Treatment
strategies in special conditions:
Some classes have preferentially been used in trials in specific conditions or have shown greater effectiveness in specific types of OD.
Some classes have preferentially been used in trials in specific conditions or have shown greater effectiveness in specific types of OD.
White-coat (or isolated office/clinic) hypertension:
o In white-coat hypertensives with a higher CV risk
because of metabolic derangements or asymptomatic OD, drug treatment may be
considered in addition to lifestyle changes.
o In white-coat hypertensives without
additional risk factors, therapeutic
intervention should be considered to be
limited to lifestyle changes only, but
this decision should be accompanied by a close follow-up (including periodical
out-of-office BP monitoring) because these patients have a greater risk of
developing OD and to progress to diabetes and sustained hypertension( in &
out office B.P abnormal).
Masked( or isolated ambulatory) Hypertension:
o Isolated ambulatory or masked hypertension is
infrequently diagnosed because finding a normal clinic BP only exceptionally
leads to home or ambulatory BP measurements. When this condition is identified,
both lifestyle measures and antihypertensive drug treatment should be
considered, because this type of hypertension has been consistently found to
have a CV risk very close to that of in & out of office hypertension.
Elderly:
o The recommendation of lowering SBP to < 150
mmHg by antihypertensive in elderly individuals with systolic BP≥160 mmHg is
strongly evidence-based.
o However, at least in elderly individuals younger
than 80 years, antihypertensive treatment may be considered at SBP values >
140 mmHg and aimed at values <140 mmHg, if the individuals are fit and
treatment is well tolerated.
o In individuals older than 80 years with an
initial SBP ≥160 mmHg it is recommended to reduce SBP to between 150 and 140
mmHg, provided they are in good physical and mental conditions
o In frail elderly patients, it is recommended to
leave decisions on antihypertensive therapy to the treating physician, and
based on monitoring of the clinical effects of treatment.
o All hypertensive agents are recommended and can
be used in the elderly, although diuretics and calcium antagonists may be
preferred in isolated systolic hypertension.
Young adults:
o In young men (without stiff, diseased arteries)
the relationship of DBP to total and CV mortality was even stronger than that of
SBP, with an apparent threshold around 90 mmHg.20% of the total mortality in
these young men could be explained by their DBP. Their treatment with drugs may
be considered prudent and, especially when other risk factors are present, BP
should be reduced to < 140/90 mmHg.
Women:
o Hormone therapy and selective oestrogen receptor
modulators are not recommended and should not be used for primary or secondary
prevention of CVD. If treatment of younger perimenopausal women is considered
for severe menopausal symptoms, the benefits should be weighed against
potential risks.
o Three separate meta-analyses summarizing over 30
years of studies have shown that OC users have about a two-fold increased risk
of stroke over non-users.
o Women aged 35 years and older should be assessed
for CV risk factors, including hypertension. It is not recommended that OCs be
used in women with uncontrolled hypertension.In women who smoke and are over
the age of 35 years, OCs should be prescribed with caution.
o Drug treatment of severe hypertension in
pregnancy (SBP >160 mmHg or DBP >110 mmHg) is recommended.
o Drug treatment may also be considered in pregnant
women with persistent elevation of BP ≥150/95 mmHg, and in those with BP
≥140/90 mmHg in the presence of gestational hypertension (with or without
proteinuria), pre-existing hypertension with the superimposition of gestational
hypertension, HTN with subclinical OD or symptoms.
o In women at high risk of pre-eclampsia (from
hypertension in a previous pregnancy, CKD, autoimmune disease such as systemic
lupus erythematosus, or antiphospholipid syndrome, type 1 or 2 diabetes
orchronic hypertension) or with more than one moderate risk factor for
pre-eclampsia (first pregnancy, age≥40 years, pregnancy interval of >10
years, BMI≥35 kg/m2 at first visit, family history of pre-eclampsia and
multiple pregnancy),provided they are at low risk of gastrointestinal
haemorrhage, treatment with low dose (75 mg) aspirin from 12 weeks until
delivery may be considered.
o In women with child-bearing potential RAS
blockers are not recommended and should be avoided due to possible teratogenic
effects. This is the case also for aliskiren, a direct renin inhibitor,
although there has not been a single case report of exposure to aliskiren in
pregnancy.
o Methyldopa, labetolol and nifedipine should be
considered preferential antihypertensive drugs in pregnancy.
o Intravenous labetolol with infusion of sodium
nitroprusside or nitroglycerin should be considered in case of emergency
(pre-eclampsia).
o A recent large meta-analysis found that women
with a history of pre-eclampsia have approximately double the risk of
subsequent ischemic heart disease, stroke and venous thrombo-embolic events
over the 5 – 15 years after pregnancy. The risk of developing hypertension is
almost four-fold. There-for lifestyle modifications and regular check-ups of BP
and metabolic factors are recommended after delivery, to reduce future CVD.
Diabetes mellitus:
o The individual choice should take co-morbidities
into account to tailor therapy. Because BP control is more difficult in
diabetes. Combination therapy should most often be considered when treating
diabetic hypertensives.
o While initiation of antihypertensive drug
treatment in diabetic patients whose SBP is ≥160 mmHg is mandatory, it is
strongly recommended to start drug treatment also when SBP is ≥140 mmHg
o All classes of antihypertensive agents are
recommended and can be used in patients with diabetes; RAS blockers may be
preferred, especially in the presence of proteinuria or microalbuminuria.
o Thiazide and thiazide-like diuretics are useful
and are often used together with RAS blockers.
o Calcium antagonists have been shown to be useful,
especially when combined with an RAS blocker.
o Beta-blockers, though potentially impairing
insulin sensitivity, are useful for BP control in combination therapy,
especially in patients with CHD and heart failure.
Metabolic syndrome:
o As the metabolic syndrome can be considered a
‘pre-diabetic’ state, antihypertensive agents potentially improving or at least
not worsening insulin sensitivity, such as RAS blockers and calcium
antagonists, should be considered as the preferred drugs. Beta-blockers (with
the exception of vasodilating beta-blockers) and diuretics should be considered
only as additional drugs, preferably in association with a potassium-sparing
agent, as there is evidence that hypokalemia worsens glucose intolerance.
o It is recommended to prescribe antihypertensive
drugs with particular care in hypertensive patients with metabolic disturbances
when BP is ≥140/90 mmHg after a suitable period of lifestyle changes, and to
maintain BP <140/90 mmHg.
o BP lowering drugs are not recommended in
individuals with metabolic syndrome and high normal BP.
o Lifestyle changes, particularly weight loss and
physical exercise, are to be recommended to all individuals with the metabolic
syndrome. These interventions improve not only BP, but the metabolic components
of the syndrome and delay diabetes onset.
Diabetic and non-diabetic nephropathy:
o In patients with ESRD under dialysis, a recent
meta-analysis showed a reduction in CV events, CV death and all-cause mortality
by lowering of SBP and DBP.
o When overt proteinuria is present, SBP values
<130 mmHg may be considered, provided that changes in eGFR are monitored.
o RAS blockers are more effective in reducing
albuminuria than other antihypertensive agents, and are indicated in
hypertensive patients in the presence of micro albuminuria or overt
proteinuria.
o Aldosterone antagonists cannot be recommended in
CKD, especially in combination with a RAS blocker, because of the risk of
excessive reduction inrenal function and of hyperkalemia.
o Association of an ACE inhibitor with a calcium
antagonist, rather than a thiazide diuretic, is more effective in preventing
doubling serum creatinine and ESRD,though less effective in preventing
proteinuria.
o Loop diuretics should replace thiazides if serum
creatinine is 1.5 mg/dL or eGFR is < 30 ml/min/1.73m2.
o CKD: All antihypertensive drugs except diuretics
can be used in the haemodialysis patients, with doses determined by the
haemodynamic instability andthe ability of the drug to be dialyzed.
Source:
Dr.Qurat-ul-Ain
Hafeez, Pharm-D, RPh.
Ambulatory Care Pharmacist, Aga khan University Hospital, Karachi ,
Pakistan
Facebook: Qurat Hafeez
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