By: Frances Trosa PharmD Candidate c/o 2015
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After much anticipation, the report from the Eighth Joint National Committee (JNC 8) has arrived! Panel members appointed to the committee have created evidence – based recommendations to assist physicians in managing hypertensive patients.
A major difference between the JNC 7 report and the JNC 8 report is the recommendation on target blood pressure treatment goals in different patient populations. For example, JNC 7 determined that all adult patients with hypertension should have a systolic blood pressure (SBP) goal of less than 140 mmHg. Furthermore, patients with diabetes or renal disease should aim for a SBP of less than 130 mmHg.1
However, there are some differences with the recommendations of the panel of the Eighth Joint National Committee. In JNC8, Adults years 60 and older should be treated for hypertension with pharmacologic agents when SBP is 150 mmHg or greater, or DBP is 90 mmHg or greater. The treatment goal for this population is to maintain a blood pressure less than 150/90. The panel further stated that any adult patient in this population that has been treated to achieve a SBP of less than 140 mmHg as per the previous guidelines should continue with his or her current medication regimen as long as the medication is being well tolerated and the patient is not experiencing any adverse effects.2
JNC 8 recommends initiating pharmacologic therapy in patients younger than 60 years old when the patient’s SBP is 140 mmHg or greater or his or her DBP is 90 mmHg or greater, with a target goal of less than 140/90. It was also recommended that patients older than 18 with chronic kidney disease or diabetes receive pharmacologic treatment when their SBP is 140 mmHg or greater or their DBP is 90 mmHg or greater. Patients in this subset should also be treated to a goal of less than 140/90. 2
The report from JNC8 goes on to recommend initial antihypertensive treatment for specific populations. In the general nonblack population, the committee recommends thiazide diuretics, calcium channel blockers (CCB), angiotensin – converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARB) for initial treatment of hypertension. This recommendation also applies to nonblack, diabetic patients.2
In the general black population, the panel concluded that initial treatment with antihypertensives should include a thiazide diuretic or CCB. This recommendation is also consistent with that for the black, diabetic population.2
Therapy for patients aged 18 years and older with chronic kidney disease and hypertension should include an ACEI or ARB either as initial or add – on therapy. This recommendation is for patients of all races with chronic kidney disease, with or without proteinuria. Although these medications are not recommended as initial therapy in the general black population, black patients with chronic kidney disease and proteinuria should be initiated on either an ACEI or ARB for their renal benefits. Initial pharmacologic treatment in black patients with chronic kidney disease and without proteinuria may include a thiazide diuretic, CCB, ACEI, or ARB. If a thiazide diuretic or CCB was used as initial treatment, an ACEI or ARB can be added as second – line therapy if the patient is not at his or her blood pressure goal with monotherapy.2
It is important to acknowledge that blood pressure will not always be achieved after initial therapy. If a patient’s goal blood pressure is not reached within a month of treatment, a physician can either increase the dose of the current medication or add a second drug from the initial recommendation. Furthermore, if a patient cannot achieve a goal blood pressure with two medications, the physician may add on a third medication and titrate if needed, and so on. The panel also stated that an ACEI and ARB should not be used in the same patient.2
The report from JNC 8 offers clinicians guidance regarding blood pressure thresholds, goals, and drug therapy plans based on evidence from randomized clinical trials. These guidelines, when combined with clinical judgment, should assist clinicians in managing their hypertensive patients.
SOURCES:
- Peterson ED, Gaziano J, Greenland P. Recommendations for Treating Hypertension: What Are the Right Goals and Purposes?. JAMA Online. December 18, 2013. http://jama.jamanetwork.com/article.aspx?articleid=1791422. Accessed January 17, 2013
- James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA Online. December 18, 2013. http://jama.jamanetwork.com/article.aspx?articleid=1791497. Accessed January 17, 2013.
