Review of JNC 8 Recommendations Liz Hohner, PharmD, PGY1 Pharmacy Practice Resident Vi Gilmore, PharmD, BCPS Primary and acute care providers manage a significant amount of hypertension both in the inpatient and ambulatory care setting.1 Appropriate management can decrease the risk of myocardial infarction, stroke, renal failure and death. After nearly a decade, the muchanticipated Eighth Joint National Committee (JNC 8) guidelines for management of hypertension were released December 2013 and focused on answering three critical questions regarding adults with hypertension: Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? Does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? Compared to JNC 7, the current guidelines focused more on evidence-based management of hypertension and less on diagnosis.2 The panel did not alter the definitions of hypertension or pre-hypertension but did change the thresholds for treatment initiation and goals for treatment.1 Although not specifically addressed, the panel also emphasized the importance of lifestyle modifications in the management of hypertension. The panel only reviewed evidence from randomized controlled trials (RCTs) for developing their nine treatment recommendations. These RCTs were identified by a more systematic review than utilized in JNC 7. Included RCTs reported the effects of interventions on major health outcomes such as mortality, cardiovascular disease-related mortality, myocardial infarction, stroke, coronary revascularization, and end-stage renal disease. One major change from JNC 7 is the exclusion of initial drug treatment recommendations for certain compelling indications such as CHF or CAD. The nine treatment recommendations are summarized in Table 1(strengths of recommendation are included in parentheses). The definitions for the strengths of recommendation are explained in Table 2. Table 1: Treatment Recommendations Initiate Treatment SBP = systolic blood pressure Goal BP Initial Drug Treatment Population DBP = diastolic blood pressure (mmHg) options (mmHg) General ≥ 60 Non-black: thiazide-type SBP ≥ 150 or DBP ≥ 90 (A) < 150/90 years diuretic, ACE-I, ARB or
General < 60 years Diabetes
SBP â&#x2030;Ľ 140 or DBP â&#x2030;Ľ 90 Age 30-59 years (A) Age 18-29 years (E) Diabetes (E) CKD (E)
CCB (B) Black: thiazide-type diuretic or CCB General black population (B) Black patients with diabetes (C)
< 140/90 CKD: GFR < 60 ml/min/1.73m2 or > 30 mg ACE-I or ARB (B) albumin/g of creatinine If goal BP is not met within one month of treatment initiation or change, dosage increase or addition of second (or third) drug is recommended (E). If there is a contraindication to the above drug classes or if the patient is already using 3 recommended drugs, then drugs from other classes may be used. Table 2: Strength of Recommendation Grad Strength Definition e A Strong High certainty based on evidence of substantial net benefit Moderate certainty based on evidence of moderate to substantial B Moderate net benefit or high certainty of moderate net benefit C Weak At least moderate certainty based on evidence of small net benefit Recommendation At least moderate certainty based on evidence of no net benefit or D Against risks / harms outweigh benefit Net benefit is unclear. Balance of benefits and harms cannot be determined as there is insufficient, unclear, conflicting or no E Expert Opinion evidence; however, the committee felt it was important to provide clinical guidance. Net benefit is unclear. Balance of benefits and harms cannot be No determined as there is insufficient, unclear, conflicting or no N recommendation evidence and the committee felt no recommendation should be for or against made. Additionally, the panel provides an algorithm to guide the management of hypertension based on these guidelines; this algorithm has yet to be validated but offers clinicians a quick evidence-based reference. As the guidelines are still new, opinions and criticisms are still being developed regarding the new recommendations. As always, the guidelines should not supersede clinical judgment and management decisions should be made on an individual patient basis. References: 1. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults: Report From the Panel Members
Appointed to the Eight Johnt National Committee (JNC 8). JAMA 2013. Published online December 18, 2013. 2. Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung and Blood Institute Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: the JNC 7 Report. JAMA 2003; 289(19):2560-2572.