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Number 1 post: JZ
For our Week 3 discussion, I have reviewed a case of a 57-year-old African American female who is obese and presents to the clinic with high blood pressure (146/92). She exhibited high blood pressure recently at a health fair (168/99), then on several occasions soon after (145/90, 150/89, 140/88). She has a family history of hypertension and diabetes, so she is also at risk of such conditions. She had a previous episode of high blood pressure (135/95) five years ago, in which lifestyle modifications were recommended. Unfortunately, she was non-compliant in following recommendations for diet and keeping a daily blood pressure (BP) log at home. Her LDL and triglycerides were elevated then, but she failed to repeat labs. She presents today with a similar presentation. She has high blood pressure (146/92), BMI 36.6 (obese), and an elevated lipid profile (LDL 138, HDL 48, Triglycerides 170).
The first line of treatment recommended by the JNC8 would be for patients less than 60 years old to initiate a thiazide diuretic or calcium channel blocker (CCB) (Philippine Academy of Family Physicians [PAFP], n.d.). With her family history, being obese, and being an African American – having high-risk factors for diabetes, I probably would wait to begin a thiazide until ordering glucose or a1c if appropriate. The use of thiazides as antihypertensive agents can be associated with metabolic adverse events, including hyperglycemia – although it can decrease cardiovascular events, it may still be used in small doses in patients with hypertension and diabetes (Scheen, 2018). It is very patient-specific, and further assessment would be needed. As for the American Heart Association (AHA) / American College of Cardiology (ACC) guidelines, they focus on earlier diagnosis of hypertension. If blood pressure is >130/80, drug therapy is not recommended until >140/90 with risk factors for stroke prevention. With her high lipid profile, obesity, the risk for heart disease and diabetes, and her current BP 146/92, drug therapy may be more appropriate. Five years ago, diet, exercise, and weight loss may have been recommended with her past BP 135/95, but more is needed now. The ACC/AHA hypertension treatment guidelines are comprehensive, covering all aspects including diagnosis, evaluation, and monitoring, secondary causes, as well as drug and non-drug treatments. (Flack & Adekola, 2020).
My recommended medication to start this patient would be a drug called Amlodipine. Amlodipine is an antihypertensive drug that is in the calcium channel blocker drug class, which is also known as the generic amlodipine besylate or Norvasc trade name, with the initial starting dose for adults being 5 mg po daily (Lippincott Williams & Wilkins, 2021). This medication blocks the calcium from entering the cardiac muscle and dilates or widens the coronary arteries. This, therefore, decreases blood pressure and the oxygen demand on the heart (Lippincott Williams & Wilkins, 2021). As stated earlier, some may consider a thiazide diuretic, but I would consider a monotherapy until I assess her diabetes risk and a potential for hyperglycemia. We could also titrate the dose every 7-14 days, with a maximum of 10 mg po daily. But education would need to be provided again to this patient, and a provider judgment on compliance. Perhaps she is willing if she attended a health fair and took more interest in her health, as well as taking blood pressures soon after at her local drug store, as she reported. If she agreed to keep a BP log this time, I would reassess her in 14 days and her log and titrate her dose if appropriate. The nice part about this medication is its long half-life as well, of 30-50 hours, so with a history of non-compliance, she would only need to take it once a day as well.
As for side effects with Amlodipine – the most important is edema. Education is also suggested to discuss symptoms of edema, especially in the hands and feet. In an obese patient, sometimes this can be difficult, but reporting any associated symptoms with the edema as further weight gain, shortness of breath, or pitting edema, should be immediately reported. A patient can also experience a headache, fatigue, dizziness, palpitations, nausea, abdominal pain, or rash (Lippincott Williams & Wilkins, 2021). But monitoring for further hypotension is essential. Especially when starting the first dose.
Interactions with Amlodipine could occur if the patient were taking other medications. She reports not taking any other medicines, but she should be aware of potential interactions if new drugs are introduced. As Clarithromycin – it may increase amlodipine concentration, Sildenafil – may increase hypotension, and Simvastatin – may increase myopathy, so dosage shouldn’t exceed 20 mg daily if prescribed for cholesterol (Lippincott Williams & Wilkins, 2021). This would be incredibly important, especially if a provider planned to address her high cholesterol or elevated lipid profile with drug therapy.
Lastly, as discussed earlier, non-pharmacological interventions can be addressed with this patient. Lifestyle modifications could help tremendously, and the patient should be encouraged to continue to work on her diet, exercise, and lose weight. Perhaps a referral to a Registered Dietician (RD) to build up her support team. The RD could discuss the DASH (Diet Approaches to Stop Hypertension) diet, which consists of fruits and vegetables, fish, poultry, lean meats, beans, nuts, whole grains, and low-fat dairy (National Heart, Lung, and Blood Institute [NIH], n.d.). As well as a low sodium diet, keeping sodium to 1500 mg per day to help with her hypertension. Overall, continued support in using all these approaches can help this patient reach optimal health.
Number 2 post: NB
1. Please briefly discuss the first-line treatment recommendations from JNC8 and the AHA/ACC for a patient with no other major comorbidities.
The JNC 8 panel recommends using medications that show the best results of decreasing cardiovascular risk. They have advised that the first-line treatments should be limited to 4 classes of medications which include, thiazide-type diuretics, calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs), and angiotensin-converting enzymes (ACE) inhibitors. It is also suggested that thiazide-type diuretics should be the initial therapy for most patients. Although ACE inhibitors, ARBs, and CCBs are acceptable alternatives, thiazide-type diuretics continue to have the best evidence of efficacy (AJMC, 2014)
Q2. What are the recommended medications to start this specific patient on? Please provide the drug class, generic & trade name, and initial starting dose.
Studies have shown that in an Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) ACE inhibitors led to worse cardiovascular outcomes than thiazide-type diuretics or CCBs in patients with African ancestry (AJMC, 2014).
Thiazide Diuretic. Hydrochlorothiazide (HCTZ) (Microzide)12.5 mg PO daily.
Calcium Channel Blocker: Amlodipine (Norvasc) 2.5 -10 mg PO daily
Lipitor is a medication that is used to lower high cholesterol in individuals at risk of developing cardiac vascular disease. Elevated cholesterol levels are one of the six primary risk factors for developing cardiovascular disease (Texas Heart Institute, 2020).
HMG-CoA Reductase inhibitor (Statin): Lovastatin (Lipitor) 20 mg daily in the evening
Q3. Please discuss the mechanism of action of each of the drugs you listed.
HCTZ (Thiazide diuretics): Inhibits sodium chloride transport in the distal convoluted tubule.
– Lower blood pressure by increasing urine output by preventing water, sodium, potassium, and chloride from going through the walls of the nephron to be reabsorbed into the blood.
– Dilate arterioles by relaxing the smooth muscles in these blood vessel walls.
Amlodipine (CCB): Inhibits calcium influx into arterial smooth muscle cells
-Decrease BP by relaxing the vascular smooth muscle in the coronary and systemic arteries leading to decreased peripheral resistance
Lovastatin (Statins): – Inhibits HMG-CoA reductase, the enzyme responsible for cholesterol
– Increased production of LDL receptors in the liver
– Increase uptake of LDL from the plasma
– Decreased very-low-density lipoprotein (VLDL) secretion
Q4. Please discuss the side effect profile of each medication you listed.
HCTZ: Hypokalemia, hypocalcemia, hyponatremia, muscle weakness due to loss of sodium, pancreatitis
Amlodipine: hypotension, bradycardia, peripheral edema, constipation, and gingival hyperplasia
Lovastatin: Elevated liver transaminases, Headaches, Myopathy
Q5. Are there any interactions between any of the medications you prescribed?
No interactions were noted between the recommended prescribed medications.
Q6. What other non-pharmacological interventions would be suggested?
Drug therapy is one of the components of the management of hypertension, however, lifestyle changes are equally as important (Clayton, Willihnganz, 2017).
Increased healthy (DASH) diet with reduced sodium intake, (1500 mg daily)
Physical activity and weight loss
Smoking cessation
Potassium supplement 3500 -5000 mg daily
Limited alcohol consumption
These interventions are paramount for reducing morbidity and mortality associated with hypertension.
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