Next best treatment for htn pt?

Yeah... I kept thinking about a clonidine patch.



I think it's a money issue, too, with the VA.

Wow! We are actually talking about pharmacy! I've been absent but it was nice to come through and read this thread as I enjoy my spicy tuna sushi roll.

Continue...

PharmD RPh said:

That must be a formulary/cost issue with the succinate in the VA. I mean I understand why they would do that in that case. Although the COMIT trial showed succinate to be indicated for HF vs tartrate, there were definitely limitations in that study.

I can remember back when we had no generic for Toprol XL. A lot of ins plans gave really high copays or used step therapy making pt try tartrate first. A lot of the pts we switched from XL to immediate release due to cost ended up back on the XL because they had better control. My grandmother was one of these switches and her BP readings were profoundly different between the XL vs immediate release.

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Cost is one factor at the VA, but it's not the only factor. Veterans have access to more expensive agents if the evidence supports their use. I don't know of a trial that demonstrates the superiority of succinate over tartrate for BP. Maybe someone will PubMed it and prove me wrong. I do know that if the evidence were overwhelming, the VA would have at least considered it. When our physicians start a patient on a BB purely for hypertension, they typically choose atenolol. It also has a long duration of action and is usually dosed once daily. I think that's why it is preferred by our docs.

In terms of the HF issue: no head to head study of succinate vs tartrate exists for HF. MERIT-HF established the place in therapy for succinate in HF. It was placebo controlled. COMET was carvedilol over metoprolol tartrate for HF. There were a number of problems with that trial, including the dose of tartrate. Regardless, tartrate has never been demonstrated effective for HF and thus is not indicated, per the FDA, or the ACC/AHA guidelines. It's either carvedilol (regular or CR), metoprolol succinate or bisoprolol (CIBIS trial, I think.). I hardly EVER see bisoprolol used, not at the VA nor on any of my other rotations this year.

All4MyDaughter said:

Cost is one factor at the VA, but it's not the only factor. Veterans have access to more expensive agents if the evidence supports their use. I don't know of a trial that demonstrates the superiority of succinate over tartrate for BP. Maybe someone will PubMed it and prove me wrong. I do know that if the evidence were overwhelming, the VA would have at least considered it. When our physicians start a patient on a BB purely for hypertension, they typically choose atenolol. It also has a long duration of action and is usually dosed once daily. I think that's why it is preferred by our docs.

In terms of the HF issue: no head to head study of succinate vs tartrate exists for HF. MERIT-HF established the place in therapy for succinate in HF. It was placebo controlled. COMET was carvedilol over metoprolol tartrate for HF. There were a number of problems with that trial, including the dose of tartrate. Regardless, tartrate has never been demonstrated effective for HF and thus is not indicated, per the FDA, or the ACC/AHA guidelines. It's either carvedilol (regular or CR), metoprolol succinate or bisoprolol (CIBIS trial, I think.). I hardly EVER see bisoprolol used, not at the VA nor on any of my other rotations this year.

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It's interesting they choose atenolol seeing as it's been questioned whether it even has a mortality benefit when used for primary HTN. The studies aren't solid evidence for or against, and certainly have limitations, but some have even shown a slight increased in cardiovascular mortality compared to other BBs.

As for tartrate vs. succinate for BP I would have to go with succinate. Don't have to worry about hypotension or bumps during the day. Smooth curve which I think would be beneficial for most patients. Not saying there's necessarily a difference mortality wise, but just easier control for the most part.

ttopping said:

It's interesting they choose atenolol seeing as it's been questioned whether it even has a mortality benefit when used for primary HTN. The studies aren't solid evidence for or against, and certainly have limitations, but some have even shown a slight increased in cardiovascular mortality compared to other BBs.

As for tartrate vs. succinate for BP I would have to go with succinate. Don't have to worry about hypotension or bumps during the day. Smooth curve which I think would be beneficial for most patients. Not saying there's necessarily a difference mortality wise, but just easier control for the most part.

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We have soooo many patients on atenolol. But also a lot on metoprolol tartrate for hypertension. I am now wondering if this patient could benefit from a switch to carvedilol. Perhaps the added alpha 1 action could benefit him? I am also curious about how his blood pressure runs at different times of the day. Also had a patient who has periodic spikes of very, very high BP (but is pretty elevated all the time anyway). For the spikes (200/100 or greater) she uses PRN clonidine. Finished with this rotation now, so won't be able to follow up on that, but it was interesting.

Actually finished with ALL my rotations now. Officially a graduate intern, or so I'm told!

Congrats! 10 days left for me. Only 1 more project.

To keep this on-topic, I wills say that I see a decent amount of bisoprolol. Not alot, but at my store it moves faster than carvedilol. We hardly do any carvedilol though.

All4MyDaughter said:

Cost is one factor at the VA, but it's not the only factor. Veterans have access to more expensive agents if the evidence supports their use. I don't know of a trial that demonstrates the superiority of succinate over tartrate for BP. Maybe someone will PubMed it and prove me wrong. I do know that if the evidence were overwhelming, the VA would have at least considered it. When our physicians start a patient on a BB purely for hypertension, they typically choose atenolol. It also has a long duration of action and is usually dosed once daily. I think that's why it is preferred by our docs.

In terms of the HF issue: no head to head study of succinate vs tartrate exists for HF. MERIT-HF established the place in therapy for succinate in HF. It was placebo controlled. COMET was carvedilol over metoprolol tartrate for HF. There were a number of problems with that trial, including the dose of tartrate. Regardless, tartrate has never been demonstrated effective for HF and thus is not indicated, per the FDA, or the ACC/AHA guidelines. It's either carvedilol (regular or CR), metoprolol succinate or bisoprolol (CIBIS trial, I think.). I hardly EVER see bisoprolol used, not at the VA nor on any of my other rotations this year.

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Another reason VA may use tartrate for HTN is that given in a hospital setting compliance would be much better bc you have a nurse hand feed you your meds. Out in practice most clinicians I've spoken to and worked with over the years prefer succinate for HTN since it is now generic and allows for lower peak to trough ratio, better compliance and ease of use for equivalent beta blockade. In the ideal world I would agree that if taken appropriately you should get similar therapeutic outcomes for HTN. We all know patients cannot take their meds ideally though.

PharmD RPh said:

Another reason VA may use tartrate for HTN is that given in a hospital setting compliance would be much better bc you have a nurse hand feed you your meds. Out in practice most clinicians I've spoken to and worked with over the years prefer succinate for HTN since it is now generic and allows for lower peak to trough ratio, better compliance and ease of use for equivalent beta blockade. In the ideal world I would agree that if taken appropriately you should get similar therapeutic outcomes for HTN. We all know patients cannot take their meds ideally though.

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I'm talking about outpatient. The formulary is the same for inpatient and outpatient, but the vast majority of RXs processed and filled at our VAMC are outpatient. Succinate for HF only.

bananaface said:

Congrats! 10 days left for me. Only 1 more project.

To keep this on-topic, I wills say that I see a decent amount of bisoprolol. Not alot, but at my store it moves faster than carvedilol. We hardly do any carvedilol though.

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Don't see much carvedilol at the VA but on rotations this year at various places, it was used a lot. The cardiology group we worked with last block LOVED it. They were also really hot on dabigatran, which was not working out well. Most of our patients were insured, but most of the insurance plans were not picking up dabigatran or were requiring the highest tier copay.

owlegrad said:

We recently had to add dabigatran to our inventory at work. We had too many patients on it and it was becoming too inconvenient to require the patients to supply it. It is still non-formulary and we still encourage patients to bring there own, but at least now we have it.

Does anyone know if it is being used for it's actual indication, embolism/stroke prevention in a-fib? Seems like I see it far too often for that to be it's only use.

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I've never seen it used for anything but Afib.

owlegrad said:

Maybe Afid is more common than I realize.

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Among my VA patients, it's very very common. I could google some stats about it, but I might just choose to make some up. Like this:

99.999999% of ugly and old patients (over 30 years) have Afib. I have never worked in pharmacy but I think pretty much all patients have Afib. Except flight attendants and Victoria's Secret models. If you have Afib you can automatically get on Medicaid and get a Hummer and unlimited free food and one bag of cocaine per week.

Something like that.

owlegrad said:

You're feisty tonight. I like it.

But if I make good money or inherited it, I am safe right? I mean people who are smart and make good/have money don't get sick, right?

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You will be safest if your parents love you enough and want to help you by giving you money. You definitely won't get Afib then! If your parents don't love you enough to give you money, you might get Afib unless you are skinny and hot. But if you aren't skinny, it would be better to get sick and die anyway. I would rather DIE than be fat. Or live in the country. Of all the people with Afib, I think 99.999999999999999% are fat, old and poor so it's not a big deal. The others are the ones who live in the country with cows. They are a drain on society anyway, lol...

owlegrad said:

Maybe Afid is more common than I realize.

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The most frequently diagnosed arrhythmia: 2.2 million (~1% of population). Around 10% of people over 80yo affected as well. Just an fyi

All4MyDaughter said:

You will be safest if your parents love you enough and want to help you by giving you money. You definitely won't get Afib then! If your parents don't love you enough to give you money, you might get Afib unless you are skinny and hot. But if you aren't skinny, it would be better to get sick and die anyway. I would rather DIE than be fat. Or live in the country. Of all the people with Afib, I think 99.999999999999999% are fat, old and poor so it's not a big deal. The others are the ones who live in the country with cows. They are a drain on society anyway, lol...

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You need all caps / emphasis on at least 30% more of that post, way more "lulz", and maybe 4 more smiley faces or faces in general

ttopping said:

You need all caps / emphasis on at least 30% more of that post, way more "lulz", and maybe 4 more smiley faces or faces in general

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You're right. Totally not up to standards. I will try to do better next time, lol...