTZ was maximum that should be recommended - and that anything above causes increased hypokalemia with no benefit. The speaker, however, encouraged going up to 50mg/day HCTZ or adding another agent if BP wasn't at goal with just HCTZ. I haven't completely made up my mind about this, but it's something to look into. 

*What We MAY See in JNC8

• BB as second line therapy or just for compelling indications. 
• Goal SBP <140 for ALL patients, with specific individual goals between patient and PCP. 
• The HCTZ vs. chlorthalidone issue
• ACEI or ARB with CCB as first line combination therapy
• Tailored recommendations for the elderly with HTN.