Close Server: KOPWWW05 | Not logged in


Pharmacology Today

Pharmacologic Management of Dyslipidemia & Hypertension

Dyslipidemia and hypertension are among the most common conditions seen in primary care settings; they are leading preventable causes of morbidity and mortality. 2014 has ushered in many changes and updates in the management of dyslipidemia and hypertension. Since the Adult Treatment Panel III (ATP III) and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), numerous clinical trials produced evidence supporting the changes and updates to the 2013 American Heart Association (AHA)/American College of Cardiology (ACC) lipid guidelines and the Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). This summary highlights the major updates in recommendations for pharmacologic management of dyslipidemia and hypertension.

Summary of Changes: Dyslipidemia

The 2013 ACC/AHA Cholesterol Guidelines focus on evidence-based cardiovascular risk reduction, cardiovascular risk calculations and stratification of patients into four major statin benefit groups.1The new guidelines focus on percent reduction of LDL based on risk rather than low-density lipoprotein (LDL) goals. The Pooled Cohort Equations Cardiovascular Risk Calculator, available at http://my.americanheart.org/cvriskcalculator is a risk calculator used to estimate cardiovascular disease risk in people ages 40 to 75 who are not receiving cholesterol-lowering therapy and have an LDL level of 70 mg/dL to 189 mg/dL (1.8 to 4.9 mmol/L).2

The four major statin benefit groups are: 2

  • patients with clinical atherosclerotic cardiovascular disease
  • patients with LDL 190 mg/dL (5 mmol/L) or higher
  • patients aged 40 to 75 who have diabetes (but not clinical atherosclerotic cardiovascular disease) and LDL 70 mg/dL to 189 mg/dL (1.8 mmol/L to 4.9 mmol/L)
  • patients without clinical atherosclerotic cardiovascular disease or diabetes who have an LDL 70 mg/dL to 189 mg/dL (1.8 mmol/L to 4.9 mmol/L), with an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or higher.

The 2013 ACC/AHA Cholesterol Guidelines focus on the use of statin therapy to achieve a percent reduction in LDL based on cardiovascular risk.2 High-dose statins are used to lower LDL by at least 50% from baseline. High-dose statins are recommended for secondary prevention in patients 75 and younger; these should also be used for

  • primary prevention in the following patients: adults with LDL 190 mg/dL (5 mmol/L) or higher (Level A evidence)2 
  • adults aged 40 to 75 with LDL 70 mg/dL to 189 mg/dL and an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or higher (moderate-dose also an option) (Level A evidence)2
  • diabetes patients aged 40 to 75 with LDL 70 mg/dL to 189 mg/dL and an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or higher (Level C evidence).2

Examples of high-dose statins include atorvastatin 80 mg once daily or rosuvastatin 20 mg to 40 mg daily.

Statins in the moderate dosage range are recommended to lower LDL by 30% to 49%. They are used for secondary prevention in older adults (older than 75) and for secondary prevention in patients who cannot tolerate a high-dose statin therapy. Moderate-dose statins are recommended for primary prevention in the following patients:

  • adults aged 40 to 75 with LDL 70 mg/dL to 189 mg/dL and an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or higher (high-dose also an option) (Level A)2
  • diabetes patients aged 40 to 75 with LDL 70 mg/dL to 189 mg/dL and an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or lower.2

Statins in the lowest dosage range generally lower LDL by less than 30% and are used for patients who cannot tolerate moderate doses but require statin therapy.2 Nonstatins are reserved for patients with severe hypertriglyceridemia (greater than 500 mg/dL), which requires therapy with fenofibrates (various dosages depending on formulation), omega 3 fatty acids (doses greater than or equal to 3 g/day eicosapentaenoic acid/docosahexaenoic acid [EPA/DHA] or nicotinic acid derivatives (nicotinic acid at doses of 1,500 to 2,000 mg daily).2 Nonstatins may be required for patients who cannot tolerate statins at the recommended dose or high-risk patients with markedly elevated baseline LDL levels (greater than 190 mg/dL) who are not expected to achieve goals with statin alone.

Administration and monitoring of statin therapy has also changed since ATP III. Initiate statin dosage according to the required level of LDL-lowering intensity (e.g, high, moderate or low intensity). Assess fasting lipid panel at 4 to 12 weeks after the statin is started, then repeat every 3 to 12 months to assess LDL reduction.2 Review adherence, dietary and lifestyle modifications and potential adverse effects at every visit. Reinforce dietary changes including increased consumption of high-fiber vegetables, fruits and whole grains; low-fat dairy products; lean meats (e.g., poultry, fish and legumes) as well as healthy vegetable oils and low saturated fat intake.3 Assess alanine aminotransferase (ALT) level at baseline and repeat if symptoms or signs of liver toxicity are present. Ask patients about muscle pain, tenderness or injury prior to starting statins and consider a baseline creatine kinase (CK) level. Advise patients to report new onset of muscle pain and/or fatigue during therapy.4 If CK levels are more than 10 times the upper limit of normal, discontinue statin therapy and instruct patients to drink large amounts of fluids to facilitate renal excretion of myoglobin.4

If adverse effects arise during statin therapy, assess the severity of these effects and consider dosage reduction or switch to an alternate statin medication. Conflicting evidence about statins and diabetes risk exists, and patients on statins should be screened for diabetes according to current guidelines from the American Diabetes Association.5

In general, statins should be dosed appropriately according to cardiovascular risk and percent reduction of LDL required, and patients should be monitored at regular intervals to assess efficacy in LDL-lowering effects and potential adverse effects, such as myopathy and liver injury.2

Hypertension: JNC 8

The panel members appointed to the Eighth Joint National Committee (JNC 8) systematically reviewed evidence from relevant outcome-based, randomized, controlled trials (RCT) to provide guidelines for the management of high blood pressure in adults. RCTs in the panel's review included the effects of interventions on the following general outcomes: overall mortality, cardiovascular disease-related mortality, chronic kidney disease-related mortality, end-stage renal disease, and cardiovascular and coronary artery disease including revascularization, myocardial infarction, heart failure and stroke.6

The recommendations were based on age, blood pressure, comorbidities and ethnicity/race. In general, pharmacologic and lifestyle medications are recommended for adult patients younger than 60 to lower blood pressure to diastolic blood pressure (DBP) of  90 mm Hg or higher and to treat to a goal DBP less than 90 mm Hg.6

Pharmacologic treatment recommendations were updated from JNC 7. In the general nonblack population, including those with diabetes, recommended initial antihypertensive treatments include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB). In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. In hypertensive patients 60 and older, strive for a BP goal of less than 150/90 mm; in hypertensive patients ages 30 through 59, the diastolic BP goal is less than 90 mm Hg.6 In patients with diabetes and patients with chronic kidney disease, the goal for systolic blood pressure (SBP) is less than 140 mm Hg and DBP less than 90 mm Hg.6

The 2014 Hypertension Guideline Management Algorithm provides a basic strategy for initiation and ongoing adjustments to hypertension treatments (see Table 1). A medication or combination of two medications is selected based on patient characteristics as detailed above. In patients without comorbidities, a thiazide diuretic (e.g., chlorthalidone or hydrochlorothiazide or CCB) may be selected. Nonblack patients may also use either an ACEI or ARB as initial therapy.6

After initiation of blood pressure treatment, the patient should be reevaluated at a 1-month follow-up to assess blood pressure, adherence to medication, reinforce lifestyle changes and potential adverse effects.6 If a patient is not at goal blood pressure, the Panel suggests one of three strategies:6

A.     Titrate first medication before adding second medication.

B.     Add second medication before increasing dose of first medication.

C.     Start with two medication classes (separately or as fixed-dose combination).

If the patient is not a goal at subsequent visits, add and titrate a thiazide diuretic, ACEI, ARB or CCB, or titrate combination medication dosages. Continue to titrate medications to target blood pressure goal and if the patient cannot reach goal, consider adding a beta antagonist and referring to a hypertension specialist.6 Once a patient is at goal, follow up every 3 to 6 months and more often as needed, and monitor for adherence and adverse effects based on medication classes as shown in Table 2.6,7

A Foundation for Treatment

2014 has already brought about significant changes in the management of two of the most common chronic diseases. Dyslipidemia management is based on cardiovascular risk and strongly focused on LDL-lowering intensity. Blood pressure goals have also changed, as have some first-line medication recommendations.

In addition to pharmacologic management, guidelines have also clarified lifestyle changes to modify LDL and blood pressure. Adults with elevated LDL and elevated BP benefit from similar dietary patterns including increased intake of vegetables, fruits and whole grains, low-fat dairy and lean meats, low intake of saturated fats, low sugar and red meats. In addition, patients with hypertension should limit sodium intake to less than 2,400 mg/day.3 The Dietary Approaches to Stopping Hypertension (DASH) and AHA diet plans are effective for overall heart health in all adult patients. Aerobic physical activity for at least 40 minutes three to four times per week is also recommended to reduce LDL and BP.3 These updated guidelines provide a foundation to assist primary care providers in both health promotion and disease prevention of common chronic diseases.

 

Jennifer Hofmann Ribowsky is an assistant professor and the academic coordinator for the physician assistant program at Pace University-Lenox Hill Hospital in New York City. She has a master's degree in clinical pharmacology.

 

References

1. PL Detail-Document. Characteristics of the Various Statins. Pharmacist's Letter/Prescriber's Letter. May 2012. http://pharmacistsletter.therapeuticresearch.com/pl/ArticleDD.aspx?nidchk=1&cs=&s=PL&pt=2&segment=4422&dd=280606

2. Stone NJ, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013. DOI: 10.1161/01.cir.0000437738.63853.7a.

3. Eckel R, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk. J Am Coll Cardiol. 2013. doi: 10.1016/j.jacc.2013.11.003

4. PL Detail-Document, 2013 ACC/AHA Cholesterol Guidelines. Pharmacist's Letter/Prescriber's Letter. January 2014. http://prescribersletter.therapeuticresearch.com/pl/ArticlePDF.aspx?cs=&s=PRL&DocumentFileID=0&DetailID=300121&SegmentID=0

5. Preiss D, et al. Risk of incident diabetes with intensive-dose compared with moderate-dose statin therapy: a meta-analysis. JAMA. 2011;305(24):2556-2564.77. James PA, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.

7. PL Detail-Document, Treatment of Hypertension: JNC 8 and More. Pharmacist's Letter/Prescriber's Letter. February 2014. http://prescribersletter.therapeuticresearch.com/pl/ArticlePDF.aspx?cs=&s=PRL&DocumentFileID=0&DetailID=300219&SegmentID=0

 

 

 

 


Pharmacology Today Archives


     

Email: *

Email, first name, comment and security code are required fields; all other fields are optional. With the exception of email, any information you provide will be displayed with your comment.

First * Last
Name:
Title Field Facility
Work:
City State
Location:

Comments: *
To prevent comment spam, please type the code you see below into the code field before submitting your comment. If you cannot read the numbers in the below image, reload the page to generate a new one.

Captcha
Enter the security code below: *

Fields marked with an * are required.

 
 

Back to Top

© 2017 Merion Matters

660 American Avenue Suite 300, King of Prussia PA 19406

1-484-804-4888