Mohamed Jalloh, PharmD

Hypertension is a leading modifiable risk factor for heart disease and stroke.

 According to the CDC, between 2011 and 2014, one-third of adults 18 years and older had hypertension, which was uncontrolled (>140/90 mm Hg) in 47% of these patients. The prevalence of hypertension is highest in elderly patients (Table 1

), non-Hispanic African American patients (Table 2

The US Preventive Services Task Force recommends screening for high blood pressure (BP) every 3 to 5 years in adults aged 18 to 39 years with normal BP (<130/85 mm Hg) and every year for adults 40 and older at increased risk (BP 130-139/85-89 mm Hg, overweight or obese, African American).

A diagnosis of hypertension is made with at least 2 BP readings >140/90 mm Hg. If the clinic BP is ≥140/90 mm Hg, a second reading should be obtained with 24-hour ambulatory BP monitoring or home BP monitoring. It is suitable to begin treatment without a second reading if a patient exhibits signs of severe hypertension or organ damage (eg, headache, altered mental status, nausea, vomiting, chest pain, left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy).

GUIDELINES FOR MANAGING HYPERTENSION; BLOOD PRESSURE GOALS 

According to the Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8), the treatment goals for adults are as follows

• All adults with diabetes or chronic kidney disease: <140/90 mm Hg

The JNC 8 guideline released in 2013 is the gold standard clinical practice guideline for the management of hypertension (Table 5). The American Society of Hypertension, in conjunction with the International Society of Hypertension (ASH/ ISH), also offers a clinical practice guideline, which was published in 2013. The 2 guidelines are similar; however, the ASH/ISH guideline has stages 1 and 2 hypertension designations similar to the JNC 7 guideline and a systolic BP treatment target of 150 mm Hg beginning at age 80 (instead of 60). Also, unlike the JNC 8 guideline, the ASH/ ISH guideline recommends beta-blockers as firstline treatment for patients with coronary artery disease and heart failure.

 are recommended prior to, or in conjunction with, pharmacologic interventions. The projected effects on BP persist as long as the lifestyle option is sustained and may serve as an additional motivator for patients.

INITIAL PHARMACOLOGIC THERAPY AND CLINICAL PEARLS 

The goal of hypertension management is to attain and maintain the target BP. If the goal is not reached within a month of initial pharmacotherapy with 1 agent, one of the following strategies may be used:

• Titrate to maximum dose and then add a second drug

• Add a second drug before achieving maximum dose of the initial drug

Another possible option is to initiate 2 drugs at the same time. This is especially recommended when the systolic BP is >160 mm Hg and/or the diastolic BP is >100 mm Hg. If the target BP is not achieved with 2 drugs, select a third drug and titrate it to the maximum recommended dose. See online table 7 for possible initial agents and population-specific recommendations.

Hypertension is known as the silent killer due to its asymptomatic nature.

 About 40% of patients discontinue their medications during their first year of treatment.

Inappropriate adherence leads to higher morbidity, adverse events, and increased costs. Strategies to improve adherence include motivational interviewing (addressing patient’s fears, valued outcomes, and societal pressures), detailed drug education (including likelihood of adverse effects), discussing adherence during every office and pharmacy visit, telephone counseling, reducing pill burden/daily frequency, and using combination pills.

Table 7. Initial and Population-Specific Therapy

Initial antihypertensive treatment should include thiazide-type diuretics, a CCB, an ACE inhibitor, or an ARB alone or in combination.

An ACE inhibitor and an ARB should never be used in combination.

After a myocardial infarction, an ACE inhibitor or an ARB may be more appropriate.

For patients with heart failure, thiazide-type diuretics are more effective than a CCB or an ACE inhibitor. ACE inhibitors have been more effective than CCBs.

Thiazide-like diuretics, chlorthalidone and indapamide, are significantly more potent than the thiazide-type diuretic hydrochlorothiazide at similar dose levels.

In the general African American population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or a CCB alone or in combination.

Regarding thiazides vs ACE inhibitors: thiazides are more effective in improving cerebrovascular, heart failure, and combined cardiovascular outcomes.

Regarding CCBs vs ACE inhibitors: ACE inhibitors have a 51% higher rate of stroke in African American patients and are less effective in reducing blood pressure.

Regarding treatment in the general African American population vs treatment of African Americans with diabetes, comparisons were not reported between ACE inhibitors and CCBs.

In patients with chronic kidney disease, initial antihypertensive treatment should include an ACE inhibitor or an ARB alone or in combination with another drug class, regardless of race or diabetes status.

This recommendation applies to patients with or without proteinuria.

It is based on improved kidney outcomes and less evidence for improved cardiovascular outcomes.

There is no evidence to support ACE inhibitor or ARB use in patients older than 75 years. ACE inhibitors or ARBs, as well as thiazide-type diuretics and CCBs, may be beneficial.

ACE inhibitor = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; CCB = calcium channel blocker.

Hypertension should be approached as a modifiable risk factor for comorbid conditions. Pharmacists should continue to help optimizing pharmacotherapy, promoting adherence, and identifying drug-related causes. Lifestyle modifications should be emphasized for all patients, with and without hypertension.

Melissa Atocha, PharmD, is a 2016- 2017 PGY-1 OLE health ambulatory care resident. Mohamed Jalloh, PharmD, is an assistant professor at Touro University California.

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Articles

Hypertension: Revealing the Silent Killer

Each year, more than 80,000 Americans die of vaccine-preventable infections despite the wide availability of vaccines.

 Many patients are inadequately vaccinated due to lack of access to vaccinations, poor relationships with their health care providers, or negative attitudes toward immunizations.

 To address these concerns, pharmacists, who are highly accessible and trusted by patients, have been indirectly enlisted to help improve vaccination rates.

Pharmacy-based immunization services have significantly improved vaccination rates. In a letter to pharmacists, Rear Admiral Anne Schuchat, MD, assistant surgeon general and principal deputy director of the CDC, lauded pharmacists for significantly improving vaccination rates among patients over the past 20 years.

 However, for some vaccinations, rates are still below 50%. For example, in 2014, only 35.8% of adults 18 and older received the flu vaccine, indicating that a high percentage of adults remained vulnerable to the influenza virus.

 Therefore, innovative strategies should be implemented to improve vaccination rates among patients.

Appointment-based services are purported to effectively increase vaccination rates by scheduling vaccinations to improve pharmacy workflow. This model can be useful for very busy pharmacies by helping to predict patient volume and the types of immunizations needed.

 However, this model can place a threshold on the number of patients who can be vaccinated in a given time period.

The walk-in—based model may be useful for pharmacies with smaller volumes because this model is more likely to disturb larger pharmacy workflow due to the randomness with which patients may require services.

Pharmacists and other staff can call patients to schedule appointments. They can also help to synchronize medication refills with scheduled immunization appointments in order to decrease subsequent trips to the pharmacy.

Pharmacists can provide mobile or offsite clinics to improve immunization rates. They have historically reached out to organizations, such as school systems, apartment complexes, and churches, to ensure greater access to immunizations. For example, one North Carolina pharmacy administered more than 12,000 immunizations by offering offsite clinics at such locations as local businesses, school systems, and health fairs.

Pharmacists can consider contacting the human resources departments or main offices of organizations such as school systems and apartment complexes to set up immunization services.

 When preparing to provide offsite services, pharmacists must ensure that the relevant immunization materials (eg, privacy wall, sharps container, alcohol swabs) are in mobile containers to facilitate transportation.

There is a growing need for accessibility to immunization services. To ensure pharmacists can continue to provide high-quality immunization services, they must be educated on best practices, reimbursement design, and seamless integration of these services into their practices. Pharmacists should ensure they have thorough knowledge of immunizations and seek training if they do not. The American Pharmacists Association has a comprehensive immunization certificate program to ensure that pharmacists are fully trained.

Pharmacists continue to be one of the most accessible health care professionals, making them a key medium for vaccine administration. Whether to follow an appointment model or a walk-in model depends on patient load and availability of vaccines. Pharmacists should consider conducting immunization clinics at various locations, such as school systems, community centers, and houses of worship (if permitted), to improve access to immunizations.

Mohamed Jalloh, PharmD, is an associate professor in the Clinical Sciences Department at Touro University, California, and a community pharmacist for Walgreens.

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Vaccinations: Pharmacists Shot at Improving Community Health

Cardiovascular disease (CVD) (eg, coronary heart disease, stroke, peripheral artery disease) remains the leading cause of death among men and women.

 Although various CVD risk factors exist, most can be controlled or prevented through public health promotion, continuum of care, high-risk patient referral, and medication therapy management.

 Pharmacists worldwide are uniquely positioned to address most of these interventions for the primary prevention of CVD.

	The Framingham risk score and the American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease (ACC/AHA ASCVD) risk estimator are being used to evaluate the 10-year risk of experiencing primary CVD.

 Both tools evaluate various risk factors (eg, age, gender, total cholesterol, high-density lipoprotein cholesterol) and further risk for CVD. The ACC/AHA tool is currently being used to evaluate CVD risk by the US Preventive Services Task Force (USPSTF).

 These tools are available through various apps, and pharmacists can ask their patients simple questions to evaluate their risk.

	After evaluating a patient’s CVD risk, a pharmacist can provide evidence-based nonpharmacotherapeutic, lifestyle, and/or pharmacotherapeutic recommendations. The USPSTF recommends nonpharmacotherapy, or lifestyle, modifications for all patients to lower their risk for primary CVD, especially for patients who are obese.

 These recommendations include smoking cessation, weight loss, increased physical activity, daily consumption of fruits and vegetables (eg, a Mediterranean diet), and low consumption of alcohol.

 These behavioral counseling interventions are purported to reduce total cholesterol levels by an average of 0.12 mmol/L (95% CI, 0.16-0.07), low-density lipoprotein cholesterol levels by 0.09 mmol/L (95% CI, 0.14-0.04), systolic blood pressure by 2.03 mm Hg (95% CI, 2.91-1.15), diastolic blood pressure by 1.38 mm Hg (95% CI, 1.92-0.83), diabetes incidence by 42% (relative risk [RR], 0.58; 95% CI, 0.37-0.89), and weight outcomes by a standardized mean difference of 0.25 (95% CI, 0.35-0.16).

	Various Cochrane reviews have suggested that interventions, such as consumption of green/black tea, nuts, omega-6 fatty acids, coenzyme Q10, selenium, and increased dietary fiber, have not been shown to improve or change primary prevention of CVD.

Therefore, these complementary and alternative health interventions should be discouraged until further data suggest they have a consistent benefit in the primary prevention of CVD.

Aspirin is the key pharmacotherapeutic agent for the primary prevention of CVD. Currently, the USPSTF specifically recommends the use of low-dose aspirin (75-81 mg) for primary prevention of CVD in patients 50 years and older with the following health parameters

			At least a 10% 10-year CVD risk (using the ACC/AHA ASCVD risk calculator)

	These recommendations are based on a systematic review of 11 primary prevention trials of nearly 120,000 patients that suggested a 6% reduction in all-cause mortality (RR, 0.94; 95% CI, 0.89-0.99) during follow-up of 5 to 10 years. However, there is insufficient evidence suggesting a primary prevention benefit for patients younger than 50 years or older than 70 years; therefore, these patients should receive aspirin for specific indications (eg, post myocardial infarction). Regarding safety, there was a 58% increase in the risk of gastrointestinal bleeding (RR, 1.58; 95% CI, 1.29-1.95). Hence, many clinicians suggest that the use of aspirin for primary prevention of CVD be individualized based on a comparison of the risk versus the potential benefit.

	In addition to aspirin, other medications are used for primary prevention of CVD (Table 2

 The ACC/AHA ASCVD risk estimator may help determine whether statin therapy would be appropriate for managing dyslipidemia.

	CVD continues to be the top cause of mortality among patients worldwide. Therefore, primary prevention of CVD is highly recommended for decreasing its incidence. Pharmacists are well positioned for disseminating interventions that can modify the risk factors for CVD, as they evaluate the risk among all their patients and make nonpharmacotherapeutic recommendations, such as increased physical activity, weight loss, consumption of fruits and vegetables, and low alcohol consumption. In moderate- to high-risk patients, aspirin remains the primary agent for preventing CVD. Other pharmacotherapeutic interventions include attaining blood pressure and diabetes treatment goals and adhering to statin therapy, if indicated.

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Cardiovascular Disease: Getting to the Heart of the Matter

Medication administration remains the hallmark of medication therapy. A general goal of pharmacotherapy is to ensure a therapeutic drug concentration in specific areas of the body or throughout the body. Among the various routes of administration, 2 emerge as competing choices for clinical use: oral administration and topical administration.

Oral administration remains the most commonly used route for medication. An oral medication generally becomes active when it passes from the gastrointestinal tract and the liver into the blood.1 Most newly approved medications are developed in oral forms to improve patient access and adherence, especially for oncology-related medications. The Table

 identifies the most common oral dosage forms.

Topical administration allows drug absorption at specific areas of the skin, thereby limiting systemic absorption. Systemic absorption varies based on factors such as the site of application, the area of the skin, and the specific medication.

 Among the various forms of topical administration, transdermal administration remains innovative and historically safe.

Transdermal administration delivers medication through the skin via patches or other delivery systems.

 Although comparable to oral-dosage forms in efficacy, transdermal patches have numerous advantages over oral forms. First, transdermal administration avoids the first-pass effect of metabolism associated with the oral route. Therefore, transdermal administration allows for improved bioavailability. Second, transdermal administration allows prolonged release of certain medications, which can improve patient adherence. Third, transdermal administration minimizes adverse effects due to lower drug peak concentrations.

Although transdermal administration appears promising compared with the oral route, the mechanics of transdermal administration are not compatible with all medications.

 For example, transdermal administration requires a medication to be hydrophobic; therefore, hydrophilic medications theoretically would not absorb well transdermally, which is an issue when systemic absorption is desired.

Some researchers have tried to determine whether the oral route or the transdermal patch is superior.

 To evaluate the risk of vascular events in postmenopausal women, Mohammed et al conducted a systematic review of 15 observational studies of 28,160 women who received either oral or transdermal therapy.

 Overall, the researchers found that oral estrogen therapy was associated with a 66% higher risk of venous thromboembolism (VTE) and a 109% higher risk of deep vein thrombosis (DVT) compared with use of the transdermal patch in 11 studies.

 A major limitation of this finding is the observational studies themselves: such studies cannot account for all possible confounding factors. This suggests that transdermal estrogen therapy may be safer than oral estrogen therapy, especially in patients at risk for DVT or VTE.

Da Costa et al also conducted a systematic review of 22 randomized controlled trials of 8275 patients to evaluate the effects on pain and the safety of oral and transdermal opioids versus placebo. The researchers found there was not a significant difference between oral and transdermal opioids in improving pain in patients.

 The transdermal patch remains a compelling treatment alternative to oral administration for certain disease states, and research on the safety and efficacy of transdermal formulations of oral medications is ongoing.

Mohamed Jalloh, PharmD, is an assistant professor at Touro University in Vallejo, California, and a community pharmacist at Walgreens.

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Among the various routes of administration, 2 emerge as competing choices for clinical use: oral administration and topical administration. 