Protocol for treating the hypertensive patient in

HIGH BLOOD PRESSURE TREATMENT PROTOCOL FOR PATIENTS IN
HAITI, INCLUDING WHEN LABORATORY MONITORING IS NOT AVAILABLE

There are a number of ways to approach the treatment of the patient with high blood pressure
when laboratory testing is not available. The following is one approach.
Naturally, the particular circumstances of the individual patient and the experience and clinical
judgment of the individual medical practioner will lead to modifications of this protocol or
even a different treatment protocol altogether. However, in the hope of providing concrete and
usable information to the volunteer medical health care provider working in Haiti, the
following treatment protocol is offered as a potential starting point.
The medications that are used in this protocol are very cost effective in order to increase
the feasibility of making a sustained effort to treat hypertension in this setting.
(At wholesale prices, the cost of a 3 drug regimen is 10 cents/day.)
Prior to the use of any treatment protocol for hypertension, the medical practioner should be personally knowledgeable of the complete side effect profile of every medication that is prescribed. The following protocol is simply an approach to consider, with the final treatment decision to be made by the medical care provider seeing the individual patient while taking into account the particular clinical conditions that exist. www.HypertensionRxHaiti.com Eric Roehm, M.D. HIGH BLOOD PRESSURE TREATMENT PROTOCOL WHEN LAB
MONITORING IS NOT AVAILABLE
- If a patient has a contraindication or develops a significant side effect with a medication, delete that medication from the protocol. - The prescribing health care provider must be personally knowledgeable about the complete side effect profile of every medication prescribed. Final treatment decisions are to be made by the health care provider in the context of the particular conditions that exist for the individual patient. - All patients treated for hypertension should be advised to decrease salt intake and - If the patient develops profuse diarrhea or sustained nausea and vomiting, hold both the diuretic (HCTZ) and the ACE inhibitor therapy (lisinopril) until gastroenteritis resolves. (It may be necessary to hold other blood pressure medications as well.) ================================================================================= BP TREATMENT FLOW CHART- IF NO LAB AVAILABLE: --------------------------------->
================================================================================= atenolol1 50mg 1-2 qd (begin with 1 pill qd) (Use verapamil2 if atenolol contraindicated.) --------------------------------->
--------------------------------->
================================================================================= atenolol1 50mg 1-2 qd (Use verapamil2 if atenolol contraindicated.) -------------------------------->
amlodipine3 10mg ½ - 1 pill qd (Can not use amlodipine if ================================================================================= --------------------->
www.HypertensionRxHaiti.com Eric Roehm, M.D. HIGH BLOOD PRESSURE TREATMENT PROTOCOL WHEN LAB
MONITORING IS NOT AVAILABLE (continued)
Have patient seen by a practioner experienced in the --------------------->
treatment of hypertension in order to consider adding

Special situation:
If prior to the earthquake, the Haitian patient was recently on an ACE inhibitor (usually
enalapril) in a laboratory monitored situation and was doing fine, the protocol can be
adjusted. (Similar situation applies, if patient had recently been on an angiotensin receptor
blocker in a lab monitored setting.) In that case lisinopril 20mg ½-1 qd can be considered
earlier in protocol if no newly developed contraindications such as dehydration have
developed.
-------------------------------------------------------------------------------------------
Footnotes to medications:

Atenolol use can be limited by the development of bronchospasm or excessive slowing of heart
rate, particularly if accompanied by lightheadness. (Atenolol always slows heart rate.)
Beta blockers can also cause impotence.
Beta blockers can be less effective for the treatment of hypertension in blacks.
However, there is so much mixed ancestry in Haiti, that it is unclear whether this concern has
significant general applicability to Haiti.
Verapamil can not routinely be combined with atenolol (a beta blocker) or amlodipine.
The slow release formulation of verapamil which is needed for hypertension is relatively much
more expensive than the other medications in this protocol.
Verapamil can cause excessive slowing of heart rate, constipation, and GI upset.
Amlodipine can at times cause the development of increased heart rate and angina.
HCTZ (hydrochlorothiazide) use in the unmonitored lab setting should be limited to a
maximum dose of 25mg ½ pill qd. In the lab monitored setting, HCTZ can be used at a dose of
12.5- 50mg. The higher the dose, the greater the tendency for potassium loss. Using a dose of
12.5 mg minimizes potassium loss and side effects. HCTZ use should be accompanied by the
advice to eat 1 additional piece of fruit daily (banana, tomato, or citrus fruit) to minimize
potassium loss.
Lisinopril in this setting should not be used in patients with dehydration because of the
increased risk of renal dysfunction. Lisinopril tends to increase potassium levels.
Lisinopril (as well as any other ACE inhibitor) is not to be used during pregnancy.
www.HypertensionRxHaiti.com Eric Roehm, M.D. HIGH BLOOD PRESSURE TREATMENT PROTOCOL WHEN LAB
MONITORING IS AVAILABLE
- If a patient has a contraindication or a significant side effect develops with a medication, delete that medication from the protocol. - The prescribing health care provider must be personally knowledgeable about the complete side effect profile of every medication prescribed. Final treatment decisions are to be made by the health care provider in the context of the particular conditions that exist for the individual patient. - All patients treated for hypertension should be advised to decrease salt intake and - If the patient develops profuse diarrhea or sustained nausea and vomiting, hold the diuretic (HCTZ) and the ACE inhibitor therapy (lisinopril) until gastroenteritis resolves. (May need to hold other blood pressure medications as well.) ============================================================================================== BP TREATMENT FLOW CHART- LAB MONITORING AVAILABLE: --------------------------------->
=============================================================================================== atenolol1 50mg 1-2 qd (begin with 1 pill qd) (Use verapamil2 if atenolol contraindicated.) --------------------------------->
** with either:
--------------------------------->
=============================================================================================== atenolol1 50mg 1-2 qd (Use verapamil2 if atenolol contraindicated) -------------------------------->
amlodipine3 10mg ½ - 1 pill qd. (Can not use amlodipine if -------------------------->
lisinopril5 20mg qd and HCTZ 25mg ½ - 1 qd lisinopril5 20mg qd and amlodipine 10mg ½ - 1 qd www.HypertensionRxHaiti.com Eric Roehm, M.D. HIGH BLOOD PRESSURE TREATMENT PROTOCOL WHEN LAB MONITORING
IS AVAILABLE (continued)
Use a 3 drug regimen for difficult to control HTN: ------------------->
A 4th medication can subsequently be added if needed:
Footnotes to medications:
Atenolol use can be limited by the development of bronchospasm or excessive slowing of
heart rate, particularly if accompanied by lightheadness. (Atenolol always slows heart rate.)
Beta blockers can also cause impotence.
Beta blockers can be less effective for the treatment of hypertension in blacks.
However, there is so much mixed ancestry in Haiti, that it is unclear whether this concern has
significant general applicability to Haiti.
Verapamil can not routinely be combined with atenolol (a beta blocker) or amlodipine.
The slow release formulation of verapamil which is needed for hypertension is relatively much more expensive than the other medications in this protocol. Verapamil can cause excessive slowing of heart rate, constipation, and GI upset. Amlodipine can at times cause the development of increased heart rate and angina.
HCTZ (hydrochlorothiazide) use in the unmonitored lab setting should be limited to a
maximum dose of 25mg ½ pill qd. In the lab monitored setting, HCTZ can be used at a dose of 12.5- 50mg. The higher the dose, the greater the tendency for potassium loss. Using a dose of 12.5 mg minimizes potassium loss and side effects. HCTZ use should be accompanied by the advice to eat 1 additional piece of fruit daily (banana, tomato, or citrus fruit) to minimize potassium loss. Lisinopril in this setting should not be used in patients with dehydration because of the
increased risk of renal dysfunction. Lisinopril tends to increase potassium levels.
Lisinopril (as well as any other ACE inhibitor) is not to be used during pregnancy.

** Concerning the initial treatment of hypertension
Many advocate routinely using HCTZ as the initial drug of choice in the treatment of
hypertension on the basis of the ALLHAT trial and that trial’s effect on subsequent meta
analyses. However, this appears to be an inappropriate overgeneralization of the
ALLHAT trial results. The ALLHAT trial had particular requirements for treatment
protocols that do not mimic routine clinical practice. These include the prohibition of using
lisinopril (an ACE inhibitor) with a diuretic as a second agent, the prohibition of using
amlodipine with a diuretic as a second agent, and the prohibition from using amlodipine in
combination with lisinopril which is a synergistic combination frequently used in clinical
practice. For further details see:
http://www.improvingmedicalstatistics.com/ALLHAT%20Trial%20Critique.htm
In fact, the subsequent ACCOMPLISH trial found that the combination of an ACE inhibitor
with amlodipine compared favorably with HCTZ for the initial treatment of hypertension.
For details: http://content.nejm.org/cgi/content/short/359/23/2417
www.HypertensionRxHaiti.com Eric Roehm, M.D. ====================================
Why were verapamil, diltiazem, and clonidine not recommended as primary
drugs in this treatment protocol for hypertension?

They were not included for reasons of cost, compliance, and compatibility with other agents. It
is worthy to note that short acting generic drugs that require a long acting formulation are
almost always significantly more expensive than generic drugs in the same class of medication
with an intrinsically long half life.
VERAPAMIL and DILTIAZEM are both calcium channel blockers, but affect the body so
differently compared to amlodipine or nifedipine, that it is best to consider these drugs as
being functionally a completely different type of medication.
The reasons for not including these medications as primary medications in this protocol will be
detailed with verapamil.
Verapamil is an option for treatment of a patient in a setting without laboratory monitoring.
VERAPAMIL is useful for the treatment of the patient with hypertension with an
elevated heart rate or in the presence of angina when beta blockers can not be used.
Verapamil can also be useful for patients with hypertension and palpitations resulting from
SVT or atrial ectopy.
However, it is not used more widely in this protocol for the following reasons:
1. Verapamil slows heart rate, though less than a beta blocker. Verapamil should not used in combination with a beta blocker for the treatment of hypertension in this setting (Verapamil can be used in combination with a beta blocker in a closely monitored situation by an experienced clinician for a condition such as angina.) 2. Verapamil can not routinely be used with amlodipine or nifedipine because they are in the same class of medications (even though they have different effects). 3. Verapamil formulations which are not long acting need to be given as a bid or tid dosage which decreases compliance. Long acting formulations are preferable for the treatment of hypertension, having better documentation in the literature of benefit. 4. Long acting verapamil is much more expensive than amlodipine.
DILTIAZEM is not useful as a primary drug in this protocol for similar reasons. In addition,
long acting verapamil has much better evidence from clinical trials compared to diltiazem that
it favorably affects clinical endpoints when used for hypertension.
CLONIDINE:
Clonidine is potentially useful as a drug for hypertension in the unmonitored setting.
Side effects of dry mouth, fatigue, and postural hypotension can all be assessed without any
laboratory monitoring which is a beneficial feature. A reasonable case can be made for
including this medication for the treatment of hypertension with or without laboratory
monitoring.

However, clonidine was not included as an initial drug of choice in this protocol because of
the following:
www.HypertensionRxHaiti.com Eric Roehm, M.D. 1. The bothersome side effects of postural hypotension, dry mouth, and fatigue are common with this medication. If side effects occur early on in treatment, the patient will be less likely to continue with any blood pressure treatment or even return for follow up, particularly when there is not a broad public campaign to increase the awareness of the need for maintaining a good blood pressure. 2. Clonidine is short acting and optimally given on a bid or tid schedule. This dosing frequency will lead to decreased patient compliance. 3. Long acting transdermal formulations of clonidine are available which significantly decrease the frequency of annoying side effects to the patient, but these are much more expensive and not suitable in this setting for that reason. 4. For resistant, hypertension not responsive to other agents, a trial of clonidine 0.1-
0.2mg qhs or clonidine 0.1mg bid added to other medications is a reasonable
option.

================================
I hope this information is helpful in the care of the Haitian population. (Fellow of the American College of Cardiology) www.HypertensionRxHaiti.com Eric Roehm, M.D.

Source: http://www.hypertensionrxhaiti.com/Hypertension%20treatment%20protocols%20for%20Haiti.pdf