JNC 8Evidence to the fore?

PROCESS

>400 nominees

Members selected

Guidelines first draft - January 2013

Reviewed by 20 reviewers + 16 federal agencies - February 2013

Revised document - June 2013

QUESTIONS

In adults with HTN:-

•Starting Pharmac Rx @ specific BP threshold = benefit?

•Treating to specific BP goal = benefit?

•Diff anti-HTN drugs/classes = Diff benefit or harm in specific health outcomes?

EVIDENCE SELECTION

POPULATION CRITERIA

• Adults ≥ 18 years with HTN• Subgroups

• DM• CAD• PAD• HF• Prev Stroke• CKD• Proteinuria• Older adults• Men/Women• Racial/ethnic groups,

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

TRIALS

Only RCTs

Period Jan 1, 1966 to Dec 31, 2009

Secondary search PubMed & CINAHL Dec 2009 – Aug 2013 Major study in HTN, ≥ 2000 subjects,

multicentric, met incl/excl criteria

COLLATION

• Data tabulated• Evidence summarized• Evidence statements crafted• Voting

• Agree/disagree with evidence statement• Quality of evidence

• Clinical recommendations crafted• Voting

• Agree/disagree with recomm• Strength of recomm

RESULTANT 9 recommendations

Strength of recommendation for each

Recomm 1 – 5 Threshold and goals

Recomm 6 – 8 Selection of antiHTN drugs

Recomm 9 Summary of strategies (expert opinion)

RECOMMENDATIONS

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

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)

RECOMMENDATION 3

Gen pop < 60 years

Start at SBP ≥ 140

Goal SBP < 140

Exp Op – Grade E

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

RECOMMENDATION 5

DM ≥ 18 years

Start at SBP ≥ 140 OR DBP ≥ 90

Goal SBP < 140 AND DBP < 90

Exp Op – Grade E

RECOMMENDATION 6

Gen pop non-black (+/- DM)

Initial drug:- Thiazide diuretic CCB ACEi ARB

Mod Recomm – Grade B

CAVEATS

Only for initial drug choice. Add-on any will do

Specific to thiazide diuretics

Drugs to be adequately dosed

NOT for CAD, HF, CKD

RECOMMENDATION 7

Gen Black pop (+/- DM)

Initial drug:- Thiazide/CCB

Mod Recomm – Grade B (Gen Black)

Weak Recomm – Grade C (Black + DM)

PS:- Diuretic > CCB in preventing HF

RECOMMENDATION 8

Adults CKD (any race, +/- DM)

ACEi/ARB as initial/add-on

Mod Recomm – Grade B

PS – Only improves kidney outcomes

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

COROLLARIES 1

Assess BP regularly

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

COROLLARIES 2

3 Strategies suggested:- 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

THANK YOU ALL

For Your Kind Attention