Essay On Advanced Pharmacology
[Instructor’s name appears here]
[Date appears here]
The history presented in the scenario describes a 60 year old American belonging to the black race. He is hypertensive and diabetic for the past 12 good years. Based on current reading, his blood pressure is uncontrolled and he falls in obesity class I. He has only taken thiazide-type diuretic (12.5mg) in combination with potassium sparing diuretic; triamterene (25mg).
According to Papadakis and McPhee (2015), treatment is warranted in patients having stage II hypertension; consistently elevated blood pressure to ≥160/100 mmHg. It was also stated that patients with higher cardiovascular risk especially those with coexistent diabetes should have their blood pressure maintained to < 130/80 mmHg. Moreover, it was stressed that lowering of systolic to <130-135 mmHg only increases the risk of adverse outcomes without any benefit unless stroke is suspected, in which case, it will be justified.
The Joint National Committee (JNC) devised new guidelines for management of hypertension that succeeded the older version. The JNC-8 (2014) guidelines recommended use of following pharmacological agents for the management of hypertension with dosage:
The patient is of African descent and is a black American. According to the same JNC-8 (2014) guidelines, the diabetic population should be started with thiazide-type diuretic or a CCB to control hypertension. In a single large trial, it was observed that black patients on thiazide type diuretics had better cardiovascular outcomes than black patients on ACEI. Consequently, thiazide type diuretics are recommended in treating hypertension in black patients. On the other hand, CCB were also studied to find out the difference of outcome in black patients versus white patients. But there was no significant difference of result was obtained instead, use of ACEI increases chance of a stroke in black patients to 51% and CCB were recommended as first line anti-hypertensive medication along thiazide-type diuretics in black patients.
Since this patient has uncontrolled hypertension despite being on thiazide-type diuretics, a CCB should therefore be added in the treatment regimen of this patient. Concomitant diabetes should also be addressed to taper down the adversities of these two chronic co-morbidities. This will further improve the risk of cardiovascular diseases. Moreover, according to Papadakis and McPhee (2015) a lipid lowering agent should invariably be administered to patients who are known diabetics and are at risk of developing a thromboembolic event. In this patient, a statin, atorvastatin or simvastatin, is beneficial in reducing the risk of cardiovascular accident. This theory is further supported by study conducted by Eldor and Raz (2009) and published in Diabetes Care Journal of American Diabetes Association (ADA).
According to National Institute for Health and Care Excellence (NICE) guidelines for hypertension (2011), if obesity is present in a patient it should be addressed and patient should be encouraged to lose weight and do regular exercise. The guidelines also recommended incorporation of healthy lifestyle, DASH healthy diet, reduction of salt intake, close monitoring of blood pressure, daily exercise, moderation of alcohol consumption, avoidance coffee and caffeine containing beverages, and strict cessation of smoking.
In order to curtail the risk factors, patient education should be done and professional assistance from a qualified dietician should be sought. Strict adherence to medical treatment should be encouraged and monitoring of blood pressure with lifestyle challenges. Few interventions that are suggested are (NICE Guidelines, 2011):
Medicine record keeping
Patient monitoring of blood pressure
Simplification of dosage
Eldor, R., & Raz, I. (2009). American Diabetes Association Indications for Statins in Diabetes: Is there evidence? Diabetes Care, 32(2), S384-S391.
James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.
NICE clinical guideline 127: Hypertension: Clinical management of primary hypertension in adults. (2011). National Institute for Health and Care Excellence (NICE), 127, 1-3.
Papadakis, M., & McPhee, S. (2015). Systemic Hypertension. In Current Medical Diagnosis & Treatment 2015 (54th ed.). New York: McGraw-Hill Education/Medical.