A Summary Of The JNC 8 Hypertension Guidelines

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Volume 10, Issue 2A Summary of the JNC 8 Hypertension GuidelinesBrooke Stanton, Pharm.D. CandidateSt. Louis College of PharmacyANTHC Pharmacy Student InternFall 2014TDiabetes DispatchALASKA NATIVE DIABETES TEAMhe Eighth Joint National Committee (JNC 8)finally released the 2014 Evidenced-BasedGuidelines for the Management of HighBlood Pressure in Adults which update and replace the decade old JNC 7 hypertension guidelines. The aim of the update was to provide simplified recommendations for the management ofblood pressure based on evidence from randomized controlled trials and the panel’s expert opinion.The JNC8 guidelines differ from the JNC 7 guidelines in two key areas: blood pressure goals andfirst line medication therapies. While the previous guidelines based blood pressure goals andtreatment on comorbidities, the new guidelinestake a more generalized approach.Blood Pressure GoalsPatients with diabetes, chronic kidney disease(CKD), or younger than 60 years, have a bloodpressure goal 140/90 mmHg. Patients who are60 years or older, without comorbidities, have amore conservative blood pressure goal 150/90mmHg.Populationgeneral population. Other classes of medicationssuch as beta-blockers and alpha2-adrenergic agonists are considered alternatives when combinations of first line medications are unsuccessful atachieving blood pressure control.There are two patient populations that havemore specific drug recommendations. All patients with CKD, regardless of race, should takeeither an ACEI or ARB as first line or add-on therapy. The ALLHAT trial demonstrated that ACEIsand ARBs did not significantly reduce cardiovascular risk in black patients; thus, CCBs and thiazide diuretics are preferred first line agents inthis population.PopulationInitial DrugTreatment OptionsGeneral 60 yearsGeneral 60 yearsNonblack: thiazidediuretic, ACEI, ARB,or CCBDiabetesBlack: thiazidediuretic or CCBChronic KidneyDiseaseACEI or ARBBP GoalHypertensive Patient 18 yearsGeneral 60 years 150/90 mmHgGeneral 60 years 140/90 mmHgDiabetes 140/90 mmHgChronic Kidney Disease 140/90 mmHgFirst Line TherapyIn regards to first line medications, JNC 8 statedthat thiazide diuretics have the most evidencesupporting their use in hypertension; however,the guidelines classify angiotensin convertingenzyme inhibitors (ACEIs), angiotensin II receptorblockers (ARBs), calcium channel blockers (CCBs),and thiazide diuretics all as first line agents in theImplement lifestyle modificationsSet BP goal and initiate medicationsbased on age, diabetes, and CKDSelect a drug treatment strategy:A. Maximize 1st med before adding 2ndB. Add 2nd med before reaching max dose of 1stC. Start with 2 meds separately or as fixed comboNot at goal BP:A/B. Add and titrate1st line medicationsC. Titrate doses ofmeds to maxAt goal BP:Continue currenttreatment/monitoringObjectives: Review JNC 8 blood pressure goals and first line medications for specific patient populations Identify important considerations for Afrezza use Review the conversion between rapid-acting injectable insulin and Afrezza doses Recognize the correlation between tuberculosis and diabetes

A Summary of the JNC 8 Hypertension Guidelines—ContinuedBrooke Stanton, Pharm.D. CandidateSt. Louis College of PharmacyANTHC Pharmacy Student InternADA Standards of CareThe American Diabetes Association (ADA) has slightly differentrecommendations than JNC 8. While JNC 8 suggests treatingpatients with both diabetes and hypertension to a blood pressure goal 140/90 mmHg, ADA standards of care advise treating to a goal of 140/80 mmHg. The ADA also states that alower blood pressure goal of 130/80 mmHg may be reasonable in younger patients if it does not increase treatment burden.In regards to medication therapy, either an ACEI or ARB shouldbe included in a patient’s pharmacological regimen. Additionally, one or more medications should be administered at bedtime to prevent unsafe elevations in blood pressure overnight.Both organizations agree that lifestyle modifications such asincreased physical activity, healthy diet with reduced sodiumintake, and weight loss (if overweight), are the baseline oftreatment.ReferencesJames PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for themanagement of high blood pressure in adults: report from the panel membersappointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–520.American Diabetes Association. Standards of medical care in diabetes—2014.Diabetes Care. 2014;37(suppl 1):S14-S80.Afrezza : Conventional Insulin Administered in an Unconventional WayMatt Snyder, Pharm.D. CandidateWest Virginia School of PharmacyANTHC Pharmacy Student InternAfreeza is rapid-acting recombinant human regular insulinthat is formulated as a dry powder for inhalation. Afrezza isproduced by MannKind Corporation, a biopharmaceuticalcompany that focuses on researching treatments for diseaseslike diabetes mellitus (DM) and cancer. Two recent studiesconducted by MannKind found Afrezza to be non-inferior toinsulin aspart in patients with type 1 diabetes (AFFINITY-1) andsuperior to placebo in patients with type 2 diabetes (AFFINITY2). On June 27, 2014, the drug was granted an FDA-approvedindication to improve glycemic control in adults with both type1 and type 2 DM.Place in TherapyAs for its place in therapy, Afrezza is an alternative to therapid-acting injectable insulins (lispro, aspart, and glulisine) inpatients with type 1 and type 2 DM. It is especially appealingto patients who are afraid of or do not like to use needles. Thedrug is not a replacement for long-acting insulin, so all patientswith type 1 DM as well as some with type 2 DM must still use alonger-acting agent in addition to Afrezza . If patients are currently taking injectable rapid-acting insulin before meals, theycan be easily switched to Afrezza using the conversion chartshown to the right.Page 2PharmacokineticsAfrezza contains regular human insulin, and therefore lowersblood glucose levels by stimulating peripheral glucose uptakeby skeletal muscle and fat, and by inhibiting hepatic glucoseproduction. The inhaled insulin is absorbed faster by the bodyas peak insulin levels are achieved within 12-15 minutes ofadministration and decline back down to baseline in about 180minutes. Even though it has faster absorption, Afrezza doesnot have a faster onset of activity compared to insulin lispro.However, its quicker return to baseline insulin levels suggest itcould have less risk for hypoglycemia than its rapid-actingcounterparts. After it is absorbed through the lungs and intothe systemic circulation, the drug’s metabolism and elimination are comparable to those of regular human insulin.D I A B E T E S DI S P A T C H

Afrezza : Conventional Insulin Administered in an Unconventional WayMatt Snyder, Pharm.D. CandidateWest Virginia School of PharmacyANTHC Pharmacy Student InternHow is Afrezza Supplied?Warnings and PrecautionsAfrezza will be supplied in single-use cartridges consisting of4 and 8 units of insulin that will be given at the beginning of ameal. Dosing should be individualized to each patient’s needs.The inhaler itself is small, whistle-like, easily fits into a pocket,and can be discreetly used.Afrezza has a black box warning for patients with chronicpulmonary disease (such as asthma or chronic obstructivepulmonary disease [COPD]) due to the risk of acute bronchospasm. It must be used with caution in patients who are alsoon anti-adrenergic drugs (beta-blockers, clonidine, reserpine,etc.), as these medications could reduce or eliminate signs ofhypoglycemia resulting from Afrezza .StorageUsing the inhaler itself and handling the associated cartridgesare fairly simple. The inhaler, which can be stored in or out ofthe refrigerator, is only meant to be used for 15 days beforebeing discarded and replaced with a new one. The single-usecartridges are supplied in sealed foil packages (each containingtwo 3 X 5 blister cards of cartridges). Unused foil packagesshould be refrigerated. Once a foil package has been opened,it can be stored at room temperature, as long as unopenedstrips of the blister cards are used within 10 days, and the remaining cartridges in an opened strip are used within 3 days. Itis important to know that the cartridges and inhaler should beat left at room temperature for 10 minutes before use.Directions for UseTo use Afrezza , patients should simply remove a cartridgefrom a strip and place it flat inside the opened inhaler with thecup facing down and the pointed ends of the inhaler and cartridge lined up. After loading and closing the inhaler, theyshould be sure to keep it level to avoid loss of drug powder(otherwise they must get a new cartridge and begin again). Toinhale, patients should removethe purple mouthpiece cover,exhale fully, and then place theinhaler in their mouth while keeping their head level. The inhalershould then be tilted downward(with the head remaining level),and patients should inhale deeplythrough the inhaler, holding theirbreath for as long as comfortableand at the same time removing the inhaler from their mouth.After holding their breath, patients can exhale to resume normal breathing, put the mouthpiece back on the inhaler, andremove and discard the used cartridge.There are a few limitations of the drug. It is not recommended for the treatment of diabetic ketoacidosis or in patients who smoke or have recently quit smoking. FDA postmarketing studies for Afrezza will examine the drug’s effectson pediatric patients and assess the risk for cardiovasculardiseases associated with its use.Adverse EffectsThe most common adverse reactions occurring with the useof Afrezza include cough, throat pain or irritation, and hypoglycemia. Additionally, the drug has also been associated withincidences of pulmonary function decline, lung cancer, diabetic ketoacidosis, hypokalemia, life-threatening hypoglycemia, and fluid retention and heart failure with concomitantuse of thiazolidinediones.MonitoringIn addition to usual diabetes-related monitoring (HbA1c, fasting blood glucose, etc.), patients on Afrezza must monitorpulmonary function (FEV1) at baseline, 6 months, and yearlythereafter. Potassium levels as well as heart, kidney, and liverfunction should also be monitored over the course of therapy.Market AvailabilityIn August, MannKind announced a worldwide exclusive licensing agreement with Sanofi to help with development,commercialization, and distribution of Afrezza . Plans are inplace for the drug to become available on the market withinthe first quarter of 2015. MannKind’s executives claim thatAfrezza will be priced competitively with insulin pens. Aftermany years of delay and several setbacks, it appears that withits recent FDA approval, Afrezza is on its way to becoming anoption for the treatment of both type 1 and type 2 DM.ReferencesAfrezza [Full Prescribing Information]. Valencia, CA: MannKind Corp; 2014.Afrezza [Medication Guide]. Valencia, CA: MannKind Corp; 2014.VOLUME 10, ISSUE 2Page 3

Tuberculosis and Diabetes: an Epidemic in the Making?Brooke Stanton, Pharm.D. CandidateSt. Louis College of PharmacyANTHC Pharmacy Student InternAlaska Native People and American Indians have the highestrate of diabetes in people 20 years at 15.9% when comparedto other races and ethnicities. People with diabetes can havea suppressed immune system which puts them at an increasedrisk of contracting infectious diseases such as tuberculosis(TB). Additionally, type 1 diabetes is an autoimmune diseasethat can be triggered by viral infections and new evidence suggests that type 2 diabetes can also be activated by inflammation and immune response. According to the Centers for Disease Control and Prevention (CDC), Alaska has the highest rateof TB in the country at 9.7% (71 cases). Worldwide, a “dualepidemic” of diabetes and TB is slowly developing in low- andmiddle- income countries threatening global TB control.CDC 2013 Tuberculosis Statistics per 100,000 PeopleReportingAreaCasesUnited States 9,582CaseRateRank Accord- Populationing to Treatment of TB in patients with diabetes is more complicatedthan in the general population. With a compromised immunesystem from diabetes, latent TB is 3 times more likely to become active TB. The disease manifests itself differently in diabetes as it primarily concentrates in the lower lobes of thelung and weakens pulmonary capillaries causing blood andprotein to leak into the lung tissue. As a result, treatmentJudy B. Thompson, Pharm.D., BCPS, CDE, BC-ADMAlaska Native Diabetes Dispatch ReviewersAngela Manderfeld, RD, CDEAnn Marie Mayer, NP, MPH4315 Diplomacy DriveAnchorage, AK 99508Phone: 907-729-2164Fax: 907-729-2119Email: jbthompson@anthc.orgDiabetes Office Phone: 907-729-1125We are on the Web:www.anthc.org/anmc/services/diabetes/Page 4takes about 3 months longer than usual. Inflammation thataccompanies TB also makes achieving glycemic control moredifficult which can adversely affect the kidneys and heart.Overall, the risk of dying from TB is 4 to 5 times higher in patients with diabetes.To reduce the incidence of negative outcomes in patientswith both diabetes and TB, regular screening is important.According to the World Health Organization, patients withdiabetes should be asked about the presence of a wet, productive cough and low-grade fever lasting longer than 2weeks at initial diagnosis and each regular checkup. If a patient is positive for these symptoms, he should obtain a Tuberculin skin test (TST) and/or chest x-ray for further evaluation. All patients with tuberculosis should be screened fordiabetes using either hemoglobin A1c, oral glucose tolerance,or fasting blood glucose tests.The Indian Health Service also recommends that a TST or Tcell interferon-γ release assay (IGRA ) should be performed inpatients with diabetes at least once after diagnosis and moreoften as indicated. If a test is positive, a medical history, review of symptoms, targeted physical exam, and chest x-rayshould be obtained. For every 8 to 10 patients with tuberculosis tested for diabetes, approximately 1 to 2 patients willhave underlying disease. With regular screening, early treatment of tuberculosis with diabetes could potentially lead toless morbidity and mortality.ReferencesWorld Health Organization and International Union against Tuberculosis.Collaborative framework for care and control of tuberculosis and diabetes.2011.Nainggolan L. Double trouble: diabetes and TB are 2 converging pandemics.Medscape Medical News. Reporting from the World Diabetes Congress2013; 2-6 Dec. 2013; Melbourne, Australia.Goal-The goal of the Diabetes Dispatch is to increase the reader’s knowledge of diabetes treatments and technologies and to provide the mostcurrent information on new drugs, therapies, anddevices. UAN# 0139-9999-14-029-H01-P/TRelease date: 11/14/2014ANMC HED Activity # 13-30010Expiration Date : 11/14/2017The speakers/authors disclose that they do not have significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.D I A B E T E S DI S P A T C H

Continuing Education QuizDiabetes Dispatch: Fall 20141.According to JNC 8 guidelines, what is the blood pressure goalof a 64 year old male with diabetes?a. BP goal 150/90 mmHgb. BP goal 140/90 mmHgc. BP goal 140/80 mmHgd. BP goal 130/80 mmHg6.All of the following are potential adverse effects of Afrezzaexcept:a. Coughb. Hypoglycemiac. Throat paind. Hyperkalemia2.What is the recommended first line treatment of hypertension in 7.a patient with both CKD and diabetes per JNC 8?a. Thiazide diureticb. Calcium channel blockerc. ACE inhibitord. Any of the aboveA patient is currently using 17 units of meal-time injectableinsulin. What is the equivalent dose of Afrezza?a. 20 unitsb. 1 blue cartridge plus 2 green cartridgesc. 17 unitsd. Both a and be. None of the above3.Which of the following is not an ADA recommendation for themanagement of high blood pressure in patients with diabetes?a. Administer one or more medications at nightb. Medication regimen should include an ACEI or ARBc. Lifestyle modifications are the baseline of treatmentd. Treat to BP goal 140/90 mmHg4.A patient’s blood pressure is not at goal even though she isappropriately taking both a thiazide diuretic and an ACEI at themaximum doses. What medication should be initiated next?a. Calcium channel blockerb. Angiotensin II receptor blockerc. Beta blockerd. Aldosterone antagonist5.8.How many Afrezza cartridges does a patient need to inhale toobtain a dose of 24 units?a. 3 green cartridgesb. 2 green cartridgesc. 3 blue cartridgesd. None of the above9.According to CDC statistics, which state has the highest rateof tuberculosis in the United States?a. Alaskab. Californiac. Texasd. HawaiiWhich of the following is true regarding Afrezza?10. To reduce morbidity and mortality associated witha. Afrezza can replace long-acting insulin injectionstuberculosis in patients with diabetes, regular screening isb. Even though Afrezza is absorbed faster than injected inimportant. What are the recommendations for screening?sulin, it does not have a faster onset of activitya. Screen TB patients for diabetes upon diagnosisc. Afrezza will be supplied in multiple-use cartridges consistb. Regularly ask patients with diabetes about symptoms ofing of 8 and 4 units of regular insulincough and low-grade fever lasting 2 weeksd. Afrezza can be used in patients with COPDc. All of the abovePharmacists and Technicians:The Alaska Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider ofcontinuing pharmacy education.To obtain CPE credit for this lesson you must answer the questions on the quiz (70% correct required) return the quiz and evaluation tool. Should you score less than70%, you will be asked to repeat the quiz. This activity is accredited for 1.0 hour CPE (0.1CEU). Upon satisfactory completion, AKPhA will report participant CPE toCPE Monitor within 60 days of completion.Pharmacist and technicians may receive credit for completing this course if returned by November 14, 2017.UAN 0139-9999-14-029-H01-P/T Knowledge-based activityFor ACPE Credit Mail or Fax to: FAX (907)- 563-7880Mail: AKPhA, 203 W. 15th Ave. # 100, Anchorage, AK 99501Circle one: PharmacistDisagreeTechnicianAgreeDisagree1)The activity met my educational needs1 2 3 4 56) The activity learning assessment was appropriate2)The activity met every learning objective*1 2 3 4 57) The activity was presented in a fair and unbiased manner3)The author was knowledgeable in the topic1 2 3 4 54)The educational materials were useful1 2 3 4 55)Teaching and learning methods were effective1 2 3 4 5Agree1 2 3 4 5Yes NoIf not, please describe8) Overall, I was satisfied with the activity.Yes No*If a particular objective was not met, please explain:Additional CommentsName AddressE-Mail NABP CPE# DOB: Phone

recommendations than JNC 8. While JNC 8 suggests treating patients with both diabetes and hypertension to a blood pres-sure goal 140/90 mmHg, ADA standards of care advise treat-ing to a goal of 140/80 mmHg. The ADA also states that a lo

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