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New hypertension and cholesterol guidelines are greatly needed
New evidence and drugs are available
Hospital pharmacists, physicians, and others hopefully soon will have new hypertension and cholesterol guidelines available to inform hospital formulary and clinical practice decisions. These consensus recommendations would be the first update in more than seven years.
They're long past due, says Joe Saseen, PharmD, BCPS, FCCP, a professor at the University of Colorado School of Pharmacy in Aurora, CO.
"With science and evidence arriving at a fast pace, you should revise these guidelines every five years," Saseen says. "The diabetes standards are updated every year, so a revision every five years is a reasonable standard so long as the evidence is in alignment with that."
The lipid guidelines from the National Cholesterol Education Panel Adult Treatment Panel III (NCEP ATP III) haven't been revised since 2001, although a white paper was published in 2004, and the last report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) was published in 2003, Saseen notes.
Both are expected to be released by early 2011.
The JNC guidelines are evidence-based, but they haven't been ranked, and they need to be ranked, Saseen says.
"We need to resolve the controversy about blood pressure goal values," he says.
The JNC 7 guidelines say that individuals with systolic blood pressure of 120-139 mmHg or a diastolic blood pressure of 80-89 mmHg should be considered as prehypertensive and at risk of developing cardiovascular disease.
But research data have not shown any benefit to aggressively bringing down the blood pressure of certain high risk patients, such as diabetics, from 140 mmHG to below 120 mmHG, Saseen says.
Data supporting that standard for a diabetic population is mostly interpretation, he adds.
"If you take people with hypertension and treat them to 120 [systolic] instead of 140, then there's no proof that 120 is better. None," Saseen says. "The unpredicted consequence of JNC setting these guidelines is they've labeled blood pressure of less than 120 as normal, and anyone in the 120s as pre-hypertension, and 140 and above as different levels of hypertension."
The evidence supporting this is for populations and not for individuals.
"Epidemiological data looking across populations show that people with less than 120 systolic blood pressure are healthier and live longer," Saseen explains. "But when you take people with a diagnosis of hypertension and treat them, we have no proof that more intense treatment to achieve less than 140 [systolic] blood pressure is better."
So when the new hypertension guidelines are released, the panel making the revisions will be hard-pressed to recommend 130 or 120 systolic levels because the evidence is lacking, Saseen says.
"For the diabetic population, you should get their blood pressure at least to less than 140 with the option of more intense treatment with some subtle changes on specific endpoints," he advises. "I personally believe there are some benefits to treating more aggressively, but there are some more side effects if you treat more aggressively."
The other controversial item that the JNC guidelines might address involves the first-line drugs listed for treating hypertension.
In the last revision, one of the top five first-line drugs was a beta blocker, Saseen says.
"But there's growing evidence that as first-line therapy, beta blockers for relatively healthy hypertension is not as good as four other options," he says. "So the JNC guidelines will have to question whether beta blockers need to be in the first-line drugs for hypertension."
Another controversial item involves the preferred status for thiazide-type diuretics. These also are on the top-five list, and in JNC 7, the guidelines stated that most patients should be on a thiazide because they have the best evidence of lowering cardiovascular risk, Saseen says.
"In 2002 when the guidelines were written, that probably was true," he says. "But in 2010, it looks like thiazides are as good as calcium channel blockers, ACE [angiotensin converting enzyme] inhibitors, and ARBs [Angiotensin II receptor blockers], and all of these should be viewed as equally effective."
More clarification and guidance are needed for the update of the lipid guidelines, he says.
For instance, people increasingly are using fish oil or omega-3 fatty acid tablets for lowering cholesterol.
"You can buy these over the counter, and they're good for the heart, but are unregulated," Saseen says. "These are being used for triglyceride-lowering, and doctors prescribe and patients self-prescribe."
Omega-3 fatty acid products now are considered drugs and are used as an adjunct to statins. They can be misused, and the over-the-counter products could have ingredients that are not advisable, so these need to be addressed in the guidelines, Saseen says.
"I think the guidelines should clearly outline what the role of these high-dose omega-3 fatty acids are and what the benefits are and what the role is for these," he adds.
For instance, the guidelines might state that these can be used to lower triglycerides, but not as a substitute for statin drugs.
The 2004 white paper on cholesterol discussed new evidence suggesting that clinicians should treat LDL cholesterol with the goal of lowering it to below 100 with the option of treating to less than 70, Saseen says.
"Now, it'd be nice to adopt that as a standard and use a term that is more influential than saying it is an option for the highest risk people with heart disease," he says.
Also, the guidelines might allow for nuances in treatment, such as accounting for patients' overall health and environmental risk of heart disease, such as whether they smoke, family history, diabetes, etc., he says.
"For someone who hasn't had a heart attack, but who has high blood pressure, smokes, and is overweight, then an LDL of 150 should be treated to less than 100," Saseen suggests. "But if the patient is a young woman who doesn't smoke and who has no other risk factors than, 100 is fine."
These guidelines updates will be very important to clinical practice in and out of hospitals because government agencies, health insurance payers, and others are looking more and more at consensus guidelines, Saseen says.
"They're looking at chronic disease state management and how well your provider is treating the things that will kill people," he says.