PART B: ESH/ESC GUIDELINES FOR MANAGEMENT OF ARTERIAL HYPERTENSION, TREATMENT STRATEGIES

     Life Style Changes for the treatment :

       Salt (NaCl) intake of approximately 5 to 6 g per day(This translates into approximately 2000 to 2300 mg of sodium per day) in contrast with a typical intake of 9 to 12 g per day. A reduction to 5 g per day can decrease systolic blood pressure about 1 to 2 mm Hg in normotensive individuals and 4 to 5 mm Hg in hypertensive patients

       The guidelines recommend getting BMIs down to 25 kg/m² and reducing waist circumferences to <102 cm in men and <88 cm in women. Losing about 5 kg can reduce systolic blood pressure by as much as 4 mm Hg.Weight loss can also improve the efficacy of antihypertensive medications and the CV risk profile.

       A large French retrospective analysis provides good news for caffeine lovers: investigators showed that drinking tea or coffee was associated with a small but statistically significant reduction in systolic and diastolic blood pressure. In addition, drinking tea and coffee was also associated with a significant reduction in pulse pressure and heart rate, although the heart-rate reductions were greater with tea.

       Aerobic endurance training in hypertensive patients can reduce systolic blood pressure 7 mm Hg& diastolic blood pressure 5mm Hg.

       Moderation of alcohol consumption to no more than 20–30 g of ethanol per day in men and to no more than 10–20 g of ethanol per day in women is recommended.

       Regular exercise (walking, jogging, cycling or swimming), i.e. at least 30 min ofmoderate dynamic exercise on 5 to 7 days per week is recommended.

       Increased consumption of vegetables, fruits, and low-fat dairy products is recommended.Patients with hypertension should be advised to eat fish at least twice a week and 300 – 400 g/day of fruit and vegetables.

       Regular exercise (walking, jogging, cycling or swimming), i.e. at least 30 min of moderate dynamic exercise on 5 to 7 days per week is recommended

       It is recommended to give all smokers advice to quit smoking and to offer assistance.

     Pharmacological therapy:

       The current Guidelines reconfirm that diuretics (including thiazides, chlorthalidone and indapamide), beta-blockers, calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers are all suitable for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in some combinations.

       However, some therapeutic issues that have recently been raised are discussed below:

      Beta Blockers:

·        Equally as effective as the other major classes of antihypertensive agents in preventing coronary outcomes.

·        Highly effective in preventing CV events in patients with a recent myocardial infarction and those with heart failure.

·        A slightly lower effectiveness of beta-blockers in preventing stroke has been attributed to a lesser ability to reduce central SBP and pulse pressure.However, a lower effectiveness in stroke prevention is also shared by ACE inhibitors (but they reduce the central BP better than beta blockers).

·        To have more side-effects and  to be somewhat less effective than RAS blockers and calcium antagonists in regressing or delaying OD, such as LVH, carotid IMT, aortic stiffness and small artery remodeling.

·        Some of the vasodilating beta-blockers, such as celiprolol, carvedilol and nebivolol—more widely used today which reduce central pulse pressure and aortic stiffness better than atenolol or metoprolol and affect insulin sensitivity less than metoprolol.

·        Nebivolol has recently been shown not to worsen glucose tolerance compared with placebo and when added to hydrochlorothiazide.

·        Finally, beta-blockers have recently been reported not to increase, but even reduce, the risk of exacerbations and to reduce mortality in patients with chronic obstructive lung disease.

·        Compelling CI: Asthma, A-V block (grade 2 or 3 )

·        Possible CI:  Metabolic syndrome ,Glucose intolerance ,Athletes and physically active patients, Chronic obstructive pulmonary disease (except for vasodilator beta-blockers).

      Diuretics:

·        Spironolactone has been found to have beneficial effects in heart failure,and, although never tested in RCTs on hypertension, can be used as a third or fourth line drug and helps in effectively treating undetected cases of primary aldosteronism

·        Eplerenone has also shown a protective effect in heart failure and can be used as an alternative to spironolactone.

·        Thiazide diuretics :

o   Compelling CI :  gout

o   Possible CI : Metabolic syndrome, Glucose intolerance, Pregnancy,

 Hypercalcaemiaand Hypokalemia.

      Calcium Antagonists:

·        Calcium antagonists have shown a greater effectiveness than beta-blockers in slowing down progression of carotid atherosclerosis and in reducing LV hypertrophy in several controlled studies.

·        In the largest available meta-analysis, calcium antagonists reduced new-onset heart failure by about 20% compared with placebo but, when compared with diuretics, beta-blockers and ACE inhibitors were inferior by about 20% (which means a 19% rather than 24% reduction).

·        Dihydropyridines:

o   Possible CI:  Tachyarrhythmia, Heart failure.

·        Non Dihydropyridines ( verapamil, diltiazem ) :

o   Compelling CI: A–V block (grade 2 or 3, trifascicular block , Severe LV dysfunction, Heart failure.

      Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers:

·        The well-known ancillary properties of ACE inhibitors and ARBs, are their peculiar effectiveness in reducing proteinuria  and improving outcomes in chronic heart failure

·        As for the cancer signal that has recently been attached to ARBs, the committee unequivocally stated that such a risk has been disproven. The US Food and Drug Administration and a review by the European Medicines Agency have both concluded that no such a cancer risk exists with ARBs.

·        Compelling CI:Pregnancy, Hyperkalemia,Bilateral renal artery stenosis &Angioneurotic oedema (ACE inhibitor only).

·        Possible CI :Women with child bearing potential

      Renin Inhibitors :

·        Aliskiren, a direct inhibitor of renin at the site of its activation, is available for treating hypertensive patients, both as monotherapy and when combined with other antihypertensive agents.

·        No beneficial effect on mortality and hospitalization has recently been shown by adding aliskiren to standard treatment in heart failure.

      Other Antihypertensive Agents:

·        Centrally active agents and alpha-receptor blockers are also effective antihypertensive agents. Nowadays, they are most often used in multiple drug combinations.

Source:

Dr.Qurat-ul-Ain Hafeez, Pharm-D, RPh.

Ambulatory Care Pharmacist, Aga khan University Hospital, Karachi , Pakistan

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Asthma: How to Use Inhaler?

Metered Dose Inhaler (MDI or pMDI) | Spacers |DISKUS® | Turbuhaler® | Diskhaler®

About Inhalers
Several different kinds of asthma medicines are taken using an inhaler. Inhaled asthma medications go directly to the site of inflammation and constriction in the airways instead of traveling through the bloodstream to get there. Inhaled medications are the preferred therapy for asthma. Inhaled medications only work if they get to the airways, so learn how to use your inhaler properly.

Many people do not use their inhalers properly, so the medication does not reach their airways. It is very important that you show your doctor, pharmacist, or asthma educator how you use your inhaler to make sure the medication is getting into your lungs, where you need it.

Inhalers fall into two categories:

• Aerosol Inhalers: Pressurized metered dose inhaler is a canister filled with asthma medication suspended in a propellant. When the canister is pushed down, a measured dose of the medication is pushed out as you breathe it in. Pressurized metered dose inhalers are commonly called "puffers".

• Dry-powder inhalers: Dry powdered inhalers contain a dry powder medication that is drawn into your lungs when you breathe in.

Some people prefer dry-powder inhalers to pressurized inhalers because they find it easier to co-ordinate breathing in medication from them. However, with some dry-powder inhalers, it's necessary to inhale more quickly to get the right dose than it is with a pressurized inhaler. You may have to experiment with a number of different devices (under your doctor's supervision) before finding the one you're most comfortable with. An asthma educator can assist you in matching you with the best device.

Some inhaler devices come with built-in counters that monitor the number of doses a person has taken and how many doses the device has left. If your inhaler doesn't have a counter, ask your doctor or an asthma educator to show you how to monitor your dose.

Source: 

Nadeem Zia, B.Pharm, RPh. 

OpenDoor Team, www.OpenDoor.cc

Consulting Pharmacist, Vancouver, BC Canada

LinkedIn: http://ca.linkedin.com/in/NadeemPharmacist

Google+ : google.com/+NadeemZiaRPh

Vancouver, British Columbia, Canada

Reference:http://www.asthma.ca/adults/treatment/howToUse.php

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PART D(a): ESH/ESC GUIDELINES FOR MANAGEMENT OF ARTERIAL HYPERTENSION, TREATMENT STRATEGIES IN SPECIAL CONDITIONS

 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.

      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

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