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JNC 8
The document outlines the development and recommendations of hypertension treatment guidelines with input from numerous reviewers and agencies, culminating in a draft in June 2013. It highlights nine specific recommendations on pharmacological treatment for various adult populations, including considerations for age, race, and comorbidities. The guidelines provide a framework for initiating therapy and adjusting treatment to meet blood pressure goals effectively.
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JNC 8
- 1. JNC 8 Evidence tothe fore?
- 2. PROCESS >400 nominees Members selected Guidelinesfirst draft - January 2013 Reviewed by 20 reviewers + 16 federal agencies February 2013 Revised document - June 2013
- 3. QUESTIONS In adults withHTN:•Starting Pharmac Rx @ specific BP threshold = benefit? •Treating •Diff to specific BP goal = benefit? anti-HTN drugs/classes = Diff benefit or harm in specific health outcomes?
- 4.
- 5. POPULATION CRITERIA • • Adults ≥18 years with HTN Subgroups • • • • • • • • • • DM CAD PAD HF Prev Stroke CKD Proteinuria Older adults Men/Women Racial/ethnic groups,
- 6. OUTCOMES CONSIDERED • Mortality: overall,CVD related, CKD related • MI, HF, Hospitalization for HF, stroke • Revasc: Coronary (Plasty/Bypass), others (carotid, renal, limb) • ESRD, Creat x 2, GFR/2
- 7. TRIALS Only RCTs Period Jan1, 1966 to Dec 31, 2009 Secondary search PubMed & CINAHL Dec 2009 – Aug 2013 Major study in HTN, ≥ 2000 subjects, multicentric, met incl/excl criteria
- 8. COLLATION • • • • Data tabulated Evidence summarized Evidencestatements crafted Voting Agree/disagree with evidence statement • Quality of evidence • • • Clinical recommendations crafted Voting Agree/disagree with recomm • Strength of recomm •
- 9. RESULTANT 9 recommendations Strength ofrecommendation for each Recomm 1 – 5 Threshold Recomm 6 – 8 Selection and goals of antiHTN drugs Recomm 9 Summary of strategies (expert opinion)
- 10.
- 11. RECOMMENDATION 1 Gen pop≥ 60 years Start at SBP>150 OR DBP>90 Goal SBP<150 AND DBP<90 Strong – Grade A PS: If already having lower values + no adverse effects = continue present Rx Exp Op – Grade E
- 12. RECOMMENDATION 2 Gen pop< 60 years Start at DBP ≥ 90 Goal DBP < 90 Strong – Grade A (30-59 years) Exp Op – Grade E (18-29 years)
- 13. RECOMMENDATION 3 Gen pop< 60 years Start at SBP ≥ 140 Goal SBP < 140 Exp Op – Grade E
- 14. RECOMMENDATION 4 CKD ≥18 years Start at SBP ≥ 140 OR DBP ≥ 90 Goal SBP < 140 and DBP < 90 Exp Op – Grade E PS: No evid for BP goal – CKD > 70 years Induvidualize Rx
- 15. RECOMMENDATION 5 DM ≥18 years Start at SBP ≥ 140 OR DBP ≥ 90 Goal SBP < 140 AND DBP < 90 Exp Op – Grade E
- 16. RECOMMENDATION 6 Gen popnon-black (+/- DM) Initial drug: Thiazide diuretic CCB ACEi ARB Mod Recomm – Grade B
- 17. CAVEATS Only for initialdrug choice. Add-on any will do Specific to thiazide diuretics Drugs to be adequately dosed NOT for CAD, HF, CKD
- 18. RECOMMENDATION 7 Gen Blackpop (+/- DM) Initial drug:- Thiazide/CCB Mod Recomm – Grade B (Gen Black) Weak Recomm – Grade C (Black + DM) PS:- Diuretic > CCB in preventing HF
- 19. RECOMMENDATION 8 Adults CKD(any race, +/- DM) ACEi/ARB as initial/add-on Mod Recomm – Grade B PS – Only improves kidney outcomes
- 20. RECOMMENDATION 9 MAIN AIM– attain + maintain goal BP Not at goal by 1 mth Rx:↑ dose initial drug / add-on 2nd drug Continuous assessment and drug adjustment Use drugs from other classes if:> 3 drugs needed Contraindic/adverse effect of recomm classes Exp Op – Grade E
- 21. COROLLARIES 1 Assess BPregularly Evidence based lifestyle and adherence interventions Adjust Rx till goal attained + maintained Dose and titration not discussed (no RCTs) Algorithm suggested – not validated for benefit
- 22. COROLLARIES 2 3 Strategiessuggested: Initiate 1 drug – go to max – then add 2nd drug Initiate 1 drug – add 2nd drug before 1st @ max Initiate 2 drugs in single / fixed dose combo Drugs may be substituted if: Not effective Adverse effects
- 23. THANK YOU ALL For YourKind Attention