specialty service: · CXR. · Urinalysis. · CBC and fasting lipid. · Creatinine, sodium, potassium, fasting glucose, and EKG. · Evaluate the patient for a high-salt diet or NSAID use, and correct these factors prior to referral. · Consider obtaining a 24-hour urine for creatinine, sodium, and creatinine clearance (helpful but not required). Default medication pathway Below is a suggested default pathway for initiating and advancing blood pressure medication treatment. Following this pathway has several advantages: · It works in each patient subgroup noted above (Table 4). · By starting at ½ tab, we use resources effectively, and patients are more willing to make a dose adjustment (to 1 full tab) as needed to reach goal. · A second dose adjustment (to 2 full tabs) can be made without requiring a new prescription. Table 5. Default pathway for initiating and advancing antihypertensive medications 1 Step 1 Combination ACE inhibitor and thiazide diuretic (lisinopril/HCTZ) 20/12.5 mg tabs Initiate at: ½ tab daily Advance every 2–4 weeks, as needed, to: 1 tab daily 2 tabs daily Throughout: Lab monitoring as needed (see Table 7) Step 2 If BP remains uncontrolled, add: Calcium channel blocker (amlodipine) 5 mg tabs Initiate at: ½ tab daily Advance every 2–4 weeks, as needed, to: 1 tab daily 2 tabs daily Throughout: Lab monitoring as needed (see Table 7) 1 Frail elderly patients may require lower initial doses and slower titration schedules. Frail elderly patients may require lower therapeutic doses as well. 9 Medication dosing Table 6. Antihypertensive medications: initial and recommended maximum dosing 1 Antihypertensive medication Initial dose Recommended maximum dose Thiazide diuretics Hydrochlorothiazide (HCTZ) 12.5 mg daily 25 mg daily Chlorthalidone 12.5 mg daily 25 mg daily ACE inhibitors Lisinopril 10 mg daily 40 mg daily Combination lisinopril/HCTZ 20/12.5 mg x ½ tab daily 20/12.5 mg x 2 tabs daily Angiotensin receptor blockers Losartan 25 mg/day in 1–2 doses 100 mg/day in 1–2 doses Calcium channel blockers Amlodipine 2.5 mg daily 10 mg daily Beta-blockers Metoprolol IR (tartrate) 25 mg twice daily 100 mg twice daily Metoprolol LA (succinate) 50 mg daily 200 mg daily Atenolol 2 25 mg/day in 1–2 doses 100 mg/day in 1–2 doses 1 Frail elderly patients may require lower initial doses and slower titration schedules. Frail elderly patients may require lower therapeutic doses as well. 2 Not preferred in frail elderly patients or those with CKD. Drug timing strategies · QHS (“bedtime”) dosing: There is some evidence to support using BP medications in the evening instead of the morning (except in patients with glaucoma or vascular ischemic disorders). (See Evidence Summary, p. 14.) · BID (twice-daily) dosing: When dosing reads “in 1–2 doses,” this means the package insert states that QDAY (once-daily) dosing is acceptable. However, better clinical results are often achieved with BID dosing of these medications. Consider BID dosing more strongly as the dose increases. · When considering either of these strategies, use shared decision making. For some patients, compliance is more difficult if they have to take medications twice per day instead of once. Also note that QHS diuretic dosing may result in poor tolerance/adherence in some patients. Be sure to discuss this with patients and ask how compliant they feel they would be with a more complicated medication regimen. If patient is not meeting BP goal Determine whether the patient is taking prescribed medications according to instructions. Using openended questions, talk with the patient about any barriers to adherence and check their understanding of their condition and the treatment(s) they’ve been prescribed. See “Medication Adherence Counseling” (staff intranet) for more detailed information. If patient also has ASCVD or diabetes, consider a referral to Pharmacy. To see the exact referral criteria, consult the text of the Pharmacy referral order in Epic. 10 ASCVD Prevention See the atherosclerotic cardiovascular disease (ASCVD) guidelines, Primary Prevention and Secondary Prevention, as appropriate. Follow-up/Monitoring Note: If the patient has an abrupt increase in BP measurement, consider secondary hypertension. Medication monitoring Table 7. Lab monitoring for medication side effects Medication Test(s) Frequency ACE inhibitors or ARBs 1 Potassium and Creatinine Before initiating therapy and 2 weeks after initiating therapy and With each increase in dose and Annually Diuretics and/or aldosterone antagonists 2 Potassium and Creatinine Sodium 3 Before initiating therapy and consider at the time periods listed above. Beta-blockers and/or Calcium channel blockers No routine lab monitoring is required. Not applicable 1 For patients on ACE inhibitors or ARBs, renal function (creatinine) should be checked because treatment may be associated with deterioration of renal function and/or increases in serum creatinine, particularly in patients dependent on renin-angiotensin-aldosterone system; potassium should be checked because 2–5% of patients develop hyperkalemia. 2 For patients on diuretics or aldosterone antagonists, potassium should be checked at least once a year, and perhaps twice a year and with any change of dose because excessive dosages can lead to profound diuresis with fluid and electrolyte loss; renal function (creatinine) should be checked because use of