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Strategy Description
Age ≥ 60 years Age < 60 years All Ages All Ages and Races Start one drug, titrate to maximum
Diabetes present CKD present with or
A
dose, and then add a second drug.
No CKD without diabetes
BP Goal BP Goal B Start one drug, then add a second
< 150/90 < 140/90 drug before achieving max dose of
BP Goal BP Goal first
< 140/90 < 140/90
C Begin 2 drugs at same time, as
separate pills or combination pill.
Initiate ACEI or ARB, Initial combination therapy is
Nonblack Black
alone or combo recommended if BP is greater than
w/another class 20/10mm Hg above goal
Initiate thiazide, ACEI, ARB, Initiate thiazide or CCB,
or CCB, alone or in combo alone or combo
Lifestyle changes:
Yes • Smoking Cessation
At blood pressure goal?
• Control blood glucose and lipids
No
• Diet
Reinforce lifestyle and adherence Eat healthy (i.e., DASH diet)
Titrate medications to maximum doses or consider adding another medication (ACEI, ARB, CCB, Thiazide) Moderate alcohol consumption
Reduce sodium intake to no
Yes more than 2,400 mg/day
At blood pressure goal?
• Physical activity
No
Moderate-to-vigorous activity
Reinforce lifestyle and adherence 3-4 days a week averaging 40
Add a medication class not already selected (i.e. beta blocker, aldosterone antagonist, others) and titrate min per session.
above medications to max (see back of card)
Yes
At blood pressure goal? Continue tx and monitoring
No
Reference: James PA, Ortiz E, et al. 2014 evidence-based guideline for the management
Reinforce lifestyle and adherence of high blood pressure in adults: (JNC8). JAMA. 2014 Feb 5;311(5):507-20
Titrate meds to maximum doses, add another med and/or refer to hypertension specialist
Card developed by Cole Glenn, Pharm.D. & James L Taylor, Pharm.D.
Compelling Indications
Hypertension Treatment
Indication Treatment Choice
Heart Failure ACEI/ARB + BB + diuretic + spironolactone
Post –MI/Clinical CAD ACEI/ARB AND BB
Beta-1 Selective Beta-blockers – possibly safer in patients
CAD ACEI, BB, diuretic, CCB with COPD, asthma, diabetes, and peripheral vascular
Diabetes ACEI/ARB, CCB, diuretic disease:
• metoprolol
CKD ACEI/ARB • bisoprolol
Recurrent stroke prevention ACEI, diuretic • betaxolol
• acebutolol
Pregnancy labetolol (first line), nifedipine, methyldopa
terazosin 1-5mg, doxazosin 1-4mg given at bedtime Alpha-blockers may cause orthostatic hypotension
Centrally-acting clonidine 0.1-0.2mg twice daily, methyldopa 250-500mg twice daily Clonidine available in weekly patch formulation for
Agents resistant hypertension
guanfacine 1-3mg
PL Detail-Document #300201
−This PL Detail-Document gives subscribers
additional insight related to the Recommendations published in−
PHARMACIST’S LETTER / PRESCRIBER’S LETTER
February 2014
More. . .
Copyright © 2014 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #300201: Page 2 of 6)
ASH:2
Patients younger than 80 years of age: start pharmacotherapy at
140/90 mmHg
Patients 80 years of age and up: start pharmacotherapy at
150/90 mmHg.
Consider starting at 140/90 mmHg in those with diabetes or CKD.
Patients with uncomplicated stage 1 HTN:
(140 to 159/90 to 99 mmHg without CV abnormalities or risk
factors): consider six to 12 months of lifestyle changes (e.g., weight
loss, sodium restriction, exercise, smoking cessation) alone before
pharmacotherapy.
More. . .
Copyright © 2014 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #300201: Page 3 of 6)
ASH:2
Patients younger than 80 years of age: <140/90 mmHg
Patients 80 years of age and up: systolic of up to 150 mmHg is
acceptable [Evidence level A; high-quality RCT].3 A goal of
<140/90 mmHg can be considered for those with diabetes or CKD.
Patients 18 to 55 years of age: lower target (e.g., <130/80 mmHg)
can be considered, per prescriber discretion, if treatment is tolerated.
However, evidence of additional benefit vs goal of <140/90 mmHg is
lacking.
CKD with albuminuria: some experts recommend <130/80 mmHg.2
More. . .
Copyright © 2014 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #300201: Page 4 of 6)
Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making
clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national
organizations. Information and internet links in this article were current as of the date of publication.
More. . .
Copyright © 2014 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #300201: Page 6 of 6)
Cite this document as follows: PL Detail-Document, Treatment of Hypertension: JNC 8 and More. Pharmacist’s
Letter/Prescriber’s Letter. February 2014.
Set Blood Pressure Goal and Initiate Blood Pressure Lowering Medication Based on
Age, Diabetes, and CKD
Age >60 years and No Age <60 years and No All Ages with Diabetes
All Ages with CKD
Diabetes and No CKD Diabetes and No CKD and No CKD
Goal SBP <150 mm Hg Goal SBP <140 mm Hg Goal SBP <140 mm Hg Goal SBP <140 mm Hg
Goal DBP <90 mm Hg Goal DBP <90 mm Hg Goal DBP <90 mm Hg Goal DBP <90 mm Hg
Initiate thiazide-type diuretic or Initiate thiazide-type diuretic or ACEI Initiate ACEI or ARB alone or in
CCB alone or in combination or ARB or CCB alone or in combination combination with other class
NO
!"Reinforce medication and lifestyle adherence
!"For strategies A and B, add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use
medication class not previously selected, and avoid combined use of ACEI and ARB)
!"For strategy C, titrate doses of initial medications to maximum
Continue Current
At Goal Blood Pressure? YES Treatment and
Monitoring
NO
!"Reinforce medication and lifestyle adherence
!"Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not
previously selected, and avoid combined use of ACEI and ARB)
NO