asymptomatic HTN

[gro2001]

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Creatinine, maybe never. Electrolyte drop, I'd say about once/month when I ran the Medicaid clinic for the Catholic hospital. Heck, I put my father-in-law in the hospital with a sodium of 115 from HCTZ (Happy Easter!). The creatinine was more for ACE-Is.

Yikes, that's embarrassing.

How much HCTZ was he on? I thought this was mostly dose related?

After you have seen enough cases of thiazide induced hyponatremia you kind of learn to hate the drug.

Also, the antihypertensive effect of most drugs, including HCTZ, is more pronounced in the lower dose range. After a certain dose you end up with little extra antihypertensive effect (act and just add side effects. I pretty much never use HCTZ 25 mg.

This is important because you will be doing much better medicine and being more effective by using two or three drugs at half the maximum dose than one drug at maximum dose or worse, twice the standard dose.

My $0.02.

Are you saying 25 mg HCTZ is too high? Do you max out HCTZ at 12.5?

It seems this http://www.aafp.org/afp/2010/0601/p1333.html is saying HCTZ is the best first line drug for HTN. I am certainly not going to start multiple antihypertensives in the ER, particularly since most people still seem to think serial mono-therapy as the first line approach to HTN.

But feel free to correct me if I am wrong, I'd love to hear more from you guys on this.

 

[PlutoBoy]

Yikes, that's embarrassing.

How much HCTZ was he on? I thought this was mostly dose related?




Are you saying 25 mg HCTZ is too high? Do you max out HCTZ at 12.5?

It seems this http://www.aafp.org/afp/2010/0601/p1333.html is saying HCTZ is the best first line drug for HTN. I am certainly not going to start multiple antihypertensives in the ER, particularly since most people still seem to think serial mono-therapy as the first line approach to HTN.

But feel free to correct me if I am wrong, I'd love to hear more from you guys on this.

Well, the average fall in systolic blood pressure over 24 hours with half-standard, standard, and twice-standard doses of HCTZ was 7.4, 8.8, and 10.3 mmHg so you don't really achieve all that much by doubling or tripling the dose of the drug. This is true for all antihypertensive drugs. All you get is side effects.

Also, remember that if your SBP is 20 points above target YOU SHOULD start combination therapy from the get go. Further, the ACCOMPLISH trial (1) taught us that combinining an ACEi/ARB with a CCB may be the best option.

With regards to my personal practice (which is definitely influenced by my hospitalist background), I personally limit HCTZ at 12.5.

Adding another 12.5 mg of the drug to drop the SBP another 2 mmHg doesn't seem particularly appealing considering that I now have more risks of thiazide induced hyponatremia (and you called me to admit these guys rather frequently), hypokalemia, and diabetes.

I don't have much of an issue with going as high as 10 mg of Amlodipine or as high as 40 mg of lisinopril (provided you have normal renal function) although I typically don't . The question here is why are you increasing the dose:

Is this a patient with newly diagnosed stage one HTN? Then changing to another first class agent may be a better option.

Does the patient have resistant hypertension defined as needing three drugs, one of them being a diuretic? Then increasing the dose may be reasonable although if the BP is particularly high (SBP >160) on three agents already at appropriate doses you would probably get better results by adding spironolactone (and of course work up for secondary HTN). I also typically switch these patients to first line agents if they are not already on them.

With regards to first line therapy on patients with stage I HTN, you can't really fault anyone for starting a thiazide diuretic, preferably chlorthalidone, based on the results of ALLHAT. The only caveat would be the patient that has a greater likelihood of needing two drugs (SBP more than 10 mmHg over target).

Based on the ACCOMPLISH trial (1) it would be reasonable to start with an ACEi/ARB or a CCB in this case since patients that are in a ACE/ARB + CCB combination do better as compared to patients with ACE+Thiazide.

But again, technically there is nothing wrong with using any first line agent (thiazide, CCB, ACEi/ARB). Of course we are assuming that there is no indication to use any particular agent over another.

1)http://www.ncbi.nlm.nih.gov/m/pubmed/19052124/

Hope that helps!

 

[PlutoBoy]

*Of course for you to use this information in the ER you would need a patient that has already been diagnosed with HTN since you shouldn't be diagnosing HTN in the ER, most of the time.

 

[gro2001]

Well, the average fall in systolic blood pressure over 24 hours with half-standard, standard, and twice-standard doses of HCTZ was 7.4, 8.8, and 10.3 mmHg so you don't really achieve all that much by doubling or tripling the dose of the drug. This is true for all antihypertensive drugs. All you get is side effects.

Also, remember that if your SBP is 20 points above target YOU SHOULD start combination therapy from the get go. Further, the ACCOMPLISH trial (1) taught us that combinining an ACEi/ARB with a CCB may be the best option.

With regards to my personal practice (which is definitely influenced by my hospitalist background), I personally limit HCTZ at 12.5.

Adding another 12.5 mg of the drug to drop the SBP another 2 mmHg doesn't seem particularly appealing considering that I now have more risks of thiazide induced hyponatremia (and you called me to admit these guys rather frequently), hypokalemia, and diabetes.

I don't have much of an issue with going as high as 10 mg of Amlodipine or as high as 40 mg of lisinopril (provided you have normal renal function) although I typically don't . The question here is why are you increasing the dose:

Is this a patient with newly diagnosed stage one HTN? Then changing to another first class agent may be a better option.

Does the patient have resistant hypertension defined as needing three drugs, one of them being a diuretic? Then increasing the dose may be reasonable although if the BP is particularly high (SBP >160) on three agents already at appropriate doses you would probably get better results by adding spironolactone (and of course work up for secondary HTN). I also typically switch these patients to first line agents if they are not already on them.

With regards to first line therapy on patients with stage I HTN, you can't really fault anyone for starting a thiazide diuretic, preferably chlorthalidone, based on the results of ALLHAT. The only caveat would be the patient that has a greater likelihood of needing two drugs (SBP more than 10 mmHg over target).

Based on the ACCOMPLISH trial (1) it would be reasonable to start with an ACEi/ARB or a CCB in this case since patients that are in a ACE/ARB + CCB combination do better as compared to patients with ACE+Thiazide.

But again, technically there is nothing wrong with using any first line agent (thiazide, CCB, ACEi/ARB). Of course we are assuming that there is no indication to use any particular agent over another.

1)http://www.ncbi.nlm.nih.gov/m/pubmed/19052124/

Hope that helps!

Thanks, that's a great explanation. You've convinced me to change my practice to mostly go for 5 mg amlodipine or 12.5 mg HCTZ as first line for most patients.

*Of course for you to use this information in the ER you would need a patient that has already been diagnosed with HTN since you shouldn't be diagnosing HTN in the ER, most of the time.

Most of the time, no. This is not something I do frequently. The guy coming in with 160/80... who knows what their real BP runs at. The guy who I happen to find to have 200/90 with a non pain complaint who has not been to the doctor in 20 years is more the person I would aim to do this for.

 

[PlutoBoy]

Thanks, that's a great explanation. You've convinced me to change my practice to mostly go for 5 mg amlodipine or 12.5 mg HCTZ as first line for most patients.



Most of the time, no. This is not something I do frequently. The guy coming in with 160/80... who knows what their real BP runs at. The guy who I happen to find to have 200/90 with a non pain complaint who has not been to the doctor in 20 years is more the person I would aim to do this for.

I agree with your approach 🙂

I also never gave my ER docs any grief if they wanted to admit these patients for observation 🙂

SBP>200 and DBP>120 is kind of high and should be fairly easy to manage for the internist. And if the patient has not been compliant in the past twenty years there is a good chance that he won't be compliant next week but hey, if we controlled it a little bit and then he stops taking the medication and has a head bleed he can't blame us for discharging him!

 

[gro2001]

I agree with your approach 🙂

I also never gave my ER docs any grief if they wanted to admit these patients for observation 🙂

SBP>200 and DBP>120 is kind of high and should be fairly easy to manage for the internist. And if the patient has not been compliant in the past twenty years there is a good chance that he won't be compliant next week but hey, if we controlled it a little bit and then he stops taking the medication and has a head bleed he can't blame us for discharging him!

Sometimes I try to leverage the ER visit as a Come-to-Jesus moment for these folks. I like to think that drawing attention to the fact that they ended up in the EMERGENCY room is a signal that they should pay more attention to their health and take these meds. Who knows if it really works though.

 

[shookwell]

When I do start people on antihypertensives I start 5mg amlodipine. Good side effect profile, not expensive, you don't have to check or follow any labs, and the clinic docs like it.

 

[VA Hopeful Dr]

Yikes, that's embarrassing.

How much HCTZ was he on? I thought this was mostly dose related?




Are you saying 25 mg HCTZ is too high? Do you max out HCTZ at 12.5?

It seems this http://www.aafp.org/afp/2010/0601/p1333.html is saying HCTZ is the best first line drug for HTN. I am certainly not going to start multiple antihypertensives in the ER, particularly since most people still seem to think serial mono-therapy as the first line approach to HTN.

But feel free to correct me if I am wrong, I'd love to hear more from you guys on this.

25mg, and he's the exception to most meds - cozaar ran his potassium to 6 and a week of celebrex took his creatinine from 1 to 2.

That article was basing recommendations from JNC-7. JNC-8 has since been released which says that first line either CCB of thiazide diuretic is OK for everyone and ACE-I is OK for non-african americans as first line therapy.

 

[gro2001]

25mg, and he's the exception to most meds - cozaar ran his potassium to 6 and a week of celebrex took his creatinine from 1 to 2.

That article was basing recommendations from JNC-7. JNC-8 has since been released which says that first line either CCB of thiazide diuretic is OK for everyone and ACE-I is OK for non-african americans as first line therapy.

I feel family members and fellow physicians tend to have an unusually high complication rate.

Alright, good to know. Looks like I will just stick to 5 mg amlodipine for all of these cases from now on.