BP med of choice in diabetic AA (w/o CKD) pt per JNC 8

[winterallsummer]

Is an ACE or ARB still 1st line in African American patients who are hypertensive and diabetic but do not have CKD?  This is what I'm seeing in practice however I'm curious what everyone's interpretation of JNC 8 is, at least in this aspect.

 

From AJMC recap of JNC 8:

• When initiating therapy, patients of African descent without CKD should use CCBs and thiazides instead of ACE inhibitors.

• Use of ACE inhibitors and ARBs is recommended in all patients with CKD regardless of ethnic background, either as first-line therapy or in addition to first-line therapy. - See more at: http://www.ajmc.com/publications/evidence-based-diabetes-management/2014/jan-feb2014/The-JNC-8-Hypertension-Guidelines-An-In-Depth-Guide#sthash.MWNiDgGa.dpuf

 

So what are you all doing with AA pts with DM but not CKD?  Or AA with DM and 50 on spot microalbuminuria but a relatively good GFR?

 

Try to control BP with just an ACE or ARB?  Initiate low dose ACE but use CCB or HCTZ at a higher dose to control BP?  

 

All opinions appreciated.

[maryfran123]

Thiazide diuretic first. I use chlorthalidone(Thalitone/Hygroton brand name)  

Start low at 12.5mg. Max dosage is 50mg, above this little benefit and much more risk of hypokalemia, adverse glucose effects.

Inexpensive, very effective even at low dose, longer  half life so longer SBP control c/t HCTZ.

AA tend to respond quite well to diuretic therapy.

 

Good CV outcomes in ALLHAT study

 

http://www.nhlbi.nih.gov/health/allhat/qckref.htm

 

If BP not controlled on 50mg, add CCB.

 

I often wonder why some of my Trauma/CC pt's are on 2-4BP medications forSOLELY for  BP control and often times not one of these medications has been maxed out before adding a 2nd 3rd agent.

[EMEDPA]

Thank you MF. I will try to remember to use chlorthalidone over HCTZ. I don't think I have ever written for it but the evidence looks like it is a better drug.

[Will352ns]

Another thought, I recall there is a greater incidence of angio-edema in AA pt's associated with ACEI....which is one of the reasons they aren't prescribed as much in that population.  This is off of memory...to lazy to look it up.

[GetMeOuttaThisMess]

^^, yes, and also associated with ARB's.

[Timon]

My memory may be a little hazy with all the material being thrown at me.. But I though in AA we should avoid BB and ACE-I because they aren't as effective?

[ventana]

Thank you MF. I will try to remember to use chlorthalidone over HCTZ. I don't think I have ever written for it but the evidence looks like it is a better drug.

 

 

Briefly for about a year chlorthalidone had a resurgence, due to suspected benefit. However the latest review of the literature that I have read does not support this and are once again advocating for hydrochlorothiazide.

 

 

Also:

Angioedema is a potentially life-threatening complication of ACE inhibitor therapy with an incidence of 0.1% to 0.2% (74). The pathophysiology is poorly understood; however, a recent human study showed significant elevations in plasma bradykinin during acute attacks of captopril induced angioedema (75). There may be racial differences in susceptibility to ACE inhibitor induced angioedema; African-Americans have a greater sensitivity to accumulation of bradykinin and an increased incidence of angioedema (76).

 

As Well:

In the early 1980s, clinical differences in response to the blood pressure (BP)-lowering effects of β-blockers and, to a lesser extent, diuretics were noted between ethnic groups. The most convincing evidence at that time came from a Veterans Affairs (VA) Cooperative Trial,¹ which, along with other smaller studies, suggested that whites (those of European ancestry) had a better antihypertensive response to β-blockers than blacks (those of African ancestry), whereas blacks had a slight better response to diuretics than whites. Shortly after the first angiotensin-converting enzyme (ACE) inhibitor was approved in the mid-1980s, it was also recognized that whites responded more favorably to ACE inhibitors than did blacks. Over time, these differences in response became well accepted, such that ethnicity began to be used in helping to guide selection of antihypertensive drug therapy.^2,3 Although the ethnic differences in response between β-blockers and ACE inhibitors in hypertension are perhaps the mostly widely recognized examples of ethnic differences in response to cardiovascular drugs, there are others.

 

 

and:

Some of the older literature indicated that ACE inhibitors (and angiotensin receptor blockers, ARBs) were less efficacious in African American hypertensive patients, which unfortunately led to lower utilization of these important, beneficial drugs in African Americans.  While it is true that African Americans do not respond as well as other races to monotherapy with ACE inhibitors or ARBs, the differences are eliminated with adequate diuretic dosing. Therefore, current recommendations from the JNC 7 report are that ACE inhibitors and ARBs are appropriate for use in African Americans, with the recommendation of adequate diuretic dosing to achieve the target blood pressure.

 

 

 

 

 

 

 

 

Points are

Number one do some type of renal protective agent if there is chronic kidney disease

number two manage their blood pressure with some type of cheap diuretic not some expensive new drug.

[GetMeOuttaThisMess]

Add the triamterene to the HCTZ (Dyazide) and your low K+ isn't as much of an issue.

[Joelseff]

Frankly, in my population, I use whatever works for the pt including. BBs, CCB, and ACEi/ARB in AAs. I also use chlorthalidone and HCTZ. Anecdotally, I have had good success with chlorthalidone and tend to use that more but have seen a higher incidence of orthostatic hypotension and hypokalemia with it compared to hctz. Bottom line is jnc are guidelines not hard and fast rules. Use the most efficacious agent(s) in brining down htn without ctossing safety thresholds....you know practicing medicine....

 

On angioedema, I have had 2 AA pts in the past 2 years who had angioedema with suspected ACEi as the cause though both of them have been on lisinopril for 10 plus years. I did stop the meds and switched to CCB.

 

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[Joelseff]

Add the triamterene to the HCTZ (Dyazide) and your low K+ isn't as much of an issue.

Or add an ARB :D

 

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[Guest Paula]

I started using chlorthalidone about 9 months ago or so secondary to some literature I read plus a medscape video discussion and  I noted the nephrologists we referred to had been prescribing it almost exclusively with our patients we sent them for consults.  I had a conversation with one of them about it and he felt it was better overall.

 

I have not looked up any recent literature on it.  Ventana...do you have a source?  I actually see patients doing well on chlorthalidone, seemingly better than on HCTZ.  This is subjective on my part. 

[GetMeOuttaThisMess]

I'm curious to see anecdotally how many folks have had issues with hypokalemia when pt. is on chlorthalidone only?  This has been my only caution to keep me from using it in times past.

[Joelseff]

I'm curious to see anecdotally how many folks have had issues with hypokalemia when pt. is on chlorthalidone only? This has been my only caution to keep me from using it in times past.

Ive had a few. Some controlled on diet and some had to go on K dur.

 

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[winterallsummer]

Thanks for all the feedback.

 

Still very interested in everyone's opinion on this fact however:

 

In a diabetic AA pt without CKD but with a long standing hx of DM (+/- microalbuminuria), is an ACEI still appropriate as a 1st line BP med given its reno-protective factors??

 

I feel I would want to put them on the ACEI because it is protecting them from developing CKD.  The current guidelines seem to only suggest it for AAs with CKD, though.  So the other way to do this would be a low dose of ACEI for reno-protection and then use a ccb or thiazide to control the BP, leaving the ACEI at a low dose.

 

I guess my thinking is, given those options, I'd rather TRY to get BP control with the ACEI before putting them on two meds, because just going from 1 to 2 meds really hinders compliancy in many pts.

 

What are your thoughts???

[cbrsmurf]

Basically, the evidence for renoprotection of ACEi/ARBs in DM pts are stronger than CCB's.

ACEi/ARBs are equivalent to other anti-HTN's without proteinuria (I think)

It is pretty common for AA to be one more than one anti-HTN Rx.

Angioedema is a small risk, especially the life-threatening reactions

Reading uptodate, it looks like the relative risk reduction in progression to ESRD by using a ACEi vs other antiHTNs is about 33%.  

 

I would go with your plan, low-dose ACEi... wait to see how their BP responds, then add a CCB if needed.

[GetMeOuttaThisMess]

Remember that monitoring is more than just checking for protein.  You've got to watch the GFR.  Also be aware that while each class (ARB/ACEI) are renal protective, once renal function peaks it can be a slippery slope on the backside with these same medications.  For those who may not pay particular attention to this either by noting it on the lab report (which the major labs finally got around to reporting within the past decade) or actually computing the value themselves, you might be surprised by those who are stage IIIA CKD yet are asymptomatic (two stage III classifications).

[winterallsummer]

I would go with your plan, low-dose ACEi... wait to see how their BP responds, then add a CCB if needed.

 

How high up. if at all, would you be willing to titrate an ACEi before adding the ccb?

[UGoLong]

African Americans do generally respond very well to CCBs for BP control -- better than Caucasians -- so, after protecting the kidneys in a pt with DM, I'll start Norvasc, assuming I don't need to consider something else.

 

I personally don't like to max out ACEI/ARB before starting something else. I'll go mid-range (lisinopril 20 or losartan 50, for example) and then, assuming Cr is OK (1.5 or less), I'll add something else. I've talked with nephrologists and the 1.5 seems to be in keeping with their thinking. If the patient is ESRD on HD, then bring on the max dose of ACEI or ARB for sure.

 

Do I ever give anyone else the max dose of an ACEI or ARB: yes. But, in general, you get more side effects at the max end of dosing many meds, so I like to work up to it. It is not unusual for patients in our practice to be on multiple antihypertensives. We don't usually get the first-time hypertensives that you see in family practice though.

 

In spite of the guidelines, I seldom start someone on a diuretic for BP control. Our patients usually have something else going on too and we have to deal with that as well (CAD, cardiomyopathy, DM, bradycardia, tachycardia, MVP, near syncope, whatever). 

[cbrsmurf]

I agree. You get little return back at max recommended dose.'

 

In this patient, I would start at half of minimum recommended dose and probably titrate up to minimum recommended dose