what is the role of plasma renin activity levels in management … pgr danelich... · high renin...
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What is the Role of Plasma Renin Activity Levels in the Management of Hypertension?
Ilya Danelich, PharmD, BCPSCardiology Clinical Pharmacist
Pharmacy Grand RoundsMayo Clinic Hospital ‐ RochesterJuly 19, 2016
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Objectives
• Describe the role of PRA levels in the management of hypertension
• Review the differences between using PRA levels and traditional methods of managing hypertension
• Outline a treatment care plan using PRA levels to manage hypertension
PRA ‐ plasma renin activity
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Epidemiology of Hypertension
• Affects nearly 78 million people ≥ 20 years in the US
• 47.5% have uncontrolled hypertension• Hypertension related mortality: 18.5%
• Estimated Cost: $51 billion
Percent of patients with hypertension at first event
Myocardial Infarction 69%
Heart Failure 74%
Stroke 77%
Circulation. 2013;127:e6‐e245.
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JAMA. 2014;311:507‐20.
Implement Lifestyle Interventions
Age ≥ 60 yearsAll ages
Diabetes PresentNo CKD
Age < 60 yearsAll ages
CKD Present +/‐Diabetes
General Population(no diabetes or CKD) Diabetes or CKD present
BP Goal< 150/90 mm Hg
BP Goal< 140/90 mm Hg
BP Goal< 140/90 mm Hg
BP Goal< 140/90 mm Hg
Thiazide‐type diuretic or ACEI or ARB or CCB, alone
or in combination
Thiazide‐type diuretic or CCB, alone or in combination
ACEI or ARB, aloneor in combination with
other drug class
Nonblack Black All Races
JNC 8 Guidelines
Select a drug treatment titration strategy A. Maximize first medication before adding second or B. Add second medication before reaching maximum dose of first medication or C. Start with 2 medication classes separately or as fixed‐dose combination
ACEI ‐ angiotensin‐converting enzyme inhibitorARB ‐ angiotensin receptor blockerBP ‐ blood pressure
CCB ‐ calcium channel blockerCKD ‐ chronic kidney diseaseJNC 8 ‐ Eighth Joint National Committee
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PRA Levels: Laragh Method
Jean E. Sealey, D.Sc.John H. Laragh, MD
http://www.laraghmethod.org/
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Volume –Vasoconstriction Concep to Blood Pressure Control
Blood Pressure is sustained by:
Body sodium‐volume content (V)
Plasma renin‐angiotensin vasoconstrictor activity (R)
The V and R interacting control system sustains all normotension and all forms
of hypertension
Am J Hypertens. 2011;24:1164‐80.
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‐‐‐‐‐‐>
‐‐‐‐‐‐‐>
Interaction between Body Sodium and Circulating Renin‐Angiotensin
Am J Hypertens. 2011;24:1164‐80.
Blood Pressure
BP = V x R
Arterial Volume (V) Vasoconstriction (R)
Sodium
Renal Sodium Retention
Angiotensinogen
Angiotensin I
Angiotensin II
RENINDiuretic
ARB
ACEI
DRI ‐‐‐‐‐‐>‐‐‐‐‐‐>
||||||||||||||>
Feedback suppressionof reninsecretion
‐blocker
||
DRI ‐ direct renin inhibitor
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PRA Definitions
For Patients Not TakingACEI or ARB
PRA Level (ng/mL/hr)
Type of Hypertension
Low renin < 0.65 V
Medium renin 0.65‐6.5 R
High Renin > 6.5 R
For PatientsTakingACEI or ARB
PRA Level (ng/mL/hr)
ePRA Level(ng/mL/hr)
Type of Hypertension
Low renin < 6.5 < 0.65 V
Medium renin 6.5‐65 0.65‐6.5 R
High Renin > 65 > 6.5 R
ePRA = 0.1 x PRAePRA = effective PRA Am J Hypertens. 2011;24:1164‐80.
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Drug Types
Anti‐V Drugs
Diuretics
Aldosterone receptor antagonists
Calcium channel blockers
Alpha‐1 blockers
Anti‐R Drugs
ACEI
ARB
Direct renin inhibitors
Beta‐blockers
Central α2‐agonists
Am J Hypertens. 2011;24:1164‐80.
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Untreated Hypertensive PatientStep 1 : Measure PRA
Low PRA: < 0.65V Patient
Medium to high PRA: ≥ 0.65R Patient
Steps 2 & 3: Give anti‐R drugSteps 2 & 3: Give anti‐V drug
Step 4: If BP elevated, measure PRA
Steps 5 & 6: If PRA < 0.65 = V+ V patientAdd 2nd anti‐V Drug
Steps 5 & 6: If PRA ≥ 0.65 = V+ R patientAdd anti‐R Drug
Steps 5 & 6: If PRA (or ePRA) < 0.65 = R + V patientAdd anti‐V drug
Steps 5 & 6: If PRA (or ePRA) ≥ 0.65 = R + R patient
Add 2nd anti‐R drug
||||||||
|||||||| Am J Hypertens. 2011;24:1164‐80.
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Treated Hypertensive Patient
BP not controlled on full doses of 1 anti‐V & 1 anti‐R drug (ACEI or ARB)Step 1:Measure PRA
Am J Hypertens. 2011;24:1164‐80.
Step 2: If PRA < 0.65, there is no renin to block. Anti‐R drug may be pressor.
Subtract anti‐R drug
Steps 2 & 3:If PRA 0.65‐6.5
(ePRA < 0.65), renin is effectively blocked. Add 2nd anti‐V drug
Step 2: If PRA >6.5 (ePRA > 0.65) patient
may be volume depleted
Subtract anti‐V drug
Steps 3 & 4: If BP not controlled on monotherapy,
Add 2nd anti‐V drug
Steps 4: If BP controlled,
Test subtracting anti‐R drug
Steps 3 & 4: If BP not controlled on monotherapy,
Add 2nd anti‐R drug
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Audience Response #1
Using PRA levels in the management of hypertension helps determine which of the following?
a. Whether the patient would benefit most from ACE inhibitor vs. beta‐blocker
b. Whether the patient has R mediated hypertension vs. V mediated hypertension, thereby guiding treatment
c. Which blood pressure goal to target
d. Whether the patient would benefit most from spironolactone vs. amlodipine
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Audience Response #2Which of the following statements between using PRA levels and traditional methods of managing hypertension is true?a. JNC8 recommends thiazide‐type diuretic as initial therapy
for all patients whereas using PRA levels allows for individualized care
b. JNC8 provides the ability to individualize the pharmacotherapy plan whereas using PRA levels consists of stepped care with progressive addition of medications
c. JNC8 recommends stepped care with progressive addition of medications whereas using PRA levels focuses on individualizing the pharmacotherapy plan
d. JNC8 provides guidance for patients with treated and untreated hypertension whereas PRA levels only provide guidance for untreated hypertension
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Plasma Renin Test–Guided Drug Treatment Algorithm for Correcting Patients With Treated but Uncontrolled Hypertension: A Randomized Controlled TrialEgan BM, Basile JN, Rehman SU, et al. Am J Hypertens. 2009;22:792‐801.
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Study Design
• Randomized, unblinded (n = 77)
Am J Hypertens. 2009;22:792‐801.
Treated, uncontrolled hypertensionUncontrolled: ≥ 140/90 mm Hg or ≥ 130/80 mm Hg in patients with DM and/or nephropathy
Primary Outcome
Difference in BP
Renin Test‐Guided Therapeutics (RTGT)
Clinical Hypertension Specialists‘Care (CHSC)
n = 38
n = 39
Exclusion Criteria
Uncontrolled DM or hyperlipidemia
Alcohol or drug abuse in the past 5 years
ESRD and CKD with SCr > 2.5
Intolerance to ≥ 2 classes of anti‐hypertensive medications
DM ‐ diabetes mellitusESRD ‐ end stage renal disease SCr ‐ serum creatinine
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Baseline CharacteristicsRTGT (n = 38) CHSC (n = 39) P value
Age, years 63.9 58.2 0.02
Men, % 84 74 0.29
Race, % Caucasian 68 41 0.02
BMI, kg/m2 30.6 28.9 0.44
Diabetic, % 24 36 0.24
CKD, % 13 5 0.21
PRA, ng/mL/h 5.8 4.6 0.52
SCr, mg/dL 1.09 1.09 0.93
eGFR, mL/min/1.73m2 77 92 0.02
Am J Hypertens. 2009;22:792‐801.BMI – body mass indexeGFR ‐ estimated glomerular filtration rate
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Blood Pressure Effect
Baseline SBPBaselineDBP
Last VisitSBP
Last VisitDBP
RTGT 157 87.1 127.9 73.1CHSC 153.2 91.1 134 79.8
0
20
40
60
80
100
120
140
160
180
Blood Pressure, m
m Hg
RTGT
CHSC
Am J Hypertens. 2009;22:792‐801.
P = 0.27
P = 0.17
P = 0.10
P = 0.01
SBP ‐ systolic blood pressureDBP ‐ diastolic blood pressure
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Changes in Blood Pressure
‐29.1
‐14.1
‐19.2
‐11.3
‐35
‐30
‐25
‐20
‐15
‐10
‐5
0SBP DBP
Chan
ge in Blood Pressure, m
m Hg
RTGT
CHSC
Am J Hypertens. 2009;22:792‐801.
P = 0.03
P = 0.32
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Number of Medications
3.1 3.1
0
2.7
3
0.3
0
0.5
1
1.5
2
2.5
3
3.5
Baseline Last Visit Change
RTGT
CHSC
Am J Hypertens. 2009;22:792‐801.
P = 0.21 P = 0.73
P = 0.25
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Conclusions & Limitations
Conclusions
Using PRA levels may provide better BP control without a net increase in the number of medications
Limitations
RTGT group older, more Caucasians, worse kidney function
Unblinded
Small sample size
Hypertension specialist group may not mimic general practice
Am J Hypertens. 2009;22:792‐801.
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Pressor Responses To Antihypertensive Drug TypesAlderman MH, Cohen HW, Sealey JE, Laragh JH. Am J Hypertens. 2010;23:1031‐7.
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Study Design
• Retrospective analysis (n = 945)
• Pressor Response – SBP rise ≥ 10 mm Hg
Am J Hypertens. 2010;23:1031‐7.
Untreated hypertension
SBP ≥ 140 mm Hg
Primary EndpointIncidence of pressor responses, and influence of PRA status
Anti‐V Drug: Diuretic or CCB
Anti‐R Drug: ‐blocker or ACEI
n = 537
n = 408
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Blood Pressure ResponseV Drug(n = 537)
R Drug(n = 408)
P Value
Categories of SBP Change (%)
≥ 10 mm Hg rise 5.2 11.0 0.001
≥ 10 mm Hg fall 62.0 54.9 0.03
Categories of DBP Change (%)
≥ 5 mm Hg rise 6.3 7.8 NS
≥ 5 mm Hg fall 63.1 63 NS
Am J Hypertens. 2010;23:1031‐7.NS ‐ not significant
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Pressor Response by PRA Status
6
4
6
17
109
0
2
4
6
8
10
12
14
16
18
Low PRA Middle PRA High PRA
Incide
nce of Pressor Res
pons
e, %
V Drug
R Drug
Am J Hypertens. 2010;23:1031‐7.
P < 0.001
P = 0.02
P = 0.08
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Percent with Treatment SBP ≥ 160 mm Hg
0
5
10
15
20
25
30
35
40
Low PRA Middle PRA High PRA
V Drug
R Drug
Am J Hypertens. 2010;23:1031‐7.
P < 0.01
P = 0.16P = 0.90
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Percent with Treatment SBP ≤ 130 mm Hg
0
5
10
15
20
25
30
Low PRA Middle PRA High PRA
V Drug
R Drug
Am J Hypertens. 2010;23:1031‐7.
P = 0.72
P = 0.002
P ≤ 0.003
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Conclusions
• Overall, anti‐R drugs were associated with a greater incidence of pressor response than anti‐V drugs
• Pressor responses were most likely when anti‐R drugs were given to patients in the low‐renin tertile
• To increase likelihood of achieving BP control with monotherapyAvoid anti‐R drugs in the lowest PRA but use them in the highest PRAAvoid anti‐V drugs in the highest PRA but use them in the lowest PRA
Am J Hypertens. 2010;23:1031‐7.
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Audience Response #3
57 yo African American male with a past medical history ofdyslipidemia is diagnosed with new‐onset hypertension. Aftera trial of therapeutic lifestyle changes, the decision is made toinitiate pharmacotherapy to manage hypertension. The bloodpressure in clinic is 152/93 mmHg, HR 64 BPM. SCr – 0.9mg/dL, K 4.3 mmol/L. PRA level: 7.1 ng/mL/hr. Which of thefollowing is an appropriate first line therapy?
a. Spironolactoneb. Hydrochlorothiazidec. Amlodipined. Lisinopril
BPM ‐ beats per minute
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Proposed Clinical TrialsPatient Population
IGuiding initial and follow‐up treatment strategies in untreated hypertensive patients
IIGuiding drug subtractions and additions in patients whose BP is uncontrolledon an anti‐V and anti‐R drug combination
IIIGuiding drug subtractions and additions in patients whose BP is uncontrolledon ≥ 3 drugs
IVReducing medication burden in hypertensive patients whose BP is controlledon ≥ 4 drugs
Am J Hypertens. 2011;24:1158‐63.
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Conclusions
• PRA levels provide an individualized approach to managing hypertension
• Using PRA levels may provide better BP control without a net increase in medications
• Further clinical trials are necessary to assess hypertension control and impact on cardiovascular outcomes
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Questions & Discussion
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What is the Role of Plasma Renin Activity Levels in the Management of Hypertension?
Ilya Danelich, PharmD, BCPSCardiology Clinical Pharmacist
Pharmacy Grand RoundsMayo Clinic Hospital ‐ RochesterJuly 19, 2016