Using the best medicines regimen

Optimising medicines use is a key component of management for both hypertension and tobacco use. A key issue is the failure to treat patients with sufficient intensity, and to consider the use of combination therapy. National guidelines offer clear advice on these issues.

The chances of successful smoking cessation are about double when medicines are used (Zwar et al, 2004), while most hypertensive patients need to either initiate therapy or intensify treatment to achieve target blood pressure.

Responsible recommendations on therapy intensification should consider the following general questions:

  • If the patient is untreated, is it appropriate to commence medicines?
  • If treated, does the patient need more intensive treatment?
  • If initiation or changes to therapy are needed, what therapy is most appropriate?

It is beneficial to discuss with the patient what changes they might be willing to make (e.g. is increasing the dose preferable to adding a drug, or would they prefer to try harder at making lifestyle adjustments). These preferences should be communicated to their doctor if appropriate.

Hypertension

Just one in four hypertensive patients achieve a blood pressure lower than the defined hypertensive threshold of 140/90 mmHg:

  • One third remain undiagnosed (and hence blood pressure remains unaddressed)
  • Only half of hypertensive patients receive medicines (this figure should be about 75%)
  • Less than half of treated patients achieve target BP (Janus et al., 2009, Briganti et al, 2003)

Clearly there is a need for dramatically intensified approaches to treatment.

Guidelines identify several other factors that should be considered before concluding the need for treatment initiation or changes - especially confirmation of the measurement,  medicines  adherence, medicines-induced hypertension (e.g. from decongestants, stimulants, corticosteroids) and secondary causes of hypertension (e.g. thyroid disease, Cushings syndrome). After these have been discounted, you can consider the treatment needs for uncontrolled blood pressure.

If the patient is untreated, is it appropriate to commence medicines?

Immediate treatment is recommended if the patient (1) has a history of cardiovascular disease (e.g. previous stroke, heart attack), end-organ damage (e.g. renal failure) or diabetes, (2) if isolated systolic or severe hypertension, or (3) if an absolute risk calculation (primary prevention) suggests risk of a cardiovascular event exceeds 15% in the next five years. In the absence of these factors, a trial of lifestyle modification is first recommended subject to other clinical considerations (e.g.  socioeconomic  status, Aboriginal or Torres Strait Islanders). See guidelines for details.

If treated, does the patient need more intensive treatment?

Bear in mind that blood pressure targets are different for different groups. The general target is 140/90 mmHg, but groups at high risk of cardiovascular disease have lower targets. When a patient's  blood  pressure is confirmed above target, changes to therapy are appropriate (see guidelines). Under normal circumstances, changes to therapy should be trialled for six weeks to  ascertain  the full effect.

If initiation or changes to therapy are needed, how do you decide on therapy?

National guidelines offer clear advice and stepwise procedures for treatment intensification. As a general rule, calcium channel blockers and ACE inhibitors are the preferred agents.  Review  the patient's medical history to establish compelling indications or contraindications for particular agents (e.g. ACE inhibitors potentially beneficial for kidney disease  and  diabetes; calcium channel blockers contraindicated in pregnancy before 22 weeks' gestation). Certain combinations of antihypertensive drugs are also recommended, e.g. ACE inhibitors  plus  thiazides in heart failure and post-stroke.

Smoking cessation

If the patient is untreated, is it appropriate to commence medicines?

Assessment of nicotine dependence should be undertaken using the Fagerstrom test for nicotine dependence(Heatherton TF et al., 1991). Even asking two of these questions can give a good indication:

Question to paitent Standard responses  Dependence indicator (see below)
How soon after waking do you smoke your first cigarette?     Within 5 minutes 3
5-30 minutes 2
31-60 minutes 1
60+ minutes 0

How many cigarettes a day do you smoke?

10 or less 0
11-20 1
21-30 2
31 or more 3
Dependence indicator
1-2= very low dependence
3= low to moderate dependence
4= moderate dependence
5+= high dependence

Those who have not yet quit smoking can still commence nicotine replacement therapy (NRT) or prescription therapies. Therapy may be appropriate for pregnant women but they should seek medical advice first. Some prescription therapies are unsuitable for patients with some health conditions (e.g. varenicline  in  schizophrenia and bupropion in patients with a history of seizures).

If already treated, does the patient need more intensive treatment?

All appropriate patients should be encouraged to use and persist with therapy. There is good evidence that this increases the likelihood of successful cessation. Minimum periods of use should be eight weeks with NRT and at least seven weeks with bupropion. Varenicline has a standard course of 12 weeks  per  person per year. Evidence now suggests that more dependent smokers should use more than one form of NRT in combination to increase the likelihood of success.

If initiation or changes to therapy are needed, how do you decide on therapy?

In the absence of compelling indications or contraindications for a particular form of therapy, NRT is generally the accepted first-line therapy. Discussion with the patient is essential in deciding which NRT form to use - all NRT forms are thought to be equally successful. Higher strength nicotine  products  are recommended for patients who smoke 20 or more cigarettes per day. There is no evidence for alternative therapies such as hypnotherapy and acupuncture.


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