Yeni hipertansiyon kılavuzu -hala- hazırlık aşamasında (İng)


New Hypertension Guidelines (Still) in the Works

Editor’s note: The Joint National Committee was slated to release the eighth report on the management of patients with hypertension (JNC8) this year. However, those guidelines are still in the works.

In a special presentation at the annual midyear clinical meeting of the American Society of Health-System Pharmacists (ASHP), held December 2 to 6 in Las Vegas, Nevada, Joseph Saseen, PharmD, FASHPP, updated attendees on where those guidelines stand and outlined what changes clinicians might see.

Dr. Saseen is professor and vice chair of the Department of Clinical Pharmacy and professor in the Department of Family Medicine at the University of Colorado, Aurora.

Medscape Medical News discussed some of the highlights of his talk shortly after his presentation.

Medscape: Have the statistics on deaths/disability associated with cardiovascular disease (CVD) in the United States changed significantly in recent years?

Dr. Saseen: The numbers really have not changed that much, other than the predictable increases that go along with time. What we see is that many patients in general are living longer. Along with living longer comes an increased risk of CVD. We have many more patients now who live with CVD than we did decades ago. In a way, CVD is a part of the normal aging process, but we still try to slow it down as much as possible and decrease the associated morbidity and mortality.

Medscape: What is the projected financial impact of CVD out to 2030?

Dr. Saseen: That is the ugly reality. It’s been estimated that by 2030, the direct costs of CVD in the United States will nearly triple.

One thing is clear: In the future, we will incur a staggering increase in both direct and indirect costs related to CVD, whether related to hypertension or coronary heart disease. These cost increases have many influences; they are not just related to the cost of providing medications to patients with these conditions. As a matter of fact, many of the costs are related to the impact of CVD on decreased work productivity and other indirect costs.

Medscape: What is delaying the release of the JNC8 guidelines by the National Heart, Lung, and Blood Institute?

Dr. Saseen: Much of the holdup has been the new process for developing these guidelines. The process is sound, but increases the time required to generate a good evidence-based guideline that is user friendly and able to improve the care of patients with hypertension. The process is following Institute of Medicine (IOM) standards for developing guidelines, and incorporates several aspects and steps that will overall result in a very good document.

Medscape: How does this revised method differ from the method used to develop previous guidelines?

Dr. Saseen: The overall method is drastically different. They have adapted an approach that starts by posing relevant questions related to the treatment of hypertension, and literature searches are being used to identify the best evidence to answer the questions.

In contrast to previous guidelines, recommendations will have a clear evidence-based ranking. The overall document will go through several steps of rigorous internal and external reviews by experts, and will be released to the public in draft form. This draft form will be open for public comment prior to finalizing the guidelines. Overall, it means more work and more time, but the intent is to have a very useful document for clinicians.

Medscape: What are the most important questions the JNC8 guidelines will address?

Dr. Saseen: There are 3 critical questions that are being addressed: When should therapy start?, Which therapies should be used?, and What goal values should be targeted?

Those are all very relevant questions for the treatment of patients with hypertension.

Medscape: What are the main tenets that have been devised to develop trustworthy clinical practice guidelines?

Dr. Saseen: These have been laid out by the IOM in their 2011 Clinical Practice Guidelines We Can Trust. They call for the following when drafting clinical practice guidelines: establishing transparency; managing conflict of interest; balancing the composition of the guideline-development group; conducting a systematic review; establishing evidence foundations for and rating strength of recommendations; articulating recommendations in a meaningful manner; conducting an external review; and planning for updates.

Medscape: What are the best guidelines currently available?

Dr. Saseen: There are several other publications that are useful. They may not be “guidelines” but they are valuable. These include position papers, position articles, and consensus documents from national organizations.

Examples are the 2010 American Society of Hypertension position article entitled Combination Therapy in Hypertension. This document identifies preferred, acceptable, and less-effective combinations of antihypertensive agents. The JNC7 did not provide this level of detail regarding different types of combinations.

Then there is the American College of Cardiology Foundation/American Heart Association 2011 Expert Consensus Document on Hypertension in the Elderly. This looks at more recent evidence, provides more specific treatment recommendations for elderly patients, and highlights the fact that goal values may need to be individually tailored to the very elderly population. This provides much more information than the JNC7 did on this population, owing to the availability of additional prospective evidence from the Hypertension in the Very Elderly Trial (HYVET) trial.

In 2011, the National Institute for Health and Clinical Excellence (NICE) released the Clinical Management of Primary Hypertension in Adults guideline. This is from the United Kingdom, and recommends preferential use of thiazide-like diuretics such as chlorthalidone ahead of thiazide-type diuretics such as hydrochlorothiazide.

Medscape: What are the main advantages of chlorthalidone over hydrochlorothiazide?

Dr. Saseen: Chlorthalidone provides superior blood pressure lowering, compared with hydrochlorothiazide, and was the diuretic used in most of the major landmark clinical trials in hypertension. The bottom line is that it is stronger and we know more about the long-term benefits of this diuretic.

Hydrochlorothiazide does have the advantage of being used quite commonly to treat hypertension and is available in most fixed-dose combination antihypertensive agents. Its use is so common that it is hard not to think of using it. However, we need to recognize how it is different from chlorthalidone. Both are rather inexpensive, which is a really good thing.

Medscape: Are there special recommendations in the works for patients with diabetes?

Dr. Saseen: There is continued controversy over what is the best blood pressure goal for these patients. It’s a tough question and one that does not yet have a clear answer.

However, first-line therapy continues to consist of an ACE inhibitor or an ARB. What is new is the concept of dosing at least 1 antihypertensive medication in patients with type 2 diabetes in the evening.

There is one open-label trial of 448 patients that demonstrated superior reductions in cardiovascular events in type 2 diabetes when at least 1 antihypertensive drug was given prior to bedtime, rather than all in the morning ( Diabetes Care. 2011;34:1270-1276). It was conducted in Spain, but the American Diabetes Association recommends this with a level A recommendation. Surprisingly, it is the only A recommendation related to the treatment of hypertension in diabetes.

Medscape: What sort of changes in recommendations do you anticipate seeing in the JNC8?

Dr. Saseen: That is a loaded question. What I am pretty confident in saying is that the role of beta blockers in patients without a compelling reason for a beta blocker will likely be second line to ACE inhibitors, ARBs, CCBs, and diuretics.

I think that the JNC8 will address the discrepancy in efficacy between chlorthalidone and hydrochlorothiazide. I also expect some change in the blood pressure goal recommendations, but am not certain how it will be worded. I am sure there will be several others, but those are some big ones.

Medscape: Any other thoughts?

Dr. Saseen: We know quite a bit about treating hypertension, so even though the new guidelines have been delayed, there is no reason to wait until they are available to execute good clinical judgment and incorporate new evidence into the treatment of our patients with hypertension.

Dr. Saseen has disclosed no relevant financial relationships.