HYPERTENSION1. INTRODUCTION This document was produced by Euro Pharm Forum and the WHO CINDI Program me in order to improve hypertension control at the community level. It is mainly addressed to community pharmacists. The document should be used as a guide when organizing pharmacy-based work within hypertension management. However, it can also be used by individual health professionals interested in this type of work. The document consists of the following parts: • Background information including the development of this project; • Partnership and the involvement of pharmacists; • The pharmacy-based hypertension management model including the objectives, target population, intervention strategies as well as documentation and evaluation of process and outcomes; • The organizational structure of the project; • Guidance on training and preparatory work; • Guidance for pharmacists on how to implement a hypertension management service. Checklists and forms are attached to facilitate work at local level. High blood pressure, termed "hypertension," is a condition that afflicts more than 50 million Americans and is a leading cause of morbidity and mortality. Hypertension is much more than a "cardiovascular disease" because it affects other organ systems of the body such as kidney, brain, and eye. Tens of millions of Americans are not even aware of being hypertensive because it is usually asymptomatic until the damaging effects of hypertension (such as stroke, myocardial infarction, renal dysfunction, etc.) are observed. Hypertension is an intermittent or persistent elevation of the blood pressure (systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg) or (a systolic and diastolic pressure of 20 mm Hg above the normal baseline pressure). Hypertension has recently increased in incidence throughout the world. It is thought that the stresses of everyday life with a change in the dietary habits and lack of exercise has led to the increasing incidence of hypertension. Previously hypertension was predominant only in industrialized and developed LORDS INTERNATIONAL COLLEGE Page 1 HYPERTENSION countries. However, of late there has been a sudden increase in the number of cases in developing countries. It is often asymptomatic, but even so, the detection rate has increased over the past three decades. Untreated, hypertension can lead to devastating end organ damage. Therefore, clinicians have the important responsibilities of first detection and then adequate treatment. Women, the elderly, and minorities have traditionally been underrepresented in clinical trials dealing with hypertension. Recently, detection and treatment of hypertension in women and the elderly have received special emphasis.In the first symposium article, Drs Eileen Reynolds and Robert Baron summarize findings to date in studies including these two populations, and they discuss the implications for treatment choices. Lifestyle modification is a key initial intervention for hypertension, and continuation of changes should be encouraged even if drug therapy becomes necessary. In the second article in this symposium, Drs Christian Zellner and Krishnankutty Sudhir describe the benefits patients can gain from exercise, weight loss, cessation of smoking, reduced sodium and alcohol intake, and increased potassium and calcium intake. These modifications can improve overall health in addition to lowering blood pressure. Many patients require drug therapy to control their hypertension, and various classes of agents are available (including the new angiotensin II-receptor antagonists). There has been considerable controversy over which class or agent is best for initial therapy. As Dr. Hal Barron and I explain in the third article in this symposium, what is most important is for clinicians to work closely with patients to find a treatment regimen that is tolerable and effective. Many patients' hypertension, especiallyin the past, has proved tobe refractory to antihypertensive therapy. A few patients have a secondary cause of hypertension that must be identified and treated, but most, we now understand, have primary hypertension that is being inadequately treated. In the fourth symposium article, Drs Daumil Gandhi and Hector Santiesteban discuss patient and physician-related variables that interfere with treatment and describe how their identification often allows successful control of hypertension. LORDS INTERNATIONAL COLLEGE Page 2 HYPERTENSION DEFINITION Hypertension is high blood pressure. Blood pressure is the force of blood pushing against the walls of arteries as it flows through them. Arteries are the blood vessels that carry oxygenated blood from the heart to the body's tissues. DESCRIPTION Blood flows through arteries it pushes against the inside of the artery walls. The more pressure the blood exerts on the artery walls, the higher the blood pressure will be. The size of small arteries also affects the blood pressure. When the muscular walls of arteries are relaxed, or dilated, the pressure of the blood flowing through them is lower than when the artery walls narrow, or constrict. Blood pressure is highest when the heart beats to push blood out into the arteries. When the heart relaxes to fill with blood again, the pressure is at its lowest point. Blood pressure when the heart beats is called systolic pressure. Blood pressure when the heart is at rest is called diastolic pressure.When blood pressure is measured, the systolic, pressure is stated first and the diastolic pressure second. Blood pressure is measured in millimeters of mercury (mm Hg). For example, if a person's systolic pressure is 120 and diastolic pressure is 80, it is written as 120/80 mm Hg. The American Heart Association considers blood pressure less than 140 over 90 normal for adults. Hypertension is a major health problem, especially because it has no symptoms. Many people have hypertension without knowing it, in the United states, about 50 million people age six and older have high blood pressure. Hypertension is more common in men than women and in people over the age of 65 than in younger persons. More than half of all Americans over the age of 65 have hypertension. It is also more common in African-Americans than in white Americans. Hypertension is serious because people with the condition have a higher risk for heart disease and other medical problems than people with normal blood pressure. Serious complications can be avoided by getting regular blood pressure checks and treating hypertension as soon as it is diagnosed. LORDS INTERNATIONAL COLLEGE Page 3 HYPERTENSION 2. BACKGROUND INFORMATION 2.1. Rationale Hypertension remains a major health problem in most countries because of its impact on the population attributable mortality and morbidity due to insufficient hypertension prevention and control at community level. Indeed, hypertension accounts for more than 5.8% of total deaths, 1.9% of years of life lost and 1.4% disability adjusted life years all over the world. These figures are more dramatic in the formerly socialist economies countries (1). Concerning hypertension control, blood pressure is under control in less than 20% of patients with hypertension in many countries. This is mainly because hypertension often remains undetected, although easy to diagnose. Even though hypertension may be simple to treat, it very often remains untreated. Despite the availability of useful non-drug therapy and potent medications, treatment is too often ineffective, mainly as a consequence of the lack of patient’s compliance with therapeutic regimens. Therefore, hypertension prevention and control in the community is currently a pivotal challenge. This largely justifies the implementation of a set of interventions mainly focused on: • development and implementation of standardized health information systems; • development of integrated interventions based on interdisciplinary and intersectorial collaboration; • intensified public health education; • continuing education programmes for health professionals; • improved hypertension management practices. LORDS INTERNATIONAL COLLEGE Page 4 focusing on hypertension control. prevention and control and to draw up the basis for a collaborative project. The intervention strategies would be the following: • Health education • Screening for risk factors • counseling • Blood pressure measurement • Training in self-measurement of blood pressure.HYPERTENSION 2.3. LORDS INTERNATIONAL COLLEGE Page 5 . A draft project proposal on developing a pharmacy-based hypertension management model was presented to the EuroPharm Forum and the Forum established a task force comprising 14 countries. a joint meeting of the CINDI Working Group on Hypertension and the EuroPharm Forum was organized (3). 2. To strengthen collaboration among health professionals in the implementation of a balanced health promotion and disease prevention the CINDI programme initiated collaboration with EuroPharm Forum.2. The CINDI initiative The Action Plan of the WHO CINDI (Countrywide Integrated Noncommunicable Diseases Intervention) Programme aims to realize the potential for prevention of noncommunicable disease (NCD) through the prevention and control of major risk factors common to NCD through community based interventions and through primary health care systems (2). obesity and smoking. The idea was to involve pharmacists actively in the prevention and control of major risk factors such as hypertension. It was agreed that the main goal of the project would be to improve hypertension control at community level through the more active involvement of pharmacists in the prevention. It was aimed to share the first practical experiences of involving pharmacists in hypertension. Networks of family physicians and pharmacists working on the primary prevention of NCD with focus on hypertension have been established in a number of countries. Development of a collaborative project In 1997. In 1995 a plan for collaboration was outlined. The plan included the development of a project on noncommunicable disease prevention. detection and management of hypertension. and a followup evaluation is completed for a patient at each visit at the pharmacy. The sharing of information between partners is beneficial to all involved and is likely to contribute to care. a care plan developed. The Pharmaceutical Care concept is defined as: the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life (5). Sharing information and expectations with the patient in the team is a way of achieving patient concordance and successful hypertension management. The assessment consists of a systematic medication review by the pharmacist to identify drug related problems and other health problems. PARTNERSHIP IN HYPERTENSION MANAGEMENT A recent CINDI survey (4) identified that lifestyle modifications and better patient compliance with antihypertensive medication ought to be priority issues in hypertension management. Patients are both beneficiaries and team members. This practice is delivered when an assessment is performed. In the field of hypertension management a GP is the key partner for a patient in primary health care. This calls for a more active role of primary health care and for multidisciplinary collaboration. Partnership is a fundamental strategy of multidisciplinary collaboration. The next step – the care plan – consists of a definition of patient goals in collaboration with the GP and the pharmacist’s intervention to resolve possible problems by LORDS INTERNATIONAL COLLEGE Page 6 . Multidisciplinary collaboration means concerted action among various partners of both health and non-health sectors.HYPERTENSION 3. Pharmaceutical care is an example of a patient care system depending on partnership and a team approach. the continuity of which relies on effective movement of this shared information across disciplines and on follow-up. Within the framework of multidisciplinary collaboration the partners have different opportunities to identify and solve problems. • Pharmacists can verify and improve the patients’ knowledge about necessary lifestyle modifications and the use of medicines and improve compliance with therapy. Community pharmacies are visited by both people who are sick and people who are in good health. The pharmacist can complement the GP in hypertension management in various ways (7–10). Pharmacists are therefore the most highly accessible members of the primary health care team. use of medicines and prevention. • Pharmacists can monitor therapeutic outcomes of hypertension management. • Pharmacists can identify drug therapy related problems and recommend possible solutions including referrals to the GP. Adherence to long-term therapies Pharmaceutical care is an effective approach to improving adherence to long-term therapies.HYPERTENSION 4. 4.2. Advice. information and referral by community pharmacists have been demonstrated to significantly improve adherence to antihypertensive therapy and improve blood pressure control Pharmacists are also involved in giving information and service to patients with hypertension. Regular visits of a person with hypertension for prescribed drug therapy puts the patient in a regular contact with the pharmacist and provides opportunities for intervention. A community pharmacist is a highly trained professional who can be seen without appointment. Therefore community pharmacies have a potential for health promotion and disease prevention. WHY SHOULD PHARMACISTS BE INVOLVED IN HYPERTENSION MANAGEMENT 4. It LORDS INTERNATIONAL COLLEGE Page 7 . • Pharmacists have an extensive knowledge about the principles of drug therapy.1. Advantages More than 20 million people visit a pharmacy every day in Europe. The following are examples of such opportunities where pharmacists participate with other health care professionals in community based health promotion and disease prevention and management programmes. in an informal setting which is often considered to be part of an every day shopping experience. assistance to reach compliance and recommendations to their GPs regarding drug therapy. Spain (20) and United Kingdom (21) show that community pharmacists are capable of providing pharmaceutical care leading to good results with regards to optimizing the drug therapy and achieving more cost-effective outputs. Currently. new programmes involving community pharmacies in Good Pharmacy Practice programmes or pharmaceutical care programmes are being developed and introduced. and according to the document a number of national standards have to be elaborated within this area. LORDS INTERNATIONAL COLLEGE Page 8 .HYPERTENSION has been shown that after having provided appropriate health education and monitoring services to patients with hypertension. primary care pharmacists managed to get patients to use less expensive antihypertensive medication (11). Patients with hypertension received pharmaceutical care from community pharmacies comprehending education. Some midterm results from Portugal (19). The first element of Good Pharmacy Practice is Health Promotion and Ill-health Prevention. It represents the first set of standards for pharmacy practice developed by the Profession (17) and with the international standard for Good Pharmacy Practice (GPP) in Community and Hospital Pharmacy Setting developed by WHO (18). The involvement of pharmacists in hypertension management falls in line with the Good Pharmacy Practice document developed and adopted in 1994 by the Pharmaceutical Group of the European Union (PGEU). In several studies the intervention group showed a significant decrease in mean blood pressure . detection and management of hypertension. who might have unidentified high blood pressure. Description of the model The proposed model is intended for use in any country. smokers. any adult pharmacy customer may be counselled on health promotion and disease prevention. overweight persons. population health status and priorities and available resources and skills.3. These three levels (listed below) do not appear in any order of importance or order of progression. In order to make the protocol suitable in various countries three different levels of intervention strategies are proposed. The evaluation goal is to document the output and to monitor and assess outcomes of a pharmacybased hypertension management model. Situations differ between countries. However. As each country has different local settings and structures. Objectives The main goal is to improve hypertension control at community level through a more active involvement of pharmacists in the prevention. • those with unfavourable CVD risk profile (e. persons with diabetes and/or high level of cholesterol). THE PHARMACY-BASED HYPERTENSION MANAGEMENT MODEL 5. a uniform model is not applicable. and priorities regarding the implementation of the three types of intervention will be set at local level. LORDS INTERNATIONAL COLLEGE Page 9 . The operational goal is to establish a pharmacy-based hypertension management model. Target population The target population is the pharmacy customers with special focus on: • those being treated for hypertension. The model is thoroughly described in the Guidelines.g. 5.HYPERTENSION 5.2.1. 5. e. • to obtain and reinforce informed compliance. It would be an advantage if the pharmacy could set up audiovisual equipment to improve health education of the customer.HYPERTENSION Certain requirements have to be met by the pharmacies implementing the project.3. If level two and three of intervention strategies are implemented.g. The pharmacy customer counselling comprises lifestyle modifications. • to identify possible drug related problems and report them to the GP. 5. Simultaneous screening for other cardiovascular risk factors can be provided.3. in particular to adult individuals with unfavourable cardiovascular risk profile.1. adequate physical activity and stopping smoking.2. 5.3. Level three: Management of hypertensive patients on treatment Goals: • to monitor patients with hypertension on treatment and to refer to the GP those who do not achieve an adequate blood pressure control. healthy diet. Level two: Detection Goal: • to contribute to early detection of hypertension by measuring blood pressure of a customer and referring possible persons with possible hypertension to the GP. • to provide health education to patients with hypertension about necessary lifestyle modifications.3. At this level advice on healthy lifestyles is given to pharmacy customers. LORDS INTERNATIONAL COLLEGE Page 10 . The staff must be trained and relevant information material must be available. It is recommended that the pharmacy has a special area for ensuring privacy. it is necessary to provide the necessary training of pharmacists and calibrate the equipment for blood pressure measurement. Level one: Primary prevention Goal: • to promote healthy lifestyle for CVD prevention through health education. 5. • patient counselling and information on drug treatment (use of medicines. • measuring informed therapeutic compliance. since it complements the GP’s role and helps to ensure therapeutic compliance. • monitoring of patient health problems. Level three contributes to the monitoring of patients with hypertension on treatment. The monitoring of patients with hypertension on treatment comprises: • regular blood pressure measurement. possible side effects. • teaching of self-measurement of blood pressure and its recording in a diary. Examples of goals to be achieved at each level: LORDS INTERNATIONAL COLLEGE Page 11 . • reporting possible drug related problems to the GP. interactions with other drugs and contraindications).HYPERTENSION • to advise on treatment regimen to patients with hypertension. preferences and beliefs. It is particularly important that the pharmacist follows-up on the patient’s blood pressure and compliance to treatment in between the patient’s visits to the GP. • to teach about self-measurement of blood pressure. • counselling on lifestyle modifications. HYPERTENSION LORDS INTERNATIONAL COLLEGE Page 12 . mortality rate and hypertension detection.9. The pharmacy should keep a log over activities connected with the project. By evaluating the appropriateness of the model training can be judged and the value of the involvement of pharmacists in hypertension management can be documented. To assess the extent to which the programme has attained the proposed objectives.HYPERTENSION 5. General epidemiological indicators such as stroke. The documentation and evaluation of the project is thoroughly described in the Guidelines for pharmacists. treatment and control rates are not feasible for measuring at pharmacy level and therefore not included in the protocol. It is recommended to carry out ad hoc surveys about health professionals and pharmacy customers’ satisfaction.4. The log is divided into three levels. Examples of the indicators are in Chapter 9. Documentation and evaluation All pharmacists are encouraged to set up evaluation as part of the implementation of pharmacybased hypertension management. In the log the pharmacist should register the indicators. several indicators have been proposed (see Chapter 9). LORDS INTERNATIONAL COLLEGE Page 13 . International level EuroPharm Forum has appointed a Task Force Manager for the project and a CINDI/EuroPharm Forum Steering Committee has been established in order to ensure the preparation and coordination of the international project together with effective fund-raising. The National Task Force should: 1. ORGANIZATIONAL STRUCTURE OF THE PROJECT Successful implementation of the project requires that appropriate organizational structure be established. identify suitable areas for pilot studies. create and manage information about the international CINDI Pharmacy-based hypertension management programme. coordinate the project implementation in participating pharmacies 6. It is recommended that the collaboration between pharmacists and GPs be established at international.HYPERTENSION 6. make a strategy for the implementation for the Task Force Members in the International Task Force. collect data from the participating pharmacies 7. which would be responsible for the project at national level. analyze project implementation results LORDS INTERNATIONAL COLLEGE Page 14 . draft the project manual for the pharmacies 4. The Task Force Member and the pharmaceutical association(s) in cooperation should establish a National Task Force. 2. Contacts with the national CINDI team and with relevant patients associations should be established. provide educational materials 3. On the basis of this protocol the Task Force Manager should: 1. run training courses for pharmacists 5. 4 National level Pharmaceutical associations interested in participating in the project have to appoint a Task Force Member to start the project in their country. manage feed back of core data and national experiences. 3. if pilot studies are necessary 2. national and local level with well defined tasks. 4. give the National Task Force feedback on local experiences and the data from the project. if convenient. adjust the project protocol and the pharmacy manual to local conditions in consultation with the National Task Force. the GP’s and other relevant health care representatives. A contact group could consist of representatives from the patient association (if any). elaborate an action plan for the implementation of the project in cooperation with the National Task Force. 3. It is recommended to establish a local contact group in support of the project. collect data from the project.HYPERTENSION Local level – pharmacy level The pharmacies which have been chosen for the project should: 1. establish a local task force. 6. 2. LORDS INTERNATIONAL COLLEGE Page 15 . 5. implement the project. • how to improve informed compliance. The National Task Force is responsible for the necessary procedures.HYPERTENSION 7. contraindications etc. • communication skills and patient education.. LORDS INTERNATIONAL COLLEGE Page 16 . • links between pharmacist and the national association including agreement forms. side effects. • antihypertensive medication: types of medication used to control hypertension and their effects. 8. Training courses should be offered to pharmacists and skilled staff (if convenient) of the participating pharmacies at national and local level. TRAINING AND PREPARATORY WORK To facilitate the implementation of the hypertension management model it is recommended to elaborate and run special training programmes. • registration forms for evaluation purposes. • pharmaceutical care. In some countries it is only permitted to keep patient files if the patient has given written informed consent. ETHICAL ASPECTS In many countries it is necessary to obtain approval from the Ethical Committee if the project is implemented as a research project. It is recommended to organize local training seminars for small groups and ask the local health professionals to participate. The national programme should be supported by the pharmaceutical association(s). The training programme should be based on the guidelines on how to run a pharmacy-based hypertension management model and cover the topics outlined below: • introduction to cardiovascular disease. • levels of responsibility of pharmacists and staff at the pharmacy. • techniques for measuring blood pressure. • hypertension. • primary prevention of hypertension (lifestyle modifications). The National Task Force is responsible for obtaining approval and should also make sure if other national approvals are required for a project of this kind. • leaflets to give information about hypertension and cardiovascular diseases. • pharmacy manual. press releases) to promote the activity.e. practical training in blood pressure measurement. Preparatory work includes making project material available. • leaflets to give information about lifestyle modifications and antihypertensive medication. LORDS INTERNATIONAL COLLEGE Page 17 . Before implementing the project pharmacies should be provided with project material: • information material to promote screening activities in pharmacy windows. • information material (i. At the seminar the pharmacists should get written information about: • methods for blood pressure measurement • validation and calibration of devices for blood pressure measurement • hypertension (material produced for the training course).HYPERTENSION The training course should also include case studies. • forms for documentation. patient education and recommendations for calibration of the device for blood pressure measurement. therefore. obviously in close cooperation with the GP There are three levels of intervention strategies which are in line with different levels of time commitment from the pharmacist and trained staff. • recommended action for the pharmacist.HYPERTENSION 9. Introduction These guidelines outline various ways in which pharmacists can participate in the pharmacybased hypertension management model. National pharmaceutical associations of member countries are. naturally. free to use these guidelines or adapt them for implementation in their own countries. in order to record all steps taken when providing a pharmacy-based hypertension management service. GUIDELINES FOR THE IMPLEMENTATION OF THE PHARMACY-BASED HYPERTENSION MANAGEMENT MODEL 9. therefore. both at national and local levels. We have taken into account the usual limited amount of time available when dispensing in a pharmacy and. These guidelines aim to be of practical use and include some useful tools for the community pharmacist. the forms are not extensive. be adjusted to each country’s own reality. We draw your attention for the need to fill in the forms available. depending on national or individual plans. such as: • checklists of certain aspects that should not be forgotten when providing a hypertension management service. Remember this valuable data will be the only source of information available to assess the impact of pharmacists’ action in a hypertension management service. LORDS INTERNATIONAL COLLEGE Page 18 . in order to encourage data storage and recording. All these tools are just guidelines for intervention strategies which should.1. pharmacists can choose which level(s) of intervention (service) they are able to provide. so that. • protocols designed to harmonize procedures at the pharmacy. • forms to be filled at the pharmacy (can be adapted to pharmacy computerized databases). to limit alcohol intake. flyers or through posters/videos displayed in the pharmacy. the adult individuals most at risk to adopt healthier lifestyles in order to prevent high blood pressure and associated cardiovascular diseases. to reduce salt intake. Psychosocial stress seems to be another risk factor of high blood pressure. Level 1 – Primary prevention Goal: • to promote healthy lifestyle for CVD prevention through health education. These measures are used for four complementary reasons: • to lower blood pressure in an individual patient • to reduce the need for antihypertensive medicines • to minimize associated risk factors in an individual • to prevent hypertension and associated CVDs. regular use of contraceptives. in particular.2. Gradient of risk for CVDs increases with the increase of risk factors in an individual. smoking 6. This level is designed for pharmacists and trained staff to advise pharmacy customers and. excessive intake of calories 2. a lifestyle modification for hypertension control requires management of overall cardiovascular risk profile. Advice should be given verbally and may be completed with written information such as leaflets.HYPERTENSION 9. Based on this evidence. high intake of salt 3. The strategies have been clearly identified: to lose weight if overweight. inadequate physical activity 5. excessive intake of alcohol 4. LORDS INTERNATIONAL COLLEGE Page 19 . There is general consensus on the modifiable risk factors of elevated blood pressure: 1. high intake of saturated fatty acids 7. to maintain adequate fruits and vegetables intake. to stop smoking and to control fat intake. They reduce the profile of risk factor for atherosclerosis and may improve overall health. to increase physical activity on a regular basis. 3. This reinforces the need for a close cooperation between health professionals. Simultaneous screening for other cardiovascular risk factors can be provided. restricted to the boundaries of the medical profession. organ damage and aetiology are important with regard to future complications that may arise. it should be stressed that when managing hypertension all cardiovascular risk factors should be assessed and controlled. Obtaining an accurate blood pressure measurement is important in any situation. hence.HYPERTENSION 9. The detection consists of: • blood pressure measurement and assessment • possible screening for other risk factors. if necessary. are beyond the scope of this document since they imply a clear diagnosis of the patient and are. Operational classification of hypertension by blood pressure level* Normal blood pressure for adults is defined as systolic blood pressure below 140 mmHg and diastolic blood pressure below 90 mmHg. However. Hypertension may also be classified by extent of organ damage and aetiology which. however. Mercury or aneroid sphygmomanometers or automated devices for blood pressure measurement are available. When using automated devices it is recommended to choose exclusively the LORDS INTERNATIONAL COLLEGE Page 20 . Level 2 – Detection Goal: • to contribute to early detection of hypertension by measuring blood pressure of a customer and referring possible persons with possible hypertension to the GP. However. 9. Follow-up of patients with hypertension at the pharmacy should include: • regular blood pressure measurement and other relevant health parameters LORDS INTERNATIONAL COLLEGE Page 21 . since it complements the doctor’s role and helps to ensure therapeutic compliance. Level 3 – Management of patients with hypertension on treatment Goals: • to monitor patients with hypertension on treatment and to refer to the GP those who do not achieve an adequate blood pressure control. * This classification was defined by WHO/ISH in 1999 (29) and follows in principle the definition and classification provided in 1997 in the 6th Report of the Joint National Committee.HYPERTENSION internationally validated ones (see table I) and they must be periodically calibrated. It should be noted that aneroid devices could become inaccurate without the person measuring blood pressure noticing that. The follow-up of such patients by the pharmacist is particularly important between the patient’s visits to the doctor. • to obtain and reinforce informed compliance.4. This model implies that at this level. pharmacists monitor patients with hypertension on the nondrug/ drug treatment prescribed by the physician. • to identify possible drug related problems and report them to the GP. • to teach about self-measurement of blood pressure. • to advise on treatment regimen to patients with hypertension. The above table provides the classification of blood pressure levels in adults over the age of 18. This blood pressure levels should be complemented with the global cardiovascular risk profile as stated in the 1999 WHO/ISH guidelines (29) and in the 2003 WHO/ISH Statement (31). Hypertension is defined as a systolic blood pressure of 140 mmHg or higher and/or a diastolic blood pressure of 90 mmHg or higher in subjects who are not taking antihypertensive medication. • to provide health education to patients with hypertension about necessary lifestyle modifications. It has also been adopted by the ESH/ESC in 2003 (30) for the management of patients with hypertension. Blood pressure measurement should be performed according to the recommendations listed in these Guidelines. The lower the blood pressure. usually permanent issue. Reinforcement of compliance Compliance with a prescribed non-drug/drug treatment is a long-term. hence reducing cardiovascular morbidity and mortality. 9. 9. The following points should be particularly emphasized: • blood pressure goals and benefits for patient resulting from optimal control • the frequent lack of symptoms of hypertension • the reasons for treatment • possible side effects of drug treatment • the need for continuous (usually lifetime) treatment and extended follow-up LORDS INTERNATIONAL COLLEGE Page 22 . requiring ongoing educational efforts from pharmacists as a complement to medical advice. Pharmacists should inform patients with hypertension on relevant aspects related to drug treatment (medicine(s) taken.4.1. dosage regimen.4. Patient counselling and information on drug treatment There is evidence that early treatment may reduce the likelihood of developing more severe hypertension at a later time. the lower the risk of both stroke and coronary events.HYPERTENSION • patient counselling and information on treatment • reinforcement of therapeutic compliance • identification of possible drug related problems and report to the GP • counselling on lifestyle modifications • patient counselling and information on self-medication • teaching self-measurement of blood pressure. interactions and contraindications). possible side effects. The following six classes of antihypertensive agents are more commonly prescribed for the firstline treatment of patients with hypertension: – thiazide diuretics – β-blockers – calcium channel blockers – angiotensin converting enzyme (ACE) inhibitors – angiotensin II receptor blockers – α-blockers. Full information should be given to patients with hypertension on treatment.2. Self-measurement of blood pressure may be helpful to ensure the patient compliance with the treatment for certain patients. LORDS INTERNATIONAL COLLEGE Page 23 . Pharmacists may help patients choose the most adequate device for self-measurement and its correct use. Patient counselling and information on self-medication Pharmacists should discourage patients with hypertension to take certain medicines capable of inducing hypertension. Teaching of self-measurement The modern concept of health promotion and disease prevention determines patient’s empowerment.4. 9. self-measurement of blood pressure. even in patients on drug treatment. are of paramount importance and enable the use of fewer medicines in lower doses. is a powerful strategy to improve compliance and it encourages patients to have a more active role in blood pressure overall management. 9. without medical or pharmaceutical advice: • oral corticosteroids • non-steroidal anti-inflammatory drugs (NSAIDs) • oral and nasal decongestants • oral contraceptives • amphetamines • liquorice • bicarbonate.3. This has the advantage of providing more frequent measurements. which are also taken in a more relaxed setting.HYPERTENSION • the risk of complications if compliance with treatment fails.4. Patient education makes a significant contribution to positive patient outcomes. In fact.4. Patients should also be aware that lifestyle measures. It is known that the presence of health professionals may cause some emotional rise in blood pressure (―white-coat effect‖). as a complement to health professionals blood pressure assessment. • Pharmacists and patients should be aware that home blood pressure readings are on average lower than values recorded by health professionals. hence reducing side effects. in case of referral or previously set appointment. patients and relatives should receive appropriate instructions and training in order to ensure reliable measurements. However. will give a reasonable indication to both the patient and pharmacist of blood pressure control. depending on the severity of hypertension. in which blood pressure measurements from all sources and changes of drug treatment.HYPERTENSION • Self-measurement of blood pressure is a simple and economic tool to obtaining a blood pressure profile. Table 1. After a time this diary becomes a valuable record of blood pressure trends and can be presented to the pharmacist. The same card should be presented to the GP. List of validated blood pressure devices according to the Association for the Advancement of Medical Instrumentation (AAMI) and the British Hypertension Society (BHS) (Updated December 2002) that could be used for self-measurement of blood pressure LORDS INTERNATIONAL COLLEGE Page 24 . • Patients with mild and moderate hypertension should be given a patient card. may be recorded. a once-a-month measurement may be sufficient. Blood pressure measurement should be performed according to the recommendations listed in these Guidelines. In routine practice a twice mdaily measurement of blood pressure twice a week. Once the level of blood pressure is controlled. when existing. HYPERTENSION LORDS INTERNATIONAL COLLEGE Page 25 . its intake should be limited to no more than two drinks (each containing 10 g alcohol) per day. (20 g is approximately equivalent to 2 small glasses of wine. brandy or vodka)). – Isometric exercise such as heavy weight lifting should be avoided.HYPERTENSION 9. cured. – Sufficient consumption of fruits and vegetables. It should be limited to a maximum of 6 g/day. Fat intake should be limited to not more than 30% of daily energy and most saturated fats should be replaced with unsaturated vegetable oils or soft margarines. If alcohol is consumed. a pint of beer or 2 measures of mspirits (whisky. individuals should avoid salted.5. 30–45 min per day) depending on each individual and initial level of fitness. LORDS INTERNATIONAL COLLEGE Page 26 . • Regular physical activity – Dynamic isotonic exercise (brisk walking. hiking) is recommended on a regular basis (3–4 times a week. cycling. swimming. • Healthy diet – Reduction of salt intake. In practice. running. Checklist for lifestyle measures that contribute to lowering blood pressure • Weight reduction Body Mass Index (BMI) should be lower than 25 kg/m2. It is recommended to eat a variety of fruits and vegetables several times per day (at least 400 g per day). pickled. Severely obese patients (BMI over 37) should be encouraged to consult a specialist. processed and smoked food and not add salt to food when or after cooking. The importance of healthy eating and physical activity should be emphasized to maintain weight after a satisfactory level has been achieved. rowing. step climbing. – Control of fat intake. – Reduction of alcohol intake. BMI = Weight in Kg (Height in m)2 Overweight/obese individuals (BMI over 25) should be encouraged to set a long-term target for weight loss at a slow and gradual rate. bupropion). – Verbal advice given on lifestyle modifications should be enforced by written information (e. a.1. Attitude of observer Before taking the blood pressure. • Smoking cessation. If any interruption occurs. a. Explanation to the individual The first step in blood pressure measurement is adequate explanation of the procedure. otherwise the cuff may be deflated too rapidly.4. leaflets. a. This is perhaps the single most powerful lifestyle measure for the prevention of both cardiovascular and noncardiovascular diseases in hypertensive patients. and should not rush the procedure. LORDS INTERNATIONAL COLLEGE Page 27 . Patient education Illustrated instruction materials are helpful in this context. the exact measurement may be forgotten and an approximation made.6. • Control of diabetes (under medical surveillance). Protocol for the procedure of blood pressure measurement common to all devices (mercury/aneroid sphygmomanometers and automatic devices) An accurate and validated device must be used for blood pressure measurement. a. Position of the patient. All hypertensive patients who smoke should receive appropriate counselling and assistance for smoking cessation and drug treatment when needed (nicotine replacement. Attitude of patient Patients should be encouraged to relax and be advised that neither they nor the observer should talk for the few minutes before or during the blood pressure measurement.2. Those having blood pressure measured for the first time should be told that there is minor discomfort caused by inflation of the cuff. etc).g. a.HYPERTENSION – Patients with health problems including individuals with years of sedentarism should first get advice from a doctor. 9.5. articles for the public. The procedure a. the observer should be in a comfortable and relaxed position.3. The blood pressure should always be documented as soon as it has been measured. Arm position The forearm must be at the level of the heart as denoted by the mid-sternal level. Pharmacists should be alerted for possible hypertension induced by certain medicines: oral contraceptives. ―Cuff hypertension‖ There is unequivocal evidence that either too narrow or too short a bladder (under cuffing) will cause overestimation of blood pressure – so called ―cuff hypertension‖ – and there is growing evidence that too wide or too long a bladder (over cuffing) may cause underestimation of blood pressure. if reproducible differences greater than 20 mmHg for systolic or 10 mmHg for diastolic pressure are present on consecutive readings.9. non-steroidal anti-inflammatory drugs (NSAIDS). and when they lose their grip the cuff should be discarded. Velcro surfaces must be effective. for the arm to be supported during blood pressure measurement. 5 min is suggested to rest before blood pressure measurement is taken. oral corticosteroids. Arm support It is essential. a. a. Which arm? Bilateral measurement should be made on first consultation and. a.1. Source: Reference 33 (Adapted version) 9. a. The cuff and bladder Tapering cuffs should be long enough to encircle the arm several times: the full length should extend beyond the end of the inflatable bladder for 25 cm and then should gradually taper for a further 60 cm.HYPERTENSION Blood pressure is usually measured with the individual in the sitting position. It should be possible to remove the bladder from the cuff so that the latter can be washed from time to time. oral and LORDS INTERNATIONAL COLLEGE Page 28 .7.8.7.6. the patient should be referred for further evaluation. Checklist for screening risk factors In providing non-drug treatment (lifestyle modifications) advice or referrals. pharmacists could screen for the following other cardiovascular risk factors in addition to blood pressure measurements: • Smoking • Overweight/Obesity (BMI> 25 kg/m2) • Low physical activity (less than 30 min of moderate physical activity 3–4 times per week) • High total cholesterol (equal or higher than 190 mg/dl) • Diabetes mellitus • Men > 55 years • Women > 65 years.9. a. monoamine oxidase inhibitors. If the first drug prescribed does not lead to a satisfactory fall in blood pressure. etc 9. report this to the doctor or refer the patient to his/her doctor who may increase the dose or add a second drug. bicarbonate. 2. oestrogen therapy. Pharmacists should encourage patients with hypertension on treatment to consult their GP on a regular basis and to follow the instructions and recommendations given. blood pressure values extremely low or no response – and the pharmacist should also report this to the doctor who may substitute an agent from other of another class). refer the patient to the doctor who may increase the dose. (In other cases. cyclosporine. Hypertension in most patients is controlled by one or two antihypertensive agents. In the case of patients with diabetes it is recommended to achieve a blood pressure lower than 130/80 mmHg. Pharmacists should never forget to remind the patients about non-drug treatment of hypertension LORDS INTERNATIONAL COLLEGE Page 29 . check therapeutic compliance. Recommended follow-up based on the management of patients with hypertension on treatment : In general. ergot alkaloids.HYPERTENSION nasal decongestants. If therapeutic compliance is not the problem. If blood pressure is not adequately reduced with two antihypertensive agents it is worth checking that the patient is actually taking the prescribed medication. add a third medicine or change therapy. there may be a safety problem related to the medication – if the patient is having significant adverse effects. 1. there may be a problem related to noneffectiveness of drug therapy and the pharmacists should. erythropoietin.8. If this is not a problem. it is desirable to achieve a blood pressure level lower than 140/90 mmHg. The traditional approach to the drug treatment of hypertension has been step care. amphetamines. in that case. The data registration forms are enclosed in annex 1. Documentation and evaluation at Level 1: Primary prevention The documentation and evaluation should be performed on structure(s). The pharmacy keeps a log (Form 1) over activities connected with the project. Evaluation at level one comprises: LORDS INTERNATIONAL COLLEGE Page 30 . The log is divided into three levels according to the three levels of intervention strategies.9. Instruments for measuring satisfaction will be provided by the Task Force Manager or obtained at national level. List of Indicators Documentation and evaluation of the project in general The documentation and evaluation should be performed on structure (s). 1. Ad hoc survey about professionals and patients satisfaction should be carried out.HYPERTENSION 9. The National Task Force receives a copy of the files and records and of the log on a pre-arranged basis (monthly or quarterly). The data registration forms are enclosed in annex 1. If translation and a national adaptation are necessary. process (p) and outcome (o). In the log they should register information on the indicators mentioned in the table. the National Task Force will take care of this. process (p) and outcome (o). process (p) and outcome (o). 2. The data registration forms are enclosed in annex 1. Documentation and evaluation at Level 2: Detection The documentation and evaluation should be performed on structure(s). The National Task Force receives a copy of the files and records and of the log (monthly or quarterly).HYPERTENSION The pharmacy keeps a log (Form 1) over activities connected with the project. LORDS INTERNATIONAL COLLEGE Page 31 . The pharmacist keeps records of the blood pressure measurements and the performed screening for risk factors (Form 2).HYPERTENSION The pharmacy keeps a log over activities connected to the project as mentioned above. Documentation and evaluation at Level 3: Management of hypertensive patients on treatment The documentation and evaluation should be performed on structure(s). The data registration forms are enclosed in annex 1. 3. The registrations at level 2 should contain sufficient information for registering the indicators mentioned in the table. Evaluation at level 3 comprises: LORDS INTERNATIONAL COLLEGE Page 32 . outcome(o) and intermediate outcome(o). process(p). The National Task Force will receive a copy of the files and records as well as a copy of the log and form 2 (monthly or quarterly). The pharmacist keeps records of the blood pressure measurements and the performed screening for risk factors (Patient Profile – Form 3). The patient receives a Patient Card (Form 4) giving almost the same information as the Patient Profile – Form 3. the medical treatment of the patient and control rates. Form 3 contains a table for registration of current status at repeated consultations and an overview of the current medication.HYPERTENSION The pharmacy keeps a log over activities connected to the project as mentioned above. LORDS INTERNATIONAL COLLEGE Page 33 . Registrations on level 3 should contain sufficient information for registering the indicators mentioned in the table. The National Task Force will receive a copy of the files and records as well as a copy of the log and form 3 (monthly or quarterly). Task Force giving information about hypertension detection. high ceiling : k+spairing : 2.enalapril.HYPERTENSION 10. CLASSIFICATION: 1.ANGIOTENSIN" : (AT-1 RECEPTOR)BLOCKERS losertain.telmesartain.lecidipine. 3.DIURETICS: thaizides : hydrochlorthaizides.ACE INHIBITOR : captopril.valsartain.BETA+ALFA ADRENERGIC BLOCKERS : labetalol.CALCIUM CHANNEL BLOCKERS : verapamil. ARERIOLAR+VENOUS sodium nito prusside.minoxidil.VASODILATORS : ARTERIOLAR hydralazine. 7.etc.BETA ADRENERGIC BLOCKERS : propranolol.ramipril. 8.candesartain.CENTRAL SYMPATOLYTICS : clonidine.phentolamin.nifedipine.perindopril.felodipine.phenoxybenzene. 5.amiloride.etc. 4.fosinopril.metoprolol. LORDS INTERNATIONAL COLLEGE Page 34 .irbesertain.chlorthilidone.cavedilol 6.methyldopa.ALFA ADRENERGIC BLOCKERS : prazocin.etc.atenolol.ditiazem.etc.terazocin. 9.diazoxide. spironolactone.doxazocin.indapamide furesomide.lisinopril. This effect is associated with positive calcium balance and is associated with an increase in bone mineral density and reductions in fracture rates attributable to osteoporosis. Alternatively. Mechanisms of action : The members of this class of diuretics are derived from benzothiadiazine. such as chlortalidone and metolazone. but are likely to decrease glomerular filtration rate. There are several categories of diuretics. Thiazide may be combined with ACE inhibitors to increase diuresis without changing plasma potassium concentrations.HYPERTENSION 10. This includes forced diuresis. lowers the intracellular Ca2+ concentration so that more Ca2+ may diffuse into the cell via apical Ca2+-selective channels (TRPV5). By a lesser understood mechanism. Their combined effects on potassium cancel each other out.[12] The term "thiazide" is also often used for drugs with a similar action that do not have the thiazide chemical structure. in turn. While ACE inhibitors cause diuresis with potassium retention. Because of their promotion of calcium retention. thiazides increase the activity of the Na+/Ca2+-ATPase (Na+-Ca2+ antiporter) on the basolateral membrane to pump more Ca2+ into the interstitium. making them useful in preventing calcium-containing kidney stones. thiazides are used in the treatment of Dent's Disease or idiopathic hypercalciuria. Thiazide diuretics also increase calcium reabsorption at the distal tubule. although each class does so in a distinct way. This. thiazide increases potassium excretion. an antidiuretic such as vasopressin is an agent or drug which reduces the excretion of water in urine. Thiazides have no major effect on renal blood flow. less Ca2+ in the cell increases the driving force for reabsorption from the lumen. further slowing the course of osteoporosis. Thiazides : Thiazides also lower urinary calcium excretion. thiazides directly stimulate osteoblast differentiation and bone mineral formation. They control hypertension in part by inhibiting reabsorption of sodium (Na+) and chloride (Cl−) ions from the distal convoluted tubules in the kidneys by blocking the thiazide-sensitive Na+-Cl− symporter. By lowering the sodium concentration within the epithelial cells. In other words. LORDS INTERNATIONAL COLLEGE Page 35 . These agents are more properly termed thiazide-like diuretics.1 diuretics A diuretic is any substance that promotes the production of urine. All diuretics increase the excretion of water from bodies. such as furosemide.4% of filtered sodium in the urine. torsemide. Some of this response is due to augmentation of the action of parathyroid hormone. which is a competitive antagonist of aldosterone. furosemide and bumetanide Potassium-sparing diuretics: potassium is spared and not lost as much as in other diuretics. The term "potassium-sparing" refers to an effect rather than a mechanism or location. and as Insig in Australia. Other examples of high ceiling loop diuretics include ethacrynic acid.HYPERTENSION Thiazides are also thought to increase the reabsorption of Ca2+ by a mechanism involving the reabsorption of sodium and calcium in the proximal tubule in response to sodium depletion. preventing sodium reabsorption. which leads to an excretion of water in the urine. Loop diuretics. Spironolactone prevents aldosterone from entering the principal cells. whereas water normally follows sodium back into the extracellular fluid. LORDS INTERNATIONAL COLLEGE Page 36 . This is huge when compared to normal renal sodium reabsorption which leaves only about 0. highceiling diuretics : High ceiling diuretics may cause a substantial diuresis – up to 20% of the filtered load of NaCl (salt) and water. Indapamide: Indapamide is a thiazide-like diuretic drug marketed by Servier.Indapamide is marketed as Natrilix outside the US. The US trade name for indapamide is Lozol. the term almost always refers to two specific classes that have their effect at similar locations: Aldosterone antagonists: spironolactone. Aldosterone normally adds sodium channels in the principal cells of the collecting duct and late distal tubule of the nephron. Epithelial sodium channel blockers: amiloride and triamterene. as well as decompensated cardiac failure. inhibit the body's ability to reabsorb sodium at the ascending loop in the nephron. A similar agent is potassium canreonate. nonetheless. generally used in the treatment of hypertension. and are therefore often synonymous with high ceiling diuretics. Combination preparations with perindopril (an ACE inhibitor antihypertensive) are also available. Loop diuretics have this ability. is a major stress hormone. through AT1 receptor stimulation. The angiotensin II receptor blockers have differing potencies in relation to blood pressure control. Some of these drugs have a uricosuric effect.2 ANGIOTENSIN RECEPTOR BLOCKERS Angiotensin II receptor blockers are primarily used for the treatment of hypertension where the patient is intolerant of ACE inhibitor therapy. More recently. they were reported to have a remarkable negative association with Alzheimer's disease (AD).HYPERTENSION 10. 88% of hypertensive males with sexual dysfunction reported improvement in at least one area of sexuality. they have been used for the treatment of heart failure in patients intolerant of ACE inhibitor therapy. and because (ARBs) block these receptors. Lisinopril has been found less often effective than candesartan at preventing migraine. and are thus only rarely associated with the persistent dry cough and/or angioedema that limit ACE inhibitor therapy[citation needed]. the particular agent used may vary based on the degree of response required. The number of men reporting impotence declined from 75.8%. and may delay the progression of diabetic nephropathy. Those patients taking angiotensin receptor blockers (ARBs) were 35—40% less likely to develop AD than those using other antihypertensives. telmisartan (Micardis).3% to 11. They do not inhibit the breakdown of bradykinin or other kinins. Irbesartan and losartan have trial data showing benefit in hypertensive patients with type II diabetes. Candesartan is used experimentally in preventive treatment of migraine. in addition to their anti-hypertensive effects. Other ARBs include candesartan (Atacand). In one study after 12 weeks of treatment with an ARB called losartan (Cozaar). with statistically differing effects at the maximal doses. A retrospective analysis of five million patient records with the US Department of Veterans Affairs system found different types of commonly used antihypertensive medications had very different AD outcomes. and Valsartan (Diovan) Angiotensin II. When used in clinical practice. may be considered for the treatment of stress-related disorders. particularly candesartan. LORDS INTERNATIONAL COLLEGE Page 37 . In 2008. and ramipril. Despite their effectiveness.HYPERTENSION 10. beta blocker. Beta-blockers vary within the class regarding their properties. Beta-blockers that have low intrinsic sympathomimetic activity (ISA). Potential major risks however were mainly found to be associated with short-acting CCB's. lisinopril.3 ACE INHIBITOR An ACE inhibitor (or angiotensin-converting-enzyme inhibitor) is a medication pharmaceutical drug used primarily for the treatment of hypertension and congestive heart failure. and have been known to have multiple side effects. and high lipophilicity may be more effective. glaucoma. Frequently prescribed ACE inhibitors include perindopril. 10. low membrane stabilizing activity. and to reduce chest pain caused by angina pectoris.This group of drugs causes dilation of blood vessels which results in lower blood pressure. thereby decreasing the tension of blood vessels and blood volume.5 BETA ADRENERGIC BLOCKERS Adrenergic beta-receptor blockaders (beta-blockers) are "drugs that bind to but do not activate beta-adrenergic receptors thereby blocking the actions of beta-adrenergic agonists. Adrenergic beta-antagonists are used for treatment of hypertension. and anxiety". migraine headaches. cardiac arrhythmias. In treating heart disease ACE inhibitors are usually used with other medications. Calcium channel blockers are also frequently used to alter heart rate. LORDS INTERNATIONAL COLLEGE Page 38 . thus lowering blood pressure. angina pectoris.4 CALCIUM CHANNEL BLOCKERS A calcium channel blocker (CCB) is a chemical that disrupts the movement of calcium (Ca2+) through calcium channels. However. A typical treatment plan will often include an ACE inhibitor. ACE inhibitors inhibit angiotensin-converting enzyme (a component of the blood pressureregulating renin-angiotensin system). the most widespread clinical usage of calcium channel blockers is to decrease blood pressure in patients with hypertension. a long acting nitrate and a calcium channel blocker in combinations that are adjusted to the individual patient's needs. to prevent cerebral vasospasm.CCB drugs devised to target neurons are used as antiepileptics[citation needed]. high beta 1-selectivity. 10. CCB's often have a high mortality rate over extended periods of use. enalapril. CCBs are particularly efficacious in treating elderly patients. captopril. and oppositionality. and scleroderma. Both of these actions make your blood pressure go down. panic disorder or posttraumatic stress disorder (PTSD). hypertension. They combine the effects of two types of medicines. they are also often used to treat the symptoms of BPH (benign prostatic hyperplasia).6 BETA+ALFA ADRENERGIC BLOCKERS Alpha-beta blockers belong to a larger class of medicines called adrenergic inhibitors. impulsivity. such as generalized anxiety disorder. Panic and PTSD. The result is that your heart beats more slowly and with less force. They behave like alpha blocker medicines when they affect special receptor cells in the smooth muscles of your blood vessels. When these chemicals are blocked. It improved disturbed behavior by reducing aggression. Kinzie and Leung prescribed the combination of clonidine and imipramine to severely traumatized Cambodian refugees with Anxiety. your blood vessels relax and widen so that blood flows through them more easily. act at noradrenergic autoreceptors to inhibit the firing of cells in the locus ceruleus. LORDS INTERNATIONAL COLLEGE Page 39 . such as clonidine and guanfacine. emotional outbursts. Plus. 10. These chemicals narrow your arteries. Alpha-2 adrenergic receptor agonists. These medicines act like beta-blockers when they block these same catecholamines in your brain. such as Raynaud's disease. and blood vessels. α-blockers can also be used to treat anxiety and panic disorders. While most commonly used to treat hypertension (usually in conjunction with diuretics when other treatments are ineffective). your blood vessels can relax. This makes your blood pressure go up. Global symptoms of PTSD were reduced among sixty-six percent and nightmares among seventy-seven percent.7 ALFA ADRENERGIC BLOCKERS α-blockers are used in the treatment of several conditions. Insomnia and nightmares were also reported to be reduced. Guanfacine brand name Tenex produces less sedation than clonidine and thus may be better tolerated. resulting in lower blood pressure. Clonidine has shown promise among patients with Anxiety. effectively reducing the release of brain norepinephrine.HYPERTENSION 10. heart. This action stops your cells from receiving chemicals called catecholamines. Panic and PTSD in clinical trials and was used to treat severely and chronically abused and neglected preschool children. This in turn allows your blood to flow more easily. LORDS INTERNATIONAL COLLEGE Page 40 . A recently completed randomized doubleblind trial among veteran patients with chronic PTSD showed that augmentation with guanfacine was associated with improvement in anxiety and PTSD. Raskind and colleagues studied the efficacy of prazosin for PTSD among Vietnam combat veterans in a 20-week double-blind crossover protocol with a two-week drug washout to allow for return to baseline. Prazosin appears to have promise as an effective treatment for PTSD-related sleep disturbance.9 for hyperarousal. dilation of arterial blood vessels (mainly the arterioles) decreases blood pressure. They are also used to treat anxiety. Prazosin aka Minipress is an alpha1-receptor antagonist. large arteries. The process is essentially the opposite of vasoconstriction. In each of the PTSD symptom clusters the effect size was medium to large: 0. 0. the response may be localized to a specific organ (depending on the metabolic needs of a particular tissue.8 CENTRAL SYMPATOLYTICS A sympatholytic (or sympathoplegic) drug is a medication which inhibits the postganglionic functioning of the sympathetic nervous system (SNS). They are indicated for various functions. particularly in the large veins. or it may be systemic (seen throughout the entire systemic circulation). for example they may be used as antihypertensives. 10. including trauma-related nightmares. The reduction in CGI-C scores (overall PTSD severity and function at endpoint) also reflected a large effect size . and smaller arterioles.HYPERTENSION Guanfacine reduced the trauma-related nightmares. as well as overall Anxiety and PTSD symptoms. Patients who were taking prazosin had a robust improvement in overall sleep quality and recurrent distressing dreams . Therefore. The CAPS and the Clinical Global Impressions-Change scale (CGI-C) were the primary outcome measures.7 for reexperiencing or intrusion. as during strenuous exercise). When blood vessels dilate. the flow of blood is increased due to a decrease in vascular resistance. such as Generalized Anxiety Disorder. Panic Disorder and PTS 10.9 VASODILATORS Vasodilation refers to the widening of blood vessels. The response may be intrinsic (due to local processes in the surrounding tissue) or extrinsic (due to hormones or the nervous system).6 for avoidance and numbing. It results from relaxation of smooth muscle cells within the vessel walls. which is the narrowing of blood vessels. and 0. Additionally. Neither of these approaches to the mechanism of vasodilation is mutually exclusive of the other. Localized tissues utilize multiple ways to increase blood flow including releasing vasodilators. but can occur when the tissue in question is not receiving enough glucose or lipids or other nutrients. LORDS INTERNATIONAL COLLEGE Page 41 . This latter hypothesis is posited due to the presence of precapillary sphincters in capillary beds. This is often in response to a localized need of oxygen.HYPERTENSION ARTERIOLAR : Arteriolar vasodilators are substances that preferentially dilate arterioles. primarily adenosine. When used on people with certain heart conditions. into the local interstitial fluid which diffuses to capillary beds provoking local vasodilation. Some physiologists have suggested it is the lack of oxygen itself which causes capillary beds to vasodilate by the smooth muscle hypoxia of the vessels in the region. it causes a phenomenon known as the cardiac steal syndrome ARERIOLAR+VENOUS : The primary function of vasodilation is to increase blood flow in the body to tissues that need it most. but plans use incentives to encourage their enrollees to use the preferred drugs on the formulary. LORDS INTERNATIONAL COLLEGE Page 42 . and Modernization Act (MMA) created a new outpatient drug benefit for Medicare beneficiaries. A common incentive structure used with open formularies (accounting for 63 percent of covered workers in 2003) 4 is a three-tier copay. and the standard benefit presented in the statute would cover those drugs with a fixed 25 percent coinsurance. The MMA relies on competition among private drug plans (PDPs) and Medicare Advantage (MA) plans as the basis for offering the Part D benefit. The plans are at risk for the cost of the benefit (although the risk is tempered through reinsurance and risk sharing mechanisms). In general. CONCLUSION The Medicare Prescription Drug. plans are expected to offer beneficiaries all needed drugs.g. It is likely that most plans will offer a variety of packages that cover different drugs at different levels of cost sharing.HYPERTENSION 11. The MMA expects private plans to provide a drug benefit of an acceptable quality to beneficiaries. Improvement. In 2002. Formularies can be either ―closed‖ – in which there is no coverage at all for non-formulary drugs – or ―open‖ – in which non-formulary drugs are covered. 2 There is some evidence that in Medicare+Choice plans. or cost sharing. But the law does not require plans to use a predetermined drug classification system.. $29) for ―non-preferred. These employees pay a low copay (e. plans have flexibility to limit the drugs they cover through a formulary and to provide incentives to use preferred drugs through tiered cost sharing.‖ off-formulary drugs. about 37 percent of M+C enrollees were in a plan with a closed formulary.‖ on-formulary brand name drugs. $19) for ―preferred. designated as Medicare Part D. 3 The Veterans Health Administration began using a closed formulary for some drug classes in 1997. and the most (e. To give enrollees clear incentives to follow the formulary or use cheaper drugs. formulary. closed formularies have been more common. plans often use tiered cost sharing. and thus plans have a significant incentive to control costs.g. Instead.g. $9) for generics. Most private sector plans have responded to their enrollees’ desire for more choice by creating open formularies. so includes several provisions to ensure that beneficiaries maintain access to needed drugs. more (e. Opportunities and responsibilities in Pharmaceutical care.569). 2001. 8. Am J Health-Syst Pharm 2001.1). Copenhagen. 6.12: Role of the pharmacist in support of the WHO revised drug strategy. Carter BL et al. 1989. Geneva.1997. CINDI Protocol and Guidelines.com/viewarticle/406988. 53(Suppl):7–15. Libby EA. 2003. 12. Survey about hypertension control policies in CINDI countries. Laub JJ.\ 3. WHO Regional Office for Europe. Morley PC. Strand LM. Erickson SR. Harvard University Press. Halapy H. 1996. WHO Regional Office for Europe. Adherence to Long-Term Therapies – Evidence for Action. Mass. accessed 29 June 2004). 4. Pharmaceutical Care Practice. World Health Organization. 54:2079–2083. 1997. 13. Pharmacists ability to influence outcomes of hypertension therapy. Pharmacotherapy. World Health Assembly Resolution WHA47. Copenhagen. The global burden of disease. WHO Regional Office for Europe. 10. 7. World Health Organization.medscape. 2. REFERENCES 1. 5. 1994. ed. Interpreting the Findings of the IMPROVE Study. 17(1): 140–147. Geneva. Cambridge.159. 1998.HYPERTENSION 12. 58:1330–1337 (http://www. LORDS INTERNATIONAL COLLEGE Page 43 . p. The role of the pharmacist in the prevention of non-communicable diseases (NCD): Focus on hypertension (EUR/ICP/IVST 01 02 26. Am J Health-Syst Pharm. American Journal of Pharmaceutical Education. 11. Strand LM. Economic and clinical impact of a pharmacy-based antihypertensive replacement program in primary care. Copenhagen. Geneva. Cipolle RJ. 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The seventh report of the Joint National Committee on Prevention. 32. 2003. WHO/ISH statement on management of hypertension. and Treatment of High Blood Pressure: the JNC 7 Report. 28. Evidence-based hypertension. Spanish Society of hypertension-Spanish League against arterial hypertension. 2003. 2001. 29. BMJ Books. Izzo JL. European Society of Hypertension recommendations for conventional. Evaluation. World Health Organization – International Society of Hypertension Guidelines for the Management of Hypertension. Beilin L et al. Sassen JJ. 31. Asmar R. J Hypertens 1999. 21:1011–1053. Baltimore.HYPERTENSION 26. Bakris GL. et al. J Hypertens. Self-measurement of blood pressure. Lippincott Williams & Wilkins. Journal of Hypertension 2003. In: Koda-Kimble MA. World Health Organization/International Society of Hypertension Writing Group 2003. European Society of Hypertension – European Society of Cardiology guidelines for management of arterial hypertension. 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