Quality of Life in the Management of Hypertension

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Quality of Life in the Management of Hypertension

• Joel Handler MD
• Director, Kaiser Permanente Orange County
  Hypertension Program

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Quality of Life Issues

• What is health related quality of life (QOL)?
• Is hypertension an asymptomatic disease?
• What are the results of the QOL drug comparison
  trials?
• How can we assess the adverse effects of the
  specific drug classes (thiazide, beta blocker,
  ACEI, ARB)?
• How can we improve medication compliance?

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What is health related quality of life?(HRQOL)

• Total well being psychosocial and physical
• Total impact of an intervention on the
  biomedical, social and behavioral status of the
  patient
• HRQOL measures are a set of response variables
  beyond biomedical events capabilities,
  limitations, perceptions

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Quality of Life Components

• Physical capabilities
• Emotional status
• Social interactions
• Intellectual functioning
• Economic status
• Self-perceived health status

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Health Related Quality of Life Measures in
Chronic Disease

• Alzheimers
• Parkinsons
• Heart failure
• HIV

• MI recovery
• Asthma
• Cancer

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Bulpitt et al BHJ 197638121-128
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Percentage of Subjects in NHANES Survey Reporting
Symptoms Related to Systolic Blood Pressure
Weiss NS NEJM 1972287631-633
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Case Study

• 65 year old male with long standing anxiety
  disorder on paroxetine (Paxil) intolerant to HCTZ
  due to mouth dryness, also intolerant to atenolol
  with tremors, and both lisinopril and nifedipine
  with fatigue was referred to Hypertension Clinic
  because of refractory hypertension due to
  medication intolerance.

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Case Study

• His psychiatrist attributed these symptoms to his
  underlying anxiety disorder. Paroxetine and
  bupropion (wellbutrin) were nonefficacious, but
  clonazepam (klonopin) led to a reduction in
  somatic complaints. HCTZ was successfully
  reinitiated, and in combination with lisinopril
  and atenolol led to control of his hypertension.

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Effects of HTN Labeling on Illness Absenteeism
Haynes et al. NEJM 1978299741-744
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Effect sizes in quality of life trials comparing
angiotensin-converting enzyme inhibitors with
other treatmentsmeasures of overall wellbeing
Fletcher A. Cur Opinion Neph Hypertens
19954538-542
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Losartan Compared to HCTZ Merck Data
Goldberg et al. Am J Card 1995 75 193-795
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Frequency () of Adverse Effects
Weir et al. Am J Med 1996 101 835-925
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ALPINE Study Subjective Symptoms Assessment
Profile, Sex Life

• (n392, 12 months, none lost to follow-up)
• HCTZ 25mg add-on atenolol 50-100mg vs candesartan
  16mg add-on felodipine 2.5-5mg
• Candesartan HCTZ
• N190 N196
• Baseline 2.9(0.9) 2.9(0.9)
• 12 Months 3.1(1.1) 2.9(1.0)
• Change (mean) 0.1(0.9) 0.0(0.9)

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Thiazide Related Gout

• Thiazide related hyperuricemia is dose related
• HDFP Trial 15 episodes of gout over 5 years in
  3693 patients treated with chlorthalidone 25-100mg

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Beta Blocker Therapy and Symptoms of Depression,
Fatigue, and Sexual Dysfunction Meta Analysis

• Depression 7 trials 10,622 patients
• Fatigue 10 trials 17,682 patients
• Sexual Dysfunction 6 trials, 14,897 patients
• Fatigue 4 withdrawals/1000 patients/year
• Mostly with propanolol
• Sexual Dysfunction 2 withdrawals/1000
  patients/year
• Depression No significant difference

Ko et al. JAMA 2002 288 351-357
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ACE Inhibitor Cough

• Incidence 5-40 not dose related higher rate in
  females, blacks, orientals
• Cough characteristics not helpful in diagnosis
  (may be productive)
• Timing within a week to up to 6 months
• Resolution 1-4 days, up to 4 weeks
• Pathophysiology Bradykinin accumulation no
  pulmonary dysfunction
• Things that dont work iron, NSAIDs, cromolyn
• Consider rechallenge

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Angioneurotic edema on ACE Inhibitors

• Well-demarcated swelling of tongue, lips, ENT
  mucous membranes, esophagus, GI tract
• Timing within hours to one week up to 1 year
• History of spontaneous angioedema a relative
  contraindication, may be at increased risk
• Rare ARB overlap 1/39 in CHARM alternative

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Interventions to Enhance Patient Adherence to
Medication PrescriptionsMcDonald HP, Garg AX,
Haynes RB

• Multifactorial
• Additional oral and written instruction
• Convenience of care (simplified
• dosing, worksite care)
• Patient self monitoring via home BPs
• Telecommunications system
• Reminders, rewards
• Family support

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Conclusions

• Quality of life is improved when blood pressure
  is under control
• All drugs have adverse effect profiles
• Quality of life drug comparisons are fairly equal
  with modern low dose strategies
• Compliance strategies are challenging and need to
  be multileveled the first 6 months of therapy is
  a critical period