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Hypertension and Lipid Treatment Protocol Hypertension and Lipid Treatment Protocol

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HYPERTENSION PROTOCOL: INITIAL VISIT

  • RATIONALE
    1. This protocol will assist in the differentiation between essential hypertension and renal artery stenosis to aid in the identification of patients in need of referral to nephrology to prevent further renal damage from an unidentified renal artery stenosis. The design of the protocol for UTI encompasses these principles.
  • SYMPTOMS
    1. HYPERTENSION
      1. Blood pressure >140/90 mmHg
      2. Other possible subjective symptoms
        • Headache
        • Visual changes
        • Dyspnea
        • Chest pain
        • Sensory or motor deficit
      3. RENAL ARTERY STENOSIS
        1. Onset of hypertension age >55 years or <30 years
        2. History of accelerated, malignant, or resistant hypertension
  • History of unexplained kidney dysfunction
  1. History of multivessel coronary artery disease
  2. History of other peripheral vascular disease
  3. Abdominal bruit
  • Sudden or unexplained recurrent pulmonary edema
  • Other possible factors
    • Absence of family history of hypertension
    • Other bruits
    • History of acute kidney injury after administration of ACE inhibitor or angiotensin II receptor antagonist (ARB)
  • HISTORY
    1. Continue with the treatment of hypertension but consult supervising physician if the patient has:
      1. History of accelerated, malignant, or resistant hypertension
      2. History of unexplained kidney dysfunction
  • History of multivessel coronary artery disease
  1. History of other peripheral vascular disease
  2. Abdominal bruit
  3. Sudden or unexplained recurrent pulmonary edema
  • PHYSICAL EXAM
    1. Perform the following examinations:
      1. Vital Signs (blood pressure, pulse)
      2. Auscultation for bruits (carotid, abdominal, and femoral)
  • Palpation of thyroid
  1. Cardiac
  2. Respiratory
  3. Lower extremities for edema and pulses
  • Neurological
  1. Consult supervising physician if findings of:
    1. Abdominal bruit
    2. Another bruit
  • LAB TESTS
    1. Metabolic panel
      1. Cholesterol
      2. Blood sugar
  • Uric acid level
  1. Glomerular filtration rate
  2. Consult the supervising physician if:
    1. GFR indicates chronic kidney disease (CKD) or renal failure
  • PHARMACOLOGICAL TREATMENT
    1. List the hypertension drug classifications and examples you would prescribe in order of treatment according to clinical practice guidelines without consideration of race or ethnicity: (Provide generic names for examples. Doses are not needed or required.)
Drug Category/ Classification Example 1 Example 2 Example 3 Example 4
Thiazide Diuretics Hydrochlorothiazide chlorthalidone indapamide Metolazone
ACE Inhibitors Captopril Enalapril Lisinopril Ramipril
ARBs Losartan Valsartan Telmisartan Candesartan
Calcium Channel Blockers Nimodipine Amlodipine Verapamil Nicardipine

Citation (Provide (Author, year) and not full reference): (Katzung et al., 2021)

  1. 1st line pharmacological treatment if warranted in a non-African American patient after a thiazide diuretic has been given and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe to either add to existing treatment or replace a thiazide.)
    1. Drug: Angiotensin-Converting Enzyme Inhibitor (ACEI) – Lisinopril
    2. Dose: Dosage can vary depending on the patient’s specific condition and blood pressure response, but a common starting dose is 10 mg once daily.
  • Route: Oral (tablet)
  1. Frequency: Once daily, preferably in the morning.
  2. Instructions to provide patient: Take the medication at the same time every day. It can be taken with or without food.
  3. Caution/Precautions: Inform the healthcare provider of any signs of allergic reactions (e.g., rash, itching, swelling), as well as any persistent cough or other adverse effects.
  • Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? $4.00 to $12.03
  • What patient education is needed for this drug?
    – Explain to the patient that Lisinopril is used to treat high blood pressure and may help prevent certain heart-related conditions.
    – Instruct the patient to take the medication as prescribed by their healthcare provider, preferably at the same time each day, and not to skip doses.
    – Advise the patient to follow a healthy lifestyle, including a balanced diet low in sodium, regular exercise, and stress management, to complement the effects of the medication.
    – Inform the patient that Lisinopril may cause dizziness or lightheadedness, especially during the first few days of starting the medication, and to get up slowly from a sitting or lying position to minimize this side effect.
    – Educate the patient about the potential side effects of Lisinopril, such as a dry, persistent cough, and to promptly report any unusual or severe side effects to their healthcare provider.
    – Emphasize the importance of regular follow-up appointments to monitor blood pressure and assess the effectiveness of the medication.

Citation (Provide (Author, year) and not full reference): (Arcangelo et al., 2017; Grundy et al., 2019; Lisinopril – MedlinePlus, 2021; PAFP, 2014)

  1. 1st line pharmacological treatment if warranted in an African American patient after a thiazide diuretic has been given and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe to either add to existing treatment or replace a thiazide.)
    1. Drug: Calcium Channel Blocker (CCB) – Amlodipine
    2. Dose: Dosage can vary depending on the patient’s specific condition and blood pressure response, but a common starting dose is 5 mg once daily.
  • Route: Oral/P.O
  1. Frequency: Once daily, preferably at the same time each day.
  2. Instructions to provide patient: Take the medication as prescribed by their healthcare provider, with or without food.
  3. Caution/Precautions: Instruct the patient to avoid sudden discontinuation of the medication and to notify their healthcare provider if they experience any unusual or severe side effects.
  • Using a source such as GoodRX, what is the estimated cost of this drug for a 30-day supply? $5.45 – $20.40
  • What patient education is needed for this drug?
    – Tell the patient that Amlodipine is prescribed to lower blood pressure and may reduce the risk of developing cardiovascular disease.
    – Tell the patient to take the medicine regularly and at the same time each day as directed by their doctor.
    – Encourage the patient to supplement the medication’s benefits by adopting a healthy lifestyle, which includes eating a balanced diet low in salt, engaging in regular exercise, and managing stress.
    – Patients using Amlodipine should be warned that the drug might cause them to feel dizzy or lightheaded, particularly after getting out of a sitting or laying posture.
    – Instruct the patient to contact their doctor immediately if they have any serious or unexpected adverse effects after taking Amlodipine, such as swelling in their ankles or feet.
    – Regular follow-up consultations to check blood pressure and evaluate the medication’s efficacy should be emphasized.

Citation (Provide (Author, year) and not full reference): (Arcangelo et al., 2017; Grundy et al., 2019; MedlinePlus, 2021; PAFP, 2014)

  1. When should ACEIs be used in African Americans according to the course textbook? Include a citation with matching references in the reference section.
    1. ACE inhibitors may be considered for African American patients diagnosed with hypertensive nephrosclerosis.
    2. ACE inhibitors may be considered for African American patients whose blood pressure is not stable with a single antihypertensive drug.
  • ACE inhibitors may be considered for African American patients with type 1 diabetes and proteinuria.

Citation (Provide (Author, year) and not full reference): (Arcangelo et al., 2017)

  1. Prescribe statin therapy according to the prescription table which follows:

Complete the following table to indicate which drug at which dose would be used for different intensity statin therapies to treat high low-density lipoprotein (LDL) as noted in the course textbook. Each drug listed in each column should be a different drug with a specific dose or dose range as indicated in your course textbook.

 

High-Intensity Therapy Moderate-Intensity Therapy Low-Intensity Therapy
Daily dose lowers LDL-C on average by 

≥ 50%

 Daily dose lowers LDL-C on average by 

30% to < 50%

 Daily dose lowers LDL-C on average by 

< 30%
Drug/Dose 1: Atorvastatin 40-80 mg 

Drug/Dose 2: Rosuvastatin 20-40 mg

 Drug/Dose 1: Atorvastatin 10-20 mg 

Drug/Dose 2:Rosuvastatin 5-10 mg

Drug/Dose 3:Simvastatin 20-40 mg

Drug/Dose 4:Pravastatin 40-80 mg

Drug/Dose 5:Fluvastatin 40 mg

 Drug/Dose 1: Simvastatin 10 mg 

Drug/Dose 2:Pravastatin 10-20 mg

Drug/Dose 3:Lovastatin 20 mg

 
What patient education is needed when prescribing statins? Consider any patient counseling points and adverse effects they may need to be aware of or report if experienced. 

 

 Advise the patient to take statins at the same time every day as suggested by their doctor.
Instruct the patient to report any side effects, such as muscular discomfort or weakness, to their doctor.
To enhance statin treatment, advise the patient to eat a balanced diet, exercise regularly, and avoid smoking and alcohol.
Stress the need of frequent follow-up sessions to evaluate cholesterol levels and drug efficacy and safety.
Inform the patient that statins may interact with other drugs.
Remind the patient that statin medication is long-term and should not be stopped without medical advice.

Citation (Provide (Author, year) and not full reference): (Katzung et al., 2021; Rosenthal, 2021)

 TREATMENT MONITORING

How long until a follow-up appointment should be done with the patient?

The scheduling of the subsequent appointment with the patient ought to be predicated upon the precise treatment regimen and the unique requirements of the individual. In accordance with customary practice, it is customary to arrange a subsequent appointment within a span of 4 to 6 weeks subsequent to the commencement or modification of medication. Subsequently, it is advisable to schedule periodic appointments as necessary, with the intention of evaluating the efficacy of the treatment and attending to any apprehensions that may arise.

Monitoring needs for blood pressure medication prescribed: (Include physical assessments as well as lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.)

    1. Physical Assessments:

Regular blood pressure measurements, assessment of heart rate, monitoring for signs of medication side effects (such as dizziness and fatigue)

  1. Labs/Diagnostics:

Regular blood tests are necessary to monitor electrolyte levels, kidney function, and other relevant parameters based on the medications prescribed. Furthermore, lipid profiles should be monitored when combination therapy involves dyslipidemia medications.

Citation (Provide (Author, year) and not full reference): (Katzung et al., 2021; Rosenthal, 2021)

  1. Monitoring needs for statin medication prescribed: (Include physical assessments as well as lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.)
    1. Physical Assessments:

Evaluate for potential statin-related adverse effects, specifically muscle pain or weakness. Regularly assess liver function in patients receiving high-dose statin therapy.

  1. Labs/Diagnostics:

Lipid profiles should be checked often to determine LDL-C levels and the effectiveness of statin treatment. Periodic liver function tests may also be conducted to check for any liver enzyme increases that might be caused by statin therapy.

Citation (Provide (Author, year) and not full reference): (Katzung et al., 2021; Rosenthal, 2021)

TREATMENT FAILURE

How will you know if the treatment is not working or needs to progress? Include a citation with matching reference in the reference section.

Persistent High Blood Pressure: Treatment failure may occur if the patient’s blood pressure remains high after following the recommended antihypertensive regimen. In such circumstances, it may be important to reevaluate the patient and make alterations to the treatment strategy.

Inadequate Reduction in LDL Cholesterol Levels: In the context of patients undergoing statin therapy, the failure of low-density lipoprotein (LDL) cholesterol levels to adequately diminish in order to align with the desired treatment objectives may serve as an indication for the implementation of further therapeutic advancements or supplementary interventions.

Development of Adverse Effects: In the event that the patient encounters notable adverse reactions stemming from the prescribed medications, thereby impeding their adherence to treatment or compromising their overall quality of life, it would be prudent to contemplate alternative therapeutic avenues.

Persistent Proteinuria or Worsening Kidney Function: In the case of individuals affected with renal disease, the enduring presence or exacerbation of proteinuria or the progressive deterioration of renal function despite therapeutic intervention may necessitate a reassessment and modification of the antihypertensive course of action.

Lack of Improvement in Cardiovascular Outcomes: In the event that the patient’s cardiovascular outcomes, namely myocardial infarctions or cerebrovascular accidents, fail to exhibit amelioration or persist in their decline, it is imperative to reevaluate the effectiveness of the treatment regimen.

Lack of Symptom Improvement: If the patient’s symptoms related to hypertension or dyslipidemia fail to ameliorate or deteriorate, it may suggest the necessity for modification of the treatment regimen.

Citation (Provide (Author, year) and not full reference): (Katzung et al., 2021; Rosenthal, 2021)

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice: A practical approach. Wolters Kluwer.

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., De Ferranti, S. D., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Mark, D. B., Jones, D. W., Lloyd-Jones, D. M., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., . . . Yeboah, J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APHA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 139(25). https://doi.org/10.1161/cir.0000000000000625