HJNO Nov/Dec 2022

CHANGING THE CARE: HIGH BLOOD PRESSURE 14 NOV / DEC 2022 I  HEALTHCARE JOURNAL OF NEW ORLEANS   comes related to sequential care processes rely on the reliability of adhering to the process and ensuring that each step is reliably completed. STRUCTUREDCARE PROCESS FORMANAGING HYPERTENSION What does this sequential care process look like for high blood pressure management? In addition to recommendations about lifestyle modifications such as sodium restriction in the diet — not easy to do here in Louisiana — and exercise, it makes a ton of sense to start phar- macologic treatment with specified options. In a patient with a blood pressure that is more than 20/10 mm Hg away from goal, the follow- ing two medications should be started con- comitantly. In a nondiabetic patient, start with a calcium channel blocker, like amlodipine. In diabetic patients, especially those who may be losing small amounts of protein in the urine (an early sign of diabetic kidney damage) it makes more sense to start with an angiotensin recep- tor blocker, preferably one of the longer acting, more potent agents like valsartan or olmesar- tan. Both latter drugs are now generic, inex- pensive, and more potent and much longer acting than their older, weaker, shorter acting cousin losartan, which should really be dosed twice daily according to its package insert. Angiotensin receptor blockers (ARBs) are also safe and extremely well tolerated with a side effect profile comparable to placebo, although they do require some monitoring of labs. Next, it becomes important for providers to avoid common prescribing mistakes, like giving up on ARBs prematurely. With these drugs, providers need to know that it is both normal and expected for a patient’s creatinine — a measure of renal function — to increase by 30%. These drugs are not typically harmful to the kidneys, though. Indeed, they are most often protective of the kidneys and via their mechanism of action, they “unmask” the true state of renal function. This unmasking is be- cause as kidney function begins to decline, a phenomenon known as hyperfiltration ensues where actual estimates of renal function be- come inflated, and starting an ARB simply re- veals the accurate state of kidney function. But an easy mistake that providers make is to think the increased creatinine is a sign that these drugs are harming the kidneys. It can lead to inappropriate stoppage of the drug and loss of their protective benefit. However, it should be noted that increases in creatinine >30% in response to these drugs should prompt fur- ther evaluation for a condition known as renal artery stenosis, a process that can easily be captured in any well-designed management protocol. Another class of medications, known as angiotensin-converting enzyme inhibitors (or ACE inhibitors) can also be used but have more side effects than ARBs, including a rare severe allergic reaction known as angioedema. Next in line as a great choice for blood pres- sure treatment are the diuretics, in most cases a family of medications known as the thiazide diuretics. Hydrochlorothiazide, or HCTZ, is typi- cally the most commonly prescribed agent and is the drug commonly found in combinations with other agents such as ARBs and ACE inhibi- tors. However, HCTZ, like losartan, predisposes to BP lability because of its relatively short du- ration of action. Chlorthalidone, though not available in commonly prescribed combina- tion regimens, is probably a better choice. It is more potent than HCTZ, and it is so long act- ing that you can even get away with dosing it every other day. And according to the CLICK trial, published in the New England Journal of Medicine in December 2021, it remains safe and effective even in advanced chronic kid- ney disease. These drugs do require monitor- ing of potassium levels, and if potassium falls while taking them, this should prompt further evaluation for an aldosterone excess state. The above three drugs, when used in combi- nations with one another, and when combined with systems and processes to ensure that labs and BP are rechecked following dosage adjust- ments in a timely manner, will get us really close to >90% rates of hypertension control. And most electronic medical records have reminder systems that allow us to know when a patient is due to come back for labs or to have their BP rechecked. There are different ways of ensuring that BP gets rechecked, but my own tried and true method has been to utilize a feature of the electronic medical record, a “button” on the screen titled “remind me.” Whenever I have a patient whose BP is not adequately controlled, I click this “remind me” button, and a win- dow pops up on the screen where I type “BP check” followed by a date that is two to four weeks from the current date. If the patient’s BP has not been rechecked and a new BP re- entered into the system within that window of time, their name turns red, and my nurse proactively reaches out to them until we get a new BP reading entered in the system. Perfor- mance dashboards can also be created to let us know our exact rate of control for our patients along with lists of those patients who are not currently at goal. It’s not rocket science; it is simply implementing structured processes that reliably execute an evidence-driven protocol in a way that guarantees a specified outcome. In those rare cases where a patient requires a fourth agent, the aldosterone-blocking drugs spironolactone and eplerenone are extremely effective but often underutilized. States of aldosterone excess are also likely underrec- ognized. When spironolactone was first intro- duced, it was used in very high doses. At these dosages, kidney problems and high potassium were common, and providers became nervous about harming a patient from high potassium. However, at much smaller doses, spironolac- tone blocks some of the signaling that causes disease, lowers blood pressure significantly, and reduces blood pressure lability in pa- tients, especially those with aldosterone excess and salt sensitivity. As long as potassium and kidney function are carefully monitored at ini- tiation and with dosage changes, the drug is very safe in most people. Spironolactone can have some undesirable side effects however, and in these cases, the drug eplerenone can be used as an alternative. Eplerenone is the most expensive of all the drugs mentioned but can be made available for approximately $30 per month with a coupon discount card. If a patient’s blood pressure remains uncon- trolled despite being on the first three classes of agents listed above, then we should prob- ably be checking renin and aldosterone levels as part of our protocol, followed by adding spironolactone or eplerenone as the fourth agent. We should also consider secondary causes of hypertension, such as obstructive sleep apnea, renal artery stenosis, primary al- dosteronism, Cushing’s syndrome, and pheo- chromocytoma. And if new evidence informed by a randomized trial becomes available, the structured protocol can be easily modified. More importantly, if we are routinely measur- ing our results and outcomes, we can begin to learn from everyday care, because it is not possible to inform care only from randomized trials. Ensuring effective hypertension control utilizes many of the concepts discussed in