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Physician assistant protocols

HYPERTENSION MANAGEMENT
When using any protocol, always fol ow the Guidelines of Proper Use (page Definitions
● In adults ≥ 18 years of age, hypertension classifications are the following with 2 or more averaged seated BP measurements over 2 or more office visits (initial BP may be elevated due to anxiety) • Some controversy exists if this label should be given to patients without diabetic, cardiac Considerations
● SBP > 140 mm Hg in age > 50 years is more important cardiovascular disease (CVD) risk factor ● Risk doubles for CVD for each SBP/DBP increase of 20/10 mm Hg starting at 115/75 mm Hg blood ● Thiazide diuretics should be used initially or in combination with other antihypertensive medications ● Most patients will require 2 or more antihypertensive medications to achieve target blood pressure of < 140/90 mm Hg in patients without diabetes or chronic renal disease, or < 130/80 mm Hg for diabetic or ● If blood pressure is > 20/10 mm Hg over target BP, consideration should be given to initiating 2 antihypertensive drugs, one of which should be a ● Clinician’s judgment remains paramount in using ● Self-measured averaged blood pressures at home > 135/85 mm Hg are considered hypertensive High risk conditions that have indications for
initiation of other antihypertensive medications
besides a diuretic
● Recurrent stroke prevention in patients with Evaluation
● Auscultation for carotid, abdominal and femoral bruits ● Abdominal examination for masses and abdominal ● Check legs for edema and arterial pulses Goals of Therapy
● Target blood pressure of < 140/90 mm Hg in patients without diabetes or chronic renal disease, or <130/80 mm Hg for diabetic or chronic renal disease patients with focus on lowering SBP in both groups Treatment Options without High Risk
Conditions
Prehypertension
• Weight loss diet rich in potassium and calcium Stage 1 hypertension
• Angiotensin converting enzyme inhibitor Stage 2 hypertension
● Two drug combination of stage 1 hypertension medications usually (caution if risk of orthostatic Treatment Options with High Risk
Conditions
Prehypertension
● Drugs as applicable in condition below Heart failure
● If asymptomatic give ≥ 1 medication • Angiotensin converting enzyme inhibitor ● If symptomatic give ≥ 1 medication with a loop diuretic ― Lasix (furosemide) or Bumex • Angiotensin converting enzyme inhibitor Ischemic heart disease (stable angina)
● Long acting calcium channel blocker such as Post myocardial infarction options
High risk for coronary disease options
Diabetic hypertension options
Combination of ≥ drugs usual y needed
• Angiotensin converting enzyme inhibitor • ACEI or ARB (reduces diabetic nephropathy) Chronic renal disease options
Definition of chronic renal disease
• Glomerular filtration rate (GFR) < 60 cc/min • Creatinine > 1.5 mg/dL in men and • Albuminuria > 300 mg/day or 200 mg of Medications
• Loop diuretic such as Lasix (furosemide) may be needed with creatinine > 2.5 mg/dL • Limited rise of up to 35% of creatinine with ACEI or ARB therapy is acceptable as long as Recurrent stroke prevention options
● Low dose aspirin (160–325 mg PO qd) if African Americans
● Thiazide diuretics or CCB more effective than ● ACEI induced angioedema occurs 2–4 times more Elderly patients
● Initial lower drug doses may be needed, though standard doses and multiple drugs are needed eventually in the majority to achieve BP control ● They are at risk of postural hypotension due to the frequent use of multiple medications Follow Up and Achieving Blood Pressure
● Monthly follow up till blood pressure control is ● Follow up every 3–6 months when blood control is ● Serum creatinine and potassium should be checked 1– ● Heart failure, diabetes and other comorbidities influence frequency of visits and tests needed ● Addition of a second drug should be in a different class if a single drug regimen was started initially and failed ● Do not use 2 drugs in the same class at the same time (exception is Maxzide or Dyazide which are Consult Criteria
● Unable to achieve target blood pressure reductions ● Blood pressure ≥ 180/110 mm Hg on 2 or more ● Symptomatic high risk conditions or comorbidities (CHF, progressive renal insufficiency, hyperkalemia, Antihypertensive Medications (Refer to
PDR or Inserts)
Thiazide diuretics
● Chorothiazide (Diuril) 125–250 mg PO qd-bid ● Hydrochlorothiazide (HCTZ) 12.5–50 mg PO qd Loop diuretics
● Lasix (furosemide) 20–40 mg PO bid ● Bumex (bumetanide) 0.5–1 mg PO bid Potassium sparing diuretics
Aldosterone receptor blockers
Beta-blockers
● Toprol XL (metoprolol) 50–100 mg PO qd Beta-blockers with intrinsic sympathomimetic
activity
● Sectral (acebutolol) 200–400 mg PO bid Combined alpha and beta-blockers
● Coreg (carvedilol) 6.25–25 mg PO bid increase every 1–2 weeks as tolerated and needed up to Angiotension converting enzyme inhibitors (ACEI)
● Accupril (quinapril) 10–80 mg PO qd Angiotensin receptor blockers
● Atacand (candesartan) 8–32 mg PO qd ● Cozaar (losartan) 25–50 mg PO qd-bid ● Diovan (valsartan) 80–320 mg PO qd Calcium channel blockers―non-Dihydropyridines
● Cardizem CD (diltiazem) 180–420 mg PO qd ● Cardizem LA (diltiazem) 120–540 mg PO qd ● Calan (verapamil) SR 120–240 mg PO qd-bid Calcium channel blockers―Dihydropyridines
● Norvasc (amlodipine) 2.5–10 mg PO qd ● Procardia XL (nifedipine) 30–60 mg PO qd Alpha-1 blockers (not first line drugs)
● Cardura (doxazosin) XL 4–8 mg PO qd ● Minipres (prazosin) 1–5 mg PO bid-tid ● Caution for orthostatic hypotension — give first Central alpha-2 agonists
● Catapres –TTS (clonidine) patch 0.1–0.3 mg Combination drugs
● ACEI+CCB (Lotrel) amlodipine and benazepril ● ACEI+HCTZ (Zestoretic) Lisinopril and HCTZ ● ARBs+diuretic (Diovan-HCT) valsartan and HCTZ ● BETABLOCKER+diuretic (Tenoretic) atenolol and ● Diuretic and diuretic (Aldactazide) 25/25 to 50/50
Reference:
http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf JNC 7 ― The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and

Source: http://clinician1.com/images/book_guide_pdfs/HYPERTENSION_MANAGEMENT.pdf