Case 1: Weight Loss for Controlling High Blood Pressure (HBP)

Q: TA, a 38-year-old man, has a history of HBP and morbid obesity and has been taking a 3-drug combination pill once daily for many years to control his hypertension. TA’s primary care provider recently brought up his eligibility for weight loss surgery to help with blood pressure (BP) control and reduce his risk for other medical complications. However, TA would like to try to lose weight on his own before taking this approach. He has never attempted weight loss before and is not sure where to start. What information can you provide regarding nonpharmacologic and self-care approaches to weight loss?

A: The American College of Cardiology (ACC)/American Heart Association’s (AHA) updated 2017 primary prevention guidelines underscore the importance of weight loss as a nonpharmacologic approach to helping control and reduce BP in patients who are obese or overweight.1 Weight loss efforts should be multimodal, encompassing both dietary modification and exercise. In terms of dietary modifications, individuals should reduce their sodium intake to less than 1500 mg a day and consume a diet low in saturated and total fat that is full of fruits, vegetables, whole grains, and low-fat dairy, all of which are found in the Dietary Approaches to Stop Hypertension and Mediterranean diet plans, along with reducing their daily caloric consumption.1 Finally, if TA consumes alcohol, it is recommend that he limit his intake to 2 or fewer drinks each day. Physical activity recommendations include aerobic, dynamic resistance or isometric resistance exercises several times each week. Nonetheless, although dietary and lifestyle modifications are prudent, weight loss surgery may be indicated based on the degree of obesity and presence of underlying medical complications. Encourage TA to try these changes but to follow up with his physician about next steps after a 3- or 6-month trial period.


Case 2: Smoking Cessation for Reducing Cardiovascular Disease (CVD) Risk 

Q: WT, a 45-year-old man, recently discharged from the local hospital’s emergency department (ED) after experiencing chest pain, is inquiring about recommendations for smoking cessation. His medical history is significant for dyslipidemia, generalized anxiety, and hypertension, and he says that he takes atorvastatin (Lipitor), escitalopram (Lexapro) with as-needed lorazepam (Ativan), and lisinopril/hydrochlorothiazide for treating these conditions, respectively. WT was ruled out for acute coronary syndrome while in the ED, although the physician there recommended that he stop smoking to improve his BP control and reduce his risk of CVD. WT would like a recommendation for a nonprescription treatment option that he can start immediately to prevent chest pain recurrence and reduce his desire to smoke. He says he has smoked a pack of cigarettes a day for the past 20 years and that he often lights his first cigarette while still in bed each morning. What recommendations can you provide?

A: Cigarette smoking is a known modifiable risk factor for development of CVD, and the effects may manifest as acute increases in BP and arterial stiffening. Beyond the obvious health benefits on pulmonary function and reducing other long-term health consequences, smoking cessation may reduce WT’s CVD risk and his elevated BP. Make sure to provide a recommendation for establishing a quit date, along with education on the symptoms of nicotine withdrawal and how to manage those with pharmacologic approaches. Notably, for WT, who has a comorbid anxiety condition, point out that anxiety, insomnia, and irritability may worsen with the withdrawal of nicotine and this should be monitored accordingly. Additionally, discuss exploration of smoking triggers and the need for other lifestyle modifications to support the cessation effort. In terms of supporting quitting smoking using pharmacologic approaches, drug therapy often works best in conjunction with behavioral support and counseling. Sharing local or regional programs to support smoking cessation may be helpful in this case. Because WT is seeking a nonprescription medication to immediately help support this effort, either the nonprescription nicotine gum, lozenge, or patch could be considered, based on his preference. Make sure to offer education on the dosage, depending on the product selected. Appropriate follow-up should be established with the pharmacist or primary care provider to gauge the success of the effort.


Case 3: Nutrient Depletion Associated with Diuretic Therapy

Q: AA, a 62-year-old man, was recently discharged from the hospital after having palpitations. His physician told him that his potassium level was very low and that, upon discharge, he should continue to take his water pill with a banana each day. AA’s medical history is significant for allergies, diabetes, gout, and hypertension, and he takes allopurinol, amlodipine, atorvastatin, hydrochlorothiazide, an intranasal steroid, metformin, and pioglitazone each day. He was prescribed a potassium supplement. However, the pills are too large to swallow and unpalatable, and AA would like to talk to a pharmacist about alternatives. What information can you provide regarding the need for electrolyte supplementation with concomitant diuretic use?

A: Thiazide diuretics are known to deplete many electrolytes and other nutrients through various pathways, including increasing urinary potassium, sodium, zinc, and thiamine excretion and reducing magnesium reabsorption in the kidneys.2 Common electrolyte disturbances associated with thiazides include thiazide-induced hyponatremia, hypokalemia, and hypomagnesemia. Additionally, dietary potassium intake, independent of the need for supplementation, has been linked to improvements in BP control and is recommended as long as comorbid kidney disease and the risks of potassium accumulation do not exceed these benefits.1 In AA’s case, suggest that he consider dissolving the potassium tablets in applesauce or pudding, depending on the formulation, to ensure that he is obtaining the amount of potassium recommended by his physician. If AA’s potassium levels are chronically low upon follow-up, it may be appropriate for him to consider increasing his dietary fruit and vegetable consumption, along with low-fat dairy, some fish and meats, nuts, or soy-containing foods, which are all considered good sources of potassium.1 Remind him that a medium-size banana contains, on average, about 12 mEq of potassium, as well.3


Case 4: BP Self-monitoring 

Q: KM, a 30-year-old pregnant woman, is looking for a recommendation for a BP cuff. At her 20-week prenatal visit, her obstetrician/gynecologist (OB/GYN) was concerned about her borderline-high BP. After a 24-hour urine collection, KM was instructed to purchase a BP monitor and to record her reading twice daily at home to share at her next follow-up. She has no significant past medical history, had 1 previous pregnancy with no complications, and only takes a prescription prenatal vitamin. What recommendations or education on self-monitoring BP can you offer?

A: BP self-monitoring is commonly recommended for evaluation and medical decision making for patients outside the ambulatory-care office. The ACC/AHA’s 2017 update for detection and management of HBP delineates a 6-step checklist for ensuring patients who are self-monitoring accurately obtain their BP readings to appropriately inform health decisions.1 Notably, ACC/AHA recommends the following1:
  • Assurance of optimal technique (eg, supporting the arm with the middle of the cuff placed on the upper arm, depending on the type of device selected; use of proper-sized cuff; and use of a validated/calibrated BP measuring device)
  • Average BP readings from 2 or more assessments performed on 2 or more occasions
  • Document findings (eg, helping the patient create or obtain a log for recording results at the frequency recommended by her OB/GYN, specifying the time of day the reading was recorded and any other relevant variables)
  • Record benchmarking and repeated measures (eg, taking BP in both arms at the first medical visit and separating subsequent measurements by 1 to 2 minutes)
  • Proper patient preparation (eg, avoiding caffeine, exercise, and smoking in the 30 minutes prior to the assessment and talking during the measurement; back supported for 5 minutes or longer; relaxing; and sitting on a chair with feet flat on the floor)
  • Provide a record of in-office readings to the patient

A pharmacist is well positioned to help KM select an appropriate BP monitoring device, including a cuff of appropriate size, and reminding the proper technique for using it and recording her readings at home.


REFERENCES
  1. 1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e13-e115. doi: 10.1161/HYP.0000000000000065.
  2. Nutrient depletion tool: hydrochlorothiazide. Natural Medicines website. naturalmedicines.therapeuticresearch.com. Accessed December 2018.
  3. Mayo Clinic. Potassium supplements (oral route, parenteral route). Mayo Clinic website. mayoclinic.org/drugs-supplements/potassium-supplement-oral-route-parenteral-route/description/drg-20070753. Updated October 1, 2018. Accessed December 15, 2018.