Download Ten possible questions for the person with

Ten possible questions for the person with hypertension
Learning objectives
 To select relevant counselling points when talking to people about optimum blood pressure
control
 To list targets for optimum blood pressure levels
 To assist in optimum choice of medications for hypertension
 To identify and predict adverse effects from medications used to manage hypertension
 To refer patients for appropriate assessment to optimise their risk management
Competencies addressed
This article addresses the following competency standards: 1.3, 2.1, 4.2, 6.1, 5.2.6.3, 7.1, 7.2
Cardiovascular disease (CVD) is the term used for heart, stroke and blood vessel diseases. It
is the leading cause of death in Australia, accounting for 33% of all deaths in Australia in
2009. Cardiovascular disease is one of Australia's largest health problems. Despite
improvements over the last few decades, it remains one of the biggest burdens on our
economy. (1)
Cardiovascular disease:
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is heart, stroke and blood vessel disease
kills one Australian every 11 minutes
affects more than 3.4 million Australians
prevents 1.4 million people from living a full life because of disability caused by the
disease
affects one in six Australians, and affects two out of three families
claimed the lives of almost 46,000 Australians (33% of all deaths) in 2008 - deaths
that are largely preventable. (1)
Lowering systolic blood pressure (SBP) by 10 mmHg or diastolic blood pressure (DBP) by 5
mmHg reduces the relative risk of cardiovascular events by about 25% and stroke by about
33%, irrespective of choice of antihypertensive.(2)
Hypertension, is a major risk factor for coronary heart disease, stroke, heart failure,
peripheral vascular disease and renal failure. The risk of disease increases as the level of
blood pressure increases. High blood pressure is also associated with other risk factors such
as tobacco smoking, being overweight or obesity. (3) The dividing line between
normotension and hypertension is arbitrary, and the decision to intervene depends on the
individual’s overall cardiovascular risk profile and the presence or absence of end-organ
damage. Antihypertensive drug treatment and lower targets are recommended for all
patients with BP sensitive conditions (e.g. stroke, diabetes or Chronic Kidney Disease (CKD))
even if initial BP is within the ‘normal’ range. Optimal BP control has been shown to:
• prevent or delay the development of end-stage kidney failure
• prevent the development of CHF and help manage symptoms of existing CHF
• prevent strokes and their recurrence. (3)
The majority of patients using antihypertensive medications fail to achieve their
recommended target blood pressure. Poor daily adherence with medication regimens and a
lack of persistence with medication use are two of the major reasons for failure to reach
target blood pressure. (4) There is no single intervention to improve adherence with
antihypertensives that is consistently effective. Medication nonadherence is a multifactorial issue. Interventions, either individually or in combination, for improving adherence
with antihypertensives that have some evidence base are: simplifying dosing regimens,
motivational strategies, unit dose packaging, educational counselling over the telephone,
refill reminders, self-monitoring, and dose-tailoring [5-8]. As medicines experts in primary
care, community pharmacists are in an ideal position to address adherence and persistence
issues in people with hypertension. (4)
The first step is for pharmacists to start to talk to patients with hypertension about issues
concerning their medication, optimum blood pressure control and risk factor reduction.
This may lead to ongoing care with a range of interventions eg
 Use of blood pressure monitoring device and recording of measurements by patient
 Use of Patient Medication Profile ( a comprehensive written summary of all regular
medicines taken by a patient that assists them in understanding and managing their
medicines by informing them how, when and why to take their medicines).
 Use of Dose Administration Aid (DAA) to assist with adherence
 Reminders for refills eg SMS ,letters, email or phone call
 Medication Use Review (MUR) to identify and resolve possible medication-related
hypertension
 Home Medicines Review (HMR) to identify and resolve possible medication-related
problems, check adherence and offer education working in a team with the general
practitioner
 Referral back to prescriber if blood pressure high, side effects noted or other
concerns
This article will provide a selection of key questions of which one or more may be used in
any order for an initial intervention to engage the patient with a short discussion which may
lead to one of the above interventions. These should be recorded under the Guild 5CPA as
interventions.
Question one: What medicines are you currently taking for blood pressure control?
This question may lead to a discussion as to:
why a range of medicines are necessary for control
 what time they are taken or is preferable
 before or after meals,
 what dose
 clarification of the many combination medicines currently available
All pharmacists will have experiences patients doubling up on medications whether it is due
to generic brands or combinations being ordered to replace individual medicines.
Prescribers are advised to start antihypertensive treatment with the lowest dose of a single
antihypertensive drug. The choice of drug should take into account contraindications,
precautions, associated co-morbidities, absolute cardiovascular risk and patient response.
National Heart Foundation (NHF) guidelines recommend starting with an ACE inhibitor,
calcium channel blocker or, in people ≥ 65 years, a low-dose thiazide diuretic or thiazidelike drug .(3) Table 1 lists co-morbidities affecting choice of antihypertensive medicine .
Table 1: Coexisting conditions and antihypertensive choice (adapted from 3, 9-11)
Co-existing condition
Drugs with a favourable
effect
Angina
ACE inhibitors, beta-blockers
(except oxprenolol, pindolol),
calcium channel blockers
Drugs with an
unfavourable effect
Beta-blockers (Cardioselective
beta blockers (e.g. atenolol,
metoprolol) may be used cautiously
in mild-to-moderate reactive airways
disease.)
Asthma, COPD
Atrial fibrillation
ACE inhibitors or ARBs
(verapamil, diltiazem or beta
blockers may help rate
control)
Bradycardia, second- or thirddegree atrioventricular block
Beta blockers, verapamil,
diltiazem
Diabetes with microalbuminuria or
ACE inhibitors, ARBs
proteinuria
Betablockers (caution) ,
thiazide diuretics
Gout
Losartan
Thiazide diuretics
Heart failure
Calcium channel blockers
ACE inhibitors, beta-blockers
(especially verapamil and
(carvedilol, metoprolol CR,
diltiazem)
nebivolol, bisoprolol), thiazide Alpha blockers in aortic
diuretics, ARBs ( note not all PBS stenosis
TGA approved) , spironolactone Beta-blockers in uncontrolled
heart failure
Kidney disease
ACE inhibitors, ARBs
Post myocardial infarction
Beta blockers (except
oxprenolol, pindolol), ACE
inhibitors, ARBs
Post-stroke
ACE inhibitors, ARBs,
Low dose thiazide- like diuretics
Pregnancy
Atenolol, oxprenolol, ACE
inhitors , ARB
If the initial drug is not tolerated prescribers are advised to try an antihypertensive from a
different class, again starting at the lowest dose. Angiotensin II–receptor blockers (ARBs)
are reserved for people who do not tolerate an ACE inhibitor. They have not been shown to
be more effective than ACE inhibitors. (2)
Table 2 lists the recommended order for initiation of antihypertensive drugs
First choice
If target BP
not reached
If target BP
not reached
• ACEI (or ARB), or
• CCB, or
• LD thiazide diuretic (or thiazide-like) [consider for people>65years only ]
• ACEI (or ARB) + CCB, or
• ACEI or ARB + LD thiazide diuretic
• ACEI or ARB
• PLUS
• CCB + LD thiazide diuretic
If target BP not reached AND adherent AND lifestyle measures in place seek specialist
advice
If target blood pressure is not obtained add a second drug from a different pharmacological
class at a low dose, rather than increasing the dose of the first drug. If this does not control
blood pressure and both drugs are tolerated, incrementally increase the dose of one drug
(other than a low dose thiazide diuretic) to the maximum recommended dose before
increasing the dose of the other drug. Each drug regimen should be trialled for at least 6
weeks before altering doses, because a stable response takes at least 3–4 weeks.(3)
Beta blockers are useful in patients with both coronary heart disease and hypertension, and
also in patients with heart failure. The effects on lipids and potassium may also be
deleterious, and they are associated with erectile dysfunction in some patients, which may
limit their use.(9) They are not currently included in the standard hypertension management
by the Heart Foundation (3)
The use of combination of ACE inhibitors and ARBs is no longer recommended except under
specialist supervision. In trials the combination worsened renal function and increased the
risk of symptomatic hypotension and hyperkalaemia. The combination did not provide
additional benefit in patients at high risk of vascular disease nor improve survival in patients
with left ventricular failure/dysfunction post MI. However despite conflicting trial results, it
may be an option, eg for selected patients with chronic heart failure or non-responsive BP,
under specialist advice. (10)
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Avoid the use of ACE inhibitors or ARBs plus potassium-sparing diuretics due to risk of
hyperkalaemia).
Avoid the use of verapamil plus beta-blocker due to risk of heart block
Question two: What other medications are you taking?
As shown in Table 1 there are a number of medical conditions that impact on the choice of
antihypertensive medication. There are also a number of prescribed medications that can
increase blood pressure as listed in Table 3
Table 3: Some prescribed medicines which may increase blood pressure (9-13)
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atomoxetine
bupropion
clozapine
corticosteroids
duloxetine
haemopoietic agents (eg darbepoetin, epoetin)
immunomodifiers (eg cyclosporin, tacrolimus)
leflunomide
MAOIs
NSAIDS
oral contraceptives
phentermine
stimulants (eg dexamphetamine, methylphenidate),
sympathomimetic agents
venlafaxine and desvenlafaxine (dose-related)
Note that rebound hypertension may occur following abrupt withdrawal of
bromocriptine and clonidine. (10)
Beware the ‘triple-whammy’. Combining an ACE inhibitor or ARB, a diuretic and an NSAID
(including selective COX-2 inhibitors and non-prescription drugs such as ibuprofen) can
cause acute renal failure. This may occur even with short-term use of the NSAID. There are
many fixed-dose combination pills that combine a diuretic with an ACE inhibitor or an ARB.
Ensure that patients and carers are aware of the dangers of using an NSAID while taking one
of these products. (9)
Question three: What non- prescribed medications are you taking?
A number of Over the Counter medicines (OTC) and complementary medicines can impact
on blood pressure control. Examples include:
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NSAIDS eg aspirin ( doses >300mg), diclofenac, ibuprofen, naproxen
sodium load e.g. antacids, urinary alkalinisers
phenylephrine and pseudoephedrine - significance is debatable but the product
information has a warning. (11,12)
A number of complementary medicines may increase blood pressure as listed in Table 4.
There is no evidence for any benefit of zinc supplementation in the absence of zinc
deficiency is limited. People taking antihypertensives should only be considered for a zinc
supplement if they are deficient in zinc. Results from the only trial investigating zinc
supplementation with an antihypertensive (hydrochlorothiazide) were inconclusive. (14)
Table 4: Complementary medicines which may increase blood pressure (3)
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American mistletoe
Angel’s trumpet
Butcher’s broom
Caffeine-containing products (e.g. guarana, black tea, colanut, green tea, mate)
Ephedra (ma huang)
Gentian
Ginger
Ginseng
Liquorice
Melatonin
Peyote
Phenylalanine
Sage
St John’s wort
Question four : Adherence
The National Heart Foundation has recently developed an online learning module for health
professionals to assist with identification of adherence issues (15).
Questions may cover suggestions such as:
 Do you take your tablets as prescribed?
 What is your system for remembering?
 What do you do when you miss a dose?
Pharmacists undertaking HMRs or MURs will check reported adherence with actual
evidence from detailed examination of dispensing records, the use of programs such as
MedsCheck or questioning scales such as self-reported Morisky scale (16) and the Tool for
Adherence Behaviour Screening. (17)
As mentioned previously adherence – or persistence to medication regimes is any area
where pharmacists can make a difference. A large Australian study showed that 10–25%
had discontinued their medicines at 6 months from the start of therapy, rising to 21–47% at
24 months (18). Reasons given for non adherence included cost, side effects, treating
conditions with no symptoms, patients not understanding condition or the benefits of
treatment and the complexity of therapy. (18) Simmons et al (2008) showed that only 44%
of Australian patients persist with their antihypertensive therapy in the long term; the
median persistence time for all antihypertensive medications is 20 months. Poor
persistence was notably higher in patients prescribed calcium channel blockers. (19)
Strategies to assist with adherence include:
 Ensure the person knows their targets and encourage self measurement
 Simplify regimen
 Use long acting agents for once a day dose
 Use combination products once individual medicines stabilised
 Use Dose Administration Aids ( DAAs)
 Set reminders in place
 Regular follow-up, encouragement by all health professionals
 Involve family where appropriate
 Motivation!
Question five: Any side effects?
Suggesting side effects may encourage the person to attribute a side effect with the
medications even although there may not be a causal association. Table 5 lists potential
side effects of some antihypertensive medications.
Table 5: Potential side effects of some antihypertensive medications (3, 9-13)
Common
ACEIs
ARBs
Calcium
channel
blockers
Thiazides
Betablockers
Constipation
-
-
+ esp
verapamil
-
-
Cough, angioedema
+
±
-
-
-
Dyspnoea
-
-
-
-
+
Gout
-
-
-
+
-
Headache, flushing
-
-
+
-
-
Hyerglycaemia
-
-
-
+
-
Hyperkalaemia
+
+
-
-
-
Hypokalaemia
-
-
-
+
-
Hyponatraemia
-
-
-
+
-
Erectile dysfunction
-
-
-
+
-
Lethargy
-
-
-
-
+
Oedema
-
-
+
-
-
Postural hypotension
+
+
+
+
- ?rare
Question six: Do you know what your BP reading is?
Many people do not know what their target is although others pay extreme interest in their
readings each time they visit the doctor. Many pharmacies test blood pressure either free or
for a small fee. A written report is professional and also provides an opportunity to provide
other key lifestyle messages. Table 6 provide targets for various disease states
Table 6: Blood pressure targets (3, 12)
Target blood pressure
(mmHg)
Conditions
<125/75
•
People with proteinuria>1g/day (with or without diabetes)
<130/80
•
People with associated condition/s or end-organ damage eg
• CHD
• diabetes
•
CKD
• Proteinuria (>300mg/day)
• Stroke/TIA
<140/90
•
People with none of the following:
• CHD, diabetes, CKD, Proteinuria(>300mg/day),
stroke/TIA
Question seven: Do you have and use a blood pressure machine?
This provides an opportunity for self – management as long as the person does not become
pre-occupied with taking readings too frequently! An offer to monitor blood pressure in
the pharmacy is another option. The correct use of the machines needs to be reinforced
both for the patient and for the pharmacist if taking readings in the pharmacy:
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Use recommended technique every time
Use regularly validated and serviced meter
Measure BP on both arms on first measurement
Ensure patient is seated and relaxed
Measure sitting and standing if orthostatic hypotension is suspected
Use right cuff size (standard, large or supersize)
Repeat and average two readings if concerned
Question eight: Do you know the benefits of keeping good blood pressure control?
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This question can reinforce the message of prevention of heart disease leading to
angina and heart attacks, heart failure, stroke; transient ischaemic attacks (TIAs),
peripheral arterial disease, and blood clotting problems. The use of the Australian
Cardiovascular Risk Calculator can be used as a motivation tool for adults over 45- 75
years. People over 75 years, people with diabetes over 60 years of age or with
microalbuminuria , those with moderate or severe chronic kidney disease , existing
severe cardiovascular disease or serum total cholesterol >7.5mmol/L have a risk
over 15% of a cardio or cerebrovascular event within the next five years. This can
be downloaded from http://www.cvdcheck.org.au/
Question nine: Lifestyle issues
The patient’s doctor may have addressed lifestyle issues or the person may initiate
discussion, Issues such as weight, diet, cholesterol, alcohol intake, and use of salt, smoking,
exercise or the possibility of sleep apnoea. The National Heart Foundation offers the follow
advice to consumers plus information about blood pressure (20):
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be smoke-free (for information on quitting smoking, call the Quitline on 13 QUIT)
reduce your salt intake
achieve and maintain a healthy body weight
limit your alcohol intake to no more than two drinks per day (for men), or one drink per day
(for women)
undertake regular physical activity.
Question ten: Targets
Following on from Question nine could be a discussion on targets and how to achieve them.
Targets include not only blood pressure and cholesterol readings but lifestyle and
adherence targets eg to lose 2 Kg weight in the next 3 months, to walk 5 days a week etc,
not to run out of tablets. Supporting long-term lifestyle changes requires motivational
interviewing certainly not possible in a busy pharmacy however newly funded Diabetes
Medication Review and other Chronic Disease State management programs for pharmacy
in the future may allow regular review of progress.
References
1. http://www.heartfoundation.org.au/information-for-professionals/data-andstatistics/Pages/default.aspx
2. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of
cardiovascular disease: meta-analysis of 147 randomized trials in the context of
expectations from prospective epidemiological studies. BMJ 2009; 338:b1665.
3. http://www.heartfoundation.org.au/SiteCollectionDocuments/HypertensionGuidelines
2008 to 2010Update.pdf
4. Lau R, Stewart K, McNamara KP, Jackson SL, Hughes JD, Peterson GM, Bortoletto DA,
McDowell J, Bailey MJ, Hsueh A, George J. Evaluation of a community pharmacy-based
intervention for improving patient adherence to antihypertensives: a randomised
controlled trial. BMC Health Serv Res. 2010;10:34. doi: 10.1186/1472-6963-10-34
5. Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment
in patients with high blood pressure in ambulatory settings. Cochrane Database Syst
Rev. 2004. p. CD004804.
6. Skaer TL, Sclar DA, Markowski DJ, Won JK. Effect of value-added utilities on
prescription refill compliance and health care expenditures for hypertension. J Hum
Hypertens. 1993;7(5):515–518.
7. Marquez-Contreras E, Martell-Claros N, Gil-Guillen V, de la Figuera-Von Wichmann M,
Casado-Martinez JJ, Martin-de Pablos JL, Figueras M, Galera J, Serra A. Efficacy of a
home blood pressure monitoring programme on therapeutic compliance in
hypertension: the EAPACUM-HTA study. J Hypertens. 2006;24(1):169–175. doi:
10.1097/01.hjh.0000198023.53859.a2.
8. Haynes RB, Yao X, Degani A, Kripalani S, Garg A, McDonald HP. Interventions to
enhance medication adherence. Cochrane Database Syst Rev. 2005. p. CD000011.
9. NPS Prescribing Practice Review 52: Treating hypertension
10. eTG Cardiovascular Therapeutic Guidelines 2012
11. Rossi S (Editor), Australian Medicines Handbook 2012 (CD-ROM). Adelaide: Australian
Medicines Handbook Pty Ltd; 2012 Jan.
12. eMIMS 2012 CMPMedica, February 2012.
13. Koda-Kimble MA, Young LY, Kradjan WA. et al. Applied Therapeutics: The Clinical Use of
Drugs, 9th edition, Lipincott Williams & Wilkins, Philadelphia, 2009.
14. http://www.nps.org.au/topics/companion_products/Zinc_supplements_with_antihype
rtensives
15. http://www.heartfoundation.org.au/information-for-professionals/onlinelearning/Pages/Adherence-toolkit.aspx
16. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a selfreported measure of medication adherence. Med Care. 1986; 24(1):67–74.
17. George J, Mackinnon A, Kong DC, Stewart K. Development and validation of the Beliefs
and Behaviour Questionnaire (BBQ) Patient Educ Couns. 2006;64:50–60.
18. Senes S & Penm E 2007. Medicines for cardiovascular health: are they used
appropriately?. Cat. no. CVD 36. Canberra: AIHW.
19. Simons, L. Ortiz, M. et al. 2008, ‘Persistence with antihypertensive medication:
Australia-wide experience, 2004–2006’ MJA; 188: 224–227
20. http://www.heartfoundation.org.au/SiteCollectionDocuments/A_Hypert_Guidelines20
08_ISC_YourBloodPressure.pdf
Questions:
Please indicate the incorrect answer in the following questions
1. Cardiovascular disease
a
accounted for 33% of all deaths in Australia in 2009.
b
is heart, stroke and blood vessel disease
c
may be reduced by lowering systolic blood pressure
d
may be reduced by lowering diastolic blood pressure
e
never needs treatment for hypertension if the person is normotensive.*
2.
a
b
c
d
e
Adherence of medication is one of the major reasons for failure to reach target
blood pressure
Adherence is not affected by the choice of medication *
Adherence may be improved by simpler dosing regimens
Adherence may be improved by Dose Administration Aids
Adherence is improved by a person knowing what they are taking and why
3. Co-existing conditions
a
ACE inhibitors or ARBs should be used for people with diabetes with
microalbuminuria.
b
After a myocardial infarction a person should not be put on a
betablocker.*
c
ACEI or ARBs heart failure patients may improve prognosis by taking an ACEI or
approved ARBs.
d
Not all betablockers are approved for use in stable heart failure.
e
Thiazide diuretics should not be used in patients with gout.
4. Medications
a
ACE inhibitors and ARBs used together are of benefit in a large number of
patients.*
b
Care should be taken if using verapamil with betablockers.
c
LD thiazides should be considered for the management of hypertension in people
>65years only.
d
Avoid the use of ACE inhibitors with potassium sparing diuretics in the
management of hypertension due to the risk of hyperkalaemia.
e
If target BP is not reached a combination of an ACE inhibitor plus a low dose
thiazide diuretic and a calcium channel blocker may be considered.
5. Drug interactions
a
Oral corticosteroids may increase blood pressure.
b
Low dose aspirin is unlikely to increase blood pressure.
c
High doses of venlafaxine may increase blood pressure.
d
Duloxetine can cause hypertension and may affect BP control if antihypertensives are
used.
e
High doses of sertraline can cause hypertension *
6
a
b
c
d
e
The triple whammy is when an ACE inhibitor or ARB is combined with a diuretic and a
NSAID.
The triple whammy is unlikely to be a concern with low dose ibuprofen, an ARB low
dose thiazide diuretic combination.*
Products such as Ural may increase blood pressure.
There is no case for taking zinc routinely with antihypertensive medications.
St Johns’ wort can cause hypertension and may affect BP control if
antihypertensives are used.
7
Side effects
a
Calcium channel blockers such as verapamil are the most likely medications to cause
constipation.
b
Hypokalaemia may occur with thiazide diuretics.
c
Hyperglycaemia may occur with thiazide diuretics and calcium channel blockers*
d
Hyperkalaemia may occur with ACE inhibitors.
e
Peripheral oedema may occur with peripherally acting calcium channel blockers.
8
Targets
a
b
c
d
e
People with proteinuria require lower BP targets.
People who have had a stroke should aim for BP<130/80.
If blood pressure is within target range the overall risk is reduced if cholesterol
levels> 7.5mmol/L. *
A man age 60years with a number of blood pressure readings averaging
140/90mmHg may not need medication but would be advised to reduce lifestyle risk
factors.
A suitable target for someone with hypertension may be gradual weight reduction.