Forums » Open clinical » Diabetes » NICE hypertension treatment guidelines revision
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NICE hypertension treatment guidelines revision
posted at 29/1/2012 6:07 PM GMT
on bmj.com
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Posts: 142
First: 29/4/2011 Last: 14/5/2012 |
Our BMJ Editor has posted comments regarding the recent NICE hypertension guidelines revisions (BMJ 2012;344:e653). Personally I was a little surprised at the change and was unconvinced by the author's response. Perhaps because calcium channel blockers had a bad rap in the treatment of hypertension in persons with diabetes, I have generally avoided them. I am curious as to our readers' views as to the advisibility of moving calcium channel blocking agents up in older persons with hypertension, if they have co-existing diabetes. |
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Re: NICE hypertension treatment guidelines revision
posted at 30/1/2012 7:08 AM GMT
on bmj.com
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Posts: 366
First: 13/4/2011 Last: 16/5/2012 |
NICE was clear with Calcium Channel Blockers in old people with or without diabetes: - Do ABPM first. - The treatment targets are also higher for those above 80 years. - Avoid (change to diuretics or ACE-Inhibitors) if high risk for heart failure (in ALLHAT amlodipine increased Heart Failure by around 40%). Dihidropiridines CCBlockers seem do get a better stroke protection in older people, and have a neutral metabolic profile. Also in ABCD diabetic trial they did a good job. I use amlodipine quite a lot in my hypertensive diabetics. All Best, Joey
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Re: NICE hypertension treatment guidelines revision
posted at 31/1/2012 6:14 PM GMT
on bmj.com
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Posts: 7
First: 13/5/2011 Last: 18/2/2012 |
This guideline is the most practical one in the management of hypertension. Dihydropyridine-CCB (DHP-CCB) like amlodipine found highly effective in older hypertensives in my practice which I am reassured from the guideline that first-line anti-hypertensive for >55 years is DHP-CCB. More ever, irrespective of age, hypertensives from African and Caribbean descendents, first-line drug should be DHP-CCB are they belong to population of low rennin activity. |
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Re: NICE hypertension treatment guidelines revision
posted at 31/1/2012 6:19 PM GMT
on bmj.com
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Posts: 7
First: 13/5/2011 Last: 18/2/2012 |
One of the four major breakthrough of NICE/BHS guideline is the use of diuretic. In contrast to JNC7, diuretic now considered as third line anti-hypertensive and instead of thiazide diuretic either bendrofluthiazide or hydrochorthiazide, a non-thiazide diuretic, chlorthalidone is recommended which lack number of adverse metabolic outcomes. |
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Re: NICE hypertension treatment guidelines revision
posted at 1/2/2012 5:57 PM GMT
on bmj.com
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Posts: 1
First: 1/2/2012 Last: 1/2/2012 |
Iam one of the doctors in Dr.maha mustafa unit( kosti teaching hospital/sudan) who practice nice HTN ttt g-lines, and found it very effective, and highly remain Pts Bp with in the target Bp 1st line: amlodepine (or other Ca cannel bloocker) unless the pt has co-morbidity (eg DM) or has end organ damage in which the 1st line is ACEI or ARB 2nd line: ACEI or ARB unless the pt has one of the exceptions mentioned above in which the 2nd line is Ca CB |
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Re: NICE hypertension treatment guidelines revision
posted at 3/2/2012 10:10 PM GMT
on bmj.com
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Posts: 366
First: 13/4/2011 Last: 16/5/2012 |
I agree that this last version of NICE is practical. But in my everyday practice with Hypertension my feeling is that drug treatment of Hypertension is just about 50% of what should be done. Lifestyle modifications are very much negleted in hypertensive individuals. And low-dose Chlortalidone or indapamide, or even furosemide are great drugs with a very different metabolic/side-effects profile than the old scenarios of high-dose thiazide diuretics. With low-dose diuretics I have less side-effects than with amlodipine in diabetics and non-diabetics, especially in those people above 70 years of age. The other issue is that is not uncommon to see peculiar BP profiles in the ABPM. All Best, Joey
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Re: NICE hypertension treatment guidelines revision
posted at 4/2/2012 12:43 PM GMT
on bmj.com
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Posts: 366
First: 13/4/2011 Last: 16/5/2012 |
Hello Fellows: Essential Hypertension: A syndrome with more than 100 medications on the market for its drug treatment. Resistant hypertension increasing in frequency in parallel with the overweight/obesity/diabetes global epidemics.... Does it sound also about our ignorance about this disease entity??? And afterwards Dr. Diabetes is right about some aspects of CCBlockers. They are the class of anti-hypertensive drugs with the highest profile of side-effects: from edema to heart failure. No surprises at all with all this debate and controversies with this last NICE guideline. We are still going well behind in the Hypertension road. All Best, Joey
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Re: NICE hypertension treatment guidelines revision
posted at 4/2/2012 4:14 PM GMT
on bmj.com
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Posts: 7
First: 13/5/2011 Last: 18/2/2012 |
No doubt lifestyle modification occupies number one position in the management not only hypertension but other cardiometabolic diseases including type 2 diabetes but is it possible to follow the specific lifestyle modification in the era of so called “modern civilization”? For newly diagnosed type 2 diabetes patients who were candidate only for lifestyle modification for certain period of time before going to drug therapy few years back, now it is already a tradition to start metformin, if not contraindicated, along with lifestyle modification from the first day of diagnosis. Why we do so? Most of the patients of existing time cannot maintain proper lifestyle and we cannot rely on it. So if necessary, why not to start at-least one anti-hypertensive drug along with lifestyle? Hypertension can cause end organ damage. Hypertensives are specifically vulnerable to CKD and this can be diagnosed in this population without any previous complaints. We can prevent development of CKD in these patients to some extent by starting any of the RAAS modulators. Yes, for the elderly we can go for non-thiazide diutetics like chlorthalidone or indapamide but can reserve loop diuretic for patients who develope CKD. Nothing to worry about peripheral edema induced by DHP-CCB like amlodipine. If BP is OK on amlodipine, we can just reduce the dose of amlodipine to half and add small dose of either ACEI or ARB and we can reduce edema. Now, fixed-dose combinations of amlodipine along with ARB are available. |
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Re: NICE hypertension treatment guidelines revision
posted at 12/2/2012 12:46 PM GMT
on bmj.com
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Posts: 366
First: 13/4/2011 Last: 16/5/2012 |
Hello Dr. Dhar: The optimal treatment of Hypertension is a real challenge, even if we consider that High Blood Pressure is perhaps the most reliable surrogate marker of disease. This NICE guideline is a real advance but it is far from perfect, because there are many important aspects in the pathophysiology of hypertension that are still unknown. For example what are the major pathophysiological links of hypertension with obesity, the metabolic syndrome, and diabetes? We do not know a lot about these issues. What about white coat, nocturnal, and masked hypertension that can only be diagnosed by 24 hours ABPM? What about the recent early ending of the first large prospective clinical trial of the wonder pharmacological drug for hypertension - Aliskiren? All Best, Joey
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Re: NICE hypertension treatment guidelines revision
posted at 18/2/2012 6:52 PM GMT
on bmj.com
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Posts: 7
First: 13/5/2011 Last: 18/2/2012 |
Dear Joey! Although we are following recent guidelines, hypertension management remains suboptimal all over the world. Yes, you are right. Still we do not know many pathophysiological aspects of hypertension and for this reason many new drugs, combinations, once thought to be optimistic but practically found hopeless! ONTARGET has already showed us the negative results of using combination of ACEI and ARB and NICE has already quoted it. After introduction of DRI, aliskiren, we thought that this drug might offer promising result specifically in patients with diabetic nephropathy but ALTITUDE has already been prematurely halted. Hyporeninemic hypoaldosteronism or type-IV renal tubular acidosis may be the cause of adverse effects. Best Regards, Joey, Keep in touch! Dr. Dhar
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