Hypertension
Maria G. Tanzi, PharmD
A comparative effectiveness analysis published in Lancet found that thiazide or thiazide-like diuretics were superior to ACE inhibitors as first-line medications for management of hypertension.1 Nondihydropyridine calcium channel blockers (CCBs) were also found to be significantly inferior to other currently recommended first-line agents.
Researchers analyzed data from nine health care databases across various countries to assess the comparative effectiveness and safety of initial use of first-line antihypertensive agents. Of the nearly 4.9 million patients assessed, 48% were initiated on ACE inhibitors, 17% on thiazide or thiazide-like diuretics, 16% on dihydropyridine CCBs, 15% on ARBs, and 3% on nondihydropyridine CCBs.
The results showed that compared with ACE inhibitors, diuretics were associated with significantly lower risks for myocardial infarction (hazard ratio [HR] 0.84), hospitalization for heart failure (HR 0.83), and stroke (HR 0.83). Diuretics were also safer than ACE inhibitors. The nondihydropyridine CCBs appeared to be the least effective agents.
Applicability of the data
The 2017 hypertension guideline by the American College of Cardiology (ACC)/American Heart Association (AHA) gives little guidance on the preferred first-line agent for those without underlying comorbidities, which may direct selection of specific agents.2 The ACC/AHA guideline recommends thiazide diuretics, ACE inhibitors, ARBs, or CCBs, unless contraindicated, as first-line agents for management of stage 1 hypertension. Chlorthalidone (12.5–25 mg) is listed as the preferred diuretic because of its long half-life and proven reduction of cardiovascular disease risk.
However, not all patients are appropriate candidates for a diuretic. According to Eric J. MacLaughlin, PharmD, FASHP, FCCP, BCPS, professor and chair at Texas Tech University Health Sciences Center in Lubbock, “select patients who should not be started on thiazide or thiazide-like diuretics may include those with borderline low potassium levels or issues such as frequent urination throughout the day.”
“Also, if a patient has a history of acute gout attacks, particularly if the attacks were severe or recent, I would start an alternative first-line agent,” said MacLaughlin, who was not involved in the study.
MacLaughlin also noted that while much discussion in the systematic review focuses on optimal monotherapy for high blood pressure (BP), it is important to remember that the vast majority of patients will need two or more medications to reach their goal. The 2017 ACC/AHA guideline recommends considering initial two-drug combination therapy, with one of those medications often being a diuretic, for patients with stage 2 hypertension (BP ≥ 140/90 mm Hg).2 Therefore, the majority of patients with hypertension are not going to be on monotherapy.
“The initiation of any drug therapy should involve a full evaluation of the patient, with an assessment of underlying conditions and laboratory abnormalities,” MacLaughlin said. “Pharmacists in a variety of settings can help increase correct first-line medication use per the [ACC/AHA] hypertension guidelines both through working with patients directly and working with their primary care provider. If the pharmacist is working in a clinic providing comprehensive medication management (CMM) services, then they can be directly involved in prescribing appropriate first-line medication and following up with the patients as needed.”
Home BP monitoring, lifestyle modifications
Pharmacists in both the community and clinic setting should ask patients about their home BP readings and if they are at goal. Encourage patients to obtain a home BP monitor if they don’t have one so they can record their readings to take back to their primary care provider. Out-of-office BP monitoring, when done correctly, is a great tool, not only to detect white coat or masked hypertension, but also to assess if a patient is at goal and to decide whether to intensify therapy.
If a patient is not at goal, pharmacists can either adjust medication if they are providing CMM under protocol or encourage the patient to speak with their primary care provider and give them their BP readings.
Patients should also be educated on the importance of lifestyle modifications. Educational tips can include eating a heart-healthy diet, restricting sodium, increasing physical activity, and consuming alcohol in moderation (if applicable).
References
1. Suchard MA, et al. Lancet. 2019;394: 1816–26
2. Whelton PK, et al. J Am Coll Cardiol. 2018;71:e127–e248