Caution: Contents Under Pressure Identifying DrugInduced - PDF document

5/21/2019 Caution: Contents Under Pressure Identifying Drug‐Induced Hypertension Melanie Claborn, Pharm.D., BCACP Assistant Professor of Pharmacy Practice Southwestern Oklahoma State University College of Pharmacy Clinical Pharmacy Specialist‐Oklahoma City Indian Clinic Oklahoma City, OK 1 Disclosure • Under guidelines established by the Accreditation Council for Pharmacy Education, disclosure must be made regarding financial relationships with commercial interests within the last 12 months. • I have no relevant financial relationships or affiliations with commercial interests to disclose. 2 1

5/21/2019 Learning Objectives At the completion of this activity, pharmacists will be able to: • Describe the complications of untreated hypertension • List drugs/supplements associated with secondary hypertension 3 Pre‐Assessment Question: What is the leading cause of death in the United States? a. Heart disease b. Cancer c. Accidents d. Influenza 4 2

5/21/2019 Pre‐Assessment Question: A patient has blood pressure readings in the clinic that are consistently 136/82. How would you classify his blood pressure? a. Normal b. Elevated c. Stage 1 HTN d. Stage 2 HTN 5 Pre‐Assessment Question: Which of these medications can be associated with increasing blood pressure? a. Cyclosporine b. Erythropoietin c. Indomethacin d. All of the above 6 3

5/21/2019 Why talk about the same old thing… Image: https://hochomecare.wordpress.com/ 7 Nearly half of all adults in the US have cardiovascular disease 8 4

5/21/2019 Prevalence of cardiovascular disease in adults ≥20 years of age (NHANES, 2013–2016) Benjamin EJ. Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:e56–e528 Dishonorable Awards Ischemic Heart heart disease is disease and the leading stroke lead cause of worldwide death in the US https://www.cdc.gov/nchs/fastats/leading‐causes‐of‐death.htm 10 Image: http://clipart‐library.com/medal‐cliparts.html 5

5/21/2019 CVD and other major causes of death for American Indians or Alaska Natives United States, 2016 Benjamin EJ. Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:e56–e528 Percentage of Deaths Attributable to Cardiovascular Disease (United States: 2016) Heart Failure, 9.3% Coronary Heart Disease, 43.2% Stroke, 16.9% High Blood Pressure, 9.8% Diseases of the Arteries, 3.0% Other, 17.7% 12 Adapted from Benjamin EJ. Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:e56–e528 6

5/21/2019 Physical inactivity Diabetes Mellitus Dyslipidemia Overweight/ Obesity Microalbuminuria (or GFR < 60 mL/min) Cigarette CVD smoking Age Risk Factors Hypertension Family History of Premature CVD Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2003). (NIH Publication No. 03– 13 5233). Bethesda, MD: U.S. Department of Health and Human Services.http://www.highbloodpressureinfo.org Snapshot of Hypertension in the US Images: https://healthmetrics.heart.org/heart‐disease‐and‐stroke‐statistics‐2019‐ 14 infographic/ Accessed May 2, 2019. 7

5/21/2019 Prevalence of hypertension in adults ≥20 years of age by sex and age (NHANES, 2013–2016 Benjamin EJ. Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:e56–e528 BP Control in the US NHANES NHANES NHANES NHANES NHANES 1976‐1980 1988‐ 1991‐ 1999‐ 2007‐ 1991 1994 2000 2012 Aware 51% 73% 68% 70% 83% Treated 31% 55% 54% 59% 77% Controlled 10% 29% 27% 34% 54% †SBP <140 mm Hg and DBP <90 mm Hg. •Age 18 to 74 years with SBP 140 mm Hg or DBP 90 mm Hg or taking antihypertensive medication. JNC VI. Arch Intern Med . 1997;157:2413‐46. JNC VII. JAMA 2003; 289:2560‐2572 16 8

5/21/2019 Extent of awareness, treatment, and control of high blood pressure by age NHANES, 2013–2016 Benjamin EJ. Heart Disease and Stroke Statistics—2019 Update Circulation. 2019;139:e56–e528 Why Blood Pressure Control Matters https://healthmetrics.heart.org/heart‐disease‐and‐stroke‐statistics‐2019‐infographic/ 18 9

5/21/2019 Target Organ Damage Hypertension 19 Reducing average population systolic blood pressure by only 12‐13 mmHg could reduce: 37% 25% 21% 13% Death from Death Stroke Coronary cardiovascular from all heart cause causes disease CDC. http://www.cdc.gov/bloodpressure/infographic.htm Ogden LG, et al. Hypertension 2000; 35: 539‐543. 20 Chobanian, A. V. et al. Hypertension 2003;42:1206‐1252; Hebert. Archives Int Med 1993: Moser. Am Coll Cardiol 1996 10

5/21/2019 Categories of Blood Pressure in Adults BP Category SBP DBP Normal <120 mm Hg AND <80 mm Hg Elevated 120‐129 mm Hg AND <80 mm Hg Hypertension Stage 1 130–139 mm Hg OR 80–89 mm Hg Stage 2 ≥140 mm Hg OR ≥90 mm Hg *Individuals with SBP and DBP in 2 categories should be designated to the higher BP category Whelton PK , Hypertension. 2018;71(19):e127–248 21 HBP Guideline Tool: Updated Classification and Management of High Blood Pressure in Adults https://www.acc.org/education‐ 22 and‐meetings/image‐and‐slide‐gallery/media‐detail?id=B5A2641BE66A48C89E18066B137DE3E0 11

5/21/2019 Blood Pressure Goals JNC 7 JNC 8 ASH/ESH ACC/AHA (2003) (2014) (2013) 2017 Uncomplicated <140/90 <140/90 <140/90 <130/80 HTN Diabetes <130/80 <140/90 <140/90 <130/80 CVD <140/90 ‐‐ <140/90 <130/80 CKD <130/80 <140/90 <140/90 <130/80 Not <150/90 <150/90 <130 Elderly specified (≥60 years) (≥80 years) (SBP) <140/90 JNC 8: JAMA. 2014;311(5):507‐520,; 23 Whelton PK , Hypertension. 2018;71(19):e127–248. 24 http://www.cdc.gov/bloodpressure/infographic.htm 12

5/21/2019 Nonpharmacological Interventions for Prevention and Treatment of Hypertension Recommendation Approximate Impact on SBP Hypertension Weight loss Best goal is ideal body weight. Expect about 1 mm Hg ‐5 mm Hg for every 1‐kg reduction in body weight. Healthy diet Consume a diet rich in fruits, vegetables, whole grains, ‐11 mm Hg and low‐fat dairy products, with reduced content of saturated and total fat. Reduced intake of Optimal goal is <1500 mg/d, but aim for at least a 1000‐ ‐5/6 mm Hg dietary sodium mg/d reduction in most adults. Enhanced intake of Aim for 3500–5000 mg/d, preferably by consumption of ‐4/5 mm Hg dietary potassium a diet rich in potassium. Physical activity ● 90–150 min/wk ‐5/8 mm Hg (aerobic) ● 65%–75% heart rate reserve ● 90–150 min/wk ‐4 mm Hg (dynamic resistance) ● 50%–80% 1 rep maximum ● 6 exercises, 3 sets/exercise, 10 repetitions/set Moderation of In individuals who drink alcohol, reduce alcohol to: ‐4 mm Hg alcohol intake ● Men: ≤2 drinks daily; Women: ≤1 drink daily Whelton PK , Hypertension. 2018;71(19):e127–248 Screening for Secondary Hypertension Whelton PK, Hypertension . 2018;71(19):e127–248. 26 13

5/21/2019 Identifiable Causes of Hypertension • Accuracy A • Apnea • Aldosteronism B • Bruits (renovascular disease) • Bad kidneys • Catecholamines C • Coarctation • Cushing’s syndrome D • DRUGS • Diet E • Erythropoietin • Endocrine disorders 27 Onusko E. Am Fam Physician . 2003 Jan 1;67(1):67‐74. Secondary Causes • 1‐2% Renal parenchymal disease • 5‐34% Renovascular disease • 8‐20% Primary aldosteronism • 25‐50% Obstructive sleep apnea Pheochromocytoma, Cushings, Thyroid, • Less than 1% Aortic coarctation, Hyperparathyroism, Adrenal hyperplasia, Acromegaly 28 Whelton PK, Hypertension . 2018;71(19):e127–248. 14

5/21/2019 Accuracy of Blood Pressure Measurement • Equipment inspected • Trained operator • Patient properly positioned • Caffeine, exercise, and smoking should be avoided for at least 30 minutes before • Appropriately sized cuff • Two measurements 29 Definition of Drug‐Induced Hypertension High blood pressure caused by a response to using, or stopping the use of, a chemical substance, drug, or medication. – U.S. National Library of Medicine/National Institutes of Health http://www.nlm.nih.gov/medlineplus/ency/article/000155.htm 30 15

5/21/2019 31 Image: http://millionhearts.hhs.gov /Docs/BP_Toolkit/TipSheet_HCP_MedAdherence.pdf Risk Factors for Drug‐induced Hypertension • History of elevated blood pressure • Decreased GFR • Metabolic syndrome • Advanced age • Persistent use Image: http://www.clipartpanda.com/clipart_images/american‐indian‐elder‐70241502 32 16

5/21/2019 Drugs Associated with Increases in BP Amphetamines Bevacizumab Buspirone Caffeine Erythropoietin Cocaine Corticosteroids Cyclosporine Stimulating Agents Estrogen‐ Monoamine containing oral Herbals Licorice Oxidase contraceptives Inhibitors Phenylephrine/ Protease Sibutramine NSAIDS Pseudoephedrine Inhibitors (off market) Sorafenib/ Tacrolimus Venlafaxine Sunitinib 33 Mechanism for Increasing BP • Glucocorticoids/mineralocorticoids Volume retention • Hormones • NSAIDS Activation of the • Decongestants sympathetic nervous • Stimulants system • Cyclosporine Direct vasoconstriction • Tacrolimus • Erythropoietin Combined • Alcohol • VEGF Unknown 34 17