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Treatment of Hypertension in Pediatrics

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Treatment of Hypertension in Pediatrics Kelsey R. Green, Pharm.D. Pediatric Clinical Pharmacist LSU-HSC in Shreveport, LA Diuretics Patient s Characteristics ... – PowerPoint PPT presentation

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Title: Treatment of Hypertension in Pediatrics


1
Treatment of Hypertension in Pediatrics
  • Kelsey R. Green, Pharm.D.
  • Pediatric Clinical Pharmacist
  • LSU-HSC in Shreveport, LA

2
Objectives
  • Define hypertension in children
  • Identify when blood pressure should be taken
  • Practice determining BP percentile and
    interpreting how to use this information to best
    treat the patient
  • Discuss treatment options used in pediatrics to
    treat hypertension

3
Definitions2
  • Hypertension average SBP and/or DBP gt95th
    percentile for gender, age, and height on gt 3
    occasions
  • Prehypertension average SBP or DBP gt90th
    percentile but ltthe 95th percentile
  • Adolescents with BP levels gt120/80 mm Hg should
    be considered prehypertensive

4
Measurement of Blood Pressure2
  • Children gt3 years old should have their BP
    measured when seen in a medical setting
  • Preferred method Auscultation
  • Requires a cuff that is appropriate for the
    childs arm
  • Right arm preferred

5
Blood Pressure Cuff2
  • Equipment needed to measure BP in children
    (3-adolescents)
  • Child cuffs of different sizes
  • Standard adult cuff
  • Large adult cuff
  • Thigh cuff

6
Measurement of BP in children lt 3 years old2
  • History of prematurity, VLBW, or other neonatal
    complications
  • Congenital heart disease
  • Recurrent UTI, hematuria, or proteinuria
  • Known renal disease or urologic malformations
  • Family history of congenital renal disease
  • Solid-organ transplant
  • Malignancy or bone marrow transplant
  • Treatment with drugs known to raise BP
  • Systemic illnesses associated with hypertension
  • Evidence of elevated ICP (intracranial pressure)

7
Using the Blood Pressure Tables2
  • Use the standard height charts to determine the
    height percentile.
  • Measure and record the childs SBP and DBP.
  • Use the correct gender table for SBP and DBP.
  • Find the childs age on the left side of the
    table. Follow the age row across the table to
    the intersection of the line for the height
    percentile.
  • Find the 50th, 90th, 95th, and 99th percentiles
    for SBP in the left columns and for DBP in the
    right columns.

8
Lets Practice
  • AMF is a 5 yo female weighing 25 kg in the 75th
    percentile of height. Her BP is taken when she
    goes to the Dr. for a routine visit. Her BP is
    114/73.
  • What is her BP percentile?
  • What do we do with this information?

9
What does this percentile mean?2
10
Classification of Hypertension Therapy
Recommendations2
11
Management Algorithm2

12
Diagnostic Work-Up6
13
Possible Etiologies Causing Hypertension2
  • Chronic Renal Failure
  • Cushing Syndrome
  • Turner Syndrome
  • Hyperthyroidism
  • Systemic Lupus
  • Coarctation of the aorta
  • Wilms tumor

14
Treatment Strategies
  • Therapeutic lifestyle changes
  • Drug therapy

15
Lifestyle changes
  • Weight reduction
  • Regular physical activity
  • Restriction of sedentary activity
  • Dietary modification
  • Family-based intervention

16
Indications for Antihypertensive Drug Therapy2
  • Symptomatic hypertension
  • Secondary hypertension
  • Hypertensive target-organ damage
  • Diabetes (types 1 and 2)
  • Persistent hypertension despite nonpharmacologic
    measures

17
Step-wise Approach to Therapy2
  • Start with a small dose of a single
    anti-hypertensive drug
  • Increase dose of single anti-hypertensive drug
    (to max dose if tolerated)
  • Add a small dose of a second drug
  • Increase dose of second anti-hypertensive
    medication

18
Antihypertensive Medication
  • Angiotensin Converting Enzyme-Inhibitors
  • Angiotensin Receptor Blockers
  • Calcium Channel Blockers
  • Diuretics
  • Beta-Blockers
  • Central alpha-agonists
  • Peripheral alpha-antagonist
  • Vasodilators

19
Drug Options for Initial Therapy1
20
ACE-I1-3, 5
  • Angiotensin Converting Enzyme Inhibitors
  • Benazepril, Captopril, Enalapril, Fosinopril,
    Lisinopril, Quinapril
  • Mechanism of Action prevents conversion of
    angiotensin I to angiotensin II, a potent
    vasoconstrictor results in lower levels of
    angiotensin II which causes an increase in plasma
    renin activity and a reduction in aldosterone
    secretion

21
ACE-I
22
ACE-I
  • Patients Characteristics
  • High plasma renin activity
  • Renal insufficiency (unilateral renovascular
    hypertension, renal parenchymal disease, renal
    proteinuria)
  • Congestive heart failure
  • Diabetes
  • Hyperlipidemia

23
ACE-I
  • Comments
  • Contraindicated in pregnancy
  • Monitor serum potassium and SCr
  • Cough and angioedema
  • May require a dosing adjustment in renal
    impairment
  • Fosinopril in children gt50 kg
  • Good data on compounding Captopril into a
    suspension

24
ARB1-3, 5
  • Angiotensin Receptor Blockers
  • Irbesartan, Losartan
  • Mechanism of Action angiotensin II receptor
    antagonist blocks the vasoconstrictor and
    aldosterone-secreting effects of anigotensin II

25
ARB
26
ARB
  • Patients Characteristics same as ACE-I
  • Comments
  • Less studied than ACE-I
  • Dosing not available in Neofax or Pediatric
    Dosing Handbook
  • All are contraindicated in pregnancy
  • Check serum potassium and SCr
  • Not available currently on formulary

27
CCB1-3, 5
  • Calcium Channel Blocker
  • Amlodipine, Felodipine, Isradipine,
    Extended-release Nifedipine
  • Mechanism of Action inhibits calcium ions from
    entering the slow channels or select
    voltage-sensitive areas of vascular smooth muscle
    and myocardium during depolarization produces a
    relaxation of coronary vascular smooth muscle and
    coronary vasodilation

28
CCB
29
CCB
  • Patients Characteristics
  • Emergency hypertension (nifedipine)
  • Black race
  • Diabetes
  • Chronic obstructive lung disease
  • Broncho-pulmonary dysplasia
  • Gout
  • Hyperlipidemia
  • Peripheral Vascular Disease
  • Renal Transplant (cyclosporine-induced)

30
CCB
  • Comments
  • ADR edema, arrhythmias, headache, fatigue,
    dizziness, flushing
  • No adjustment in renal impairment
  • May need adjustment in hepatic impairment
  • Good data for compounding Amlodipine oral
    suspension

31
Diuretics1-3, 5
  • Amiloride, Chlorothiazide, Chlorthalidone,
    Triamterene, Furosemide, HCTZ, Spironolactone,
    Metolazone, Bumetanide
  • Mechanisms of Action
  • Loop Diuretic (Furosemide, Bumetanide) Inhibits
    reabsorption of Na and Cl in the ascending loop
    of Henle and distal tubule causing increased
    excretion of water, K, Na, Cl, Mg, Ca

32
Diuretics
  • Mechanism of Action continued
  • Thiazide Diuretic (HCTZ, Chlorothiazide)
    Inhibits Na reabsorption in the distal tubules
    causing increased excretion of Na and water as
    well as K, Mg, Ca, hydrogen, phosphate, bicarb
    ions
  • K Sparing Diuretic (Spironolactone) Competes
    with aldosterone for receptor sites in the distal
    renal tubules, increasing NaCl and water
    excretion while conserving K and hydrogen ions
    may block the effect of aldosterone on
    arteriolar smooth muscle as well
  • Miscellaneous (Metolazone) Inhibits sodium
    reabsorption in the cortical diluting site and
    proximal convoluted tubules

33
Diuretics
34
Diuretics
  • Patients Characteristics
  • Volume dependent, low plasma renin activity
  • Black race
  • Congestive heart failure
  • Avoid in athletes

35
Diuretics
  • Comments
  • ADR Dizziness, Photosensitivity, Rash, Vomiting
  • Monitor Electrolytes
  • Adjust in renal impairment
  • Furosemide and Chlorothiazide available in
    solutions
  • Good data to compound Spironolactone, Metolazone
    and HCTZ into oral suspensions

36
BB 1-3, 5
  • ?eta-Blocker
  • Atenolol, Bisoprolol/HCTZ, Metoprolol,
    Propranolol
  • Mechanism of Action Selective inhibitor of
    beta1-adrenergic receptors at lower doses also
    inhibits beta2-receptors at higher doses

37
BB
38
BB
  • Patients Characteristics
  • High plasma renin activity
  • Hyperdynamic circulation
  • Anxiety
  • Migraine
  • Hyperthyroidism
  • Neuroadrenergic tumors

39
BB
  • Comments
  • Good data to compound Metoprolol and Atenolol
  • Propranolol available as a solution
  • Worried about higher doses in asthma patients
  • Contraindicated in sick sinus syndrome
  • Avoid in athletes and people with diabetes

40
Goals of Therapy2
41
Long-Term Management3
  • Monitor therapy for efficacy and for potential
    adverse effects
  • Measure blood pressure every 2-4 weeks until good
    control
  • Once controlled, monitor every 3-4 months

42
Step-Down Therapy2
  • After blood pressure is stable, gradually reduce
    medication
  • Goal Discontinue medication
  • Best Candidates Children with uncomplicated HTN
    due to obesity
  • Continue to follow BP and continue lifestyle
    changes

43
Our Patient
  • AMF BP was in 95th percentile
  • Repeated BP at 3 office visits (93rd percentile)
  • Recommend Lifestyle Changes
  • Repeat BP in 6 months (95th percentile)
  • Patient work-up unilateral renovascular
    hypertension
  • Start an ACE-I

44
Conclusions
  • Use patients BP Percentile to determine if they
    have hypertension.
  • First-line agents to treat hypertension are
    ACE-I/ARB or CCB.
  • Diuretics are usually used as second line therapy.

45
References
  • 1. Seikaly, Mouin G. Hypertension in children
    an update on treatment strategies. Curr Opin
    Pediatr 2007 19170-177.
  • 2. National High Blood Pressure Education
    Program Working Group on High Blood Pressure in
    Children and Adolescents. The fourth report on
    the diagnosis, evaluation, and treatment of high
    blood pressure in children and adolescents.
    Pediatrics 2004 114555-576.
  • 3. Flynn, JT. Pharmacologic Treatment of
    Hypertension in Children and Adolescents. J
    Pediatr 2006 149746-54.
  • 4. McNiece, Karen and Portman R. Ambulatory
    blood pressure monitoring what a pediatrician
    should know. Curr Opin Rediatr 19178-182.
  • 5. Pediatric Dosage Handbook, 14th ed. Hudson,
    OH Lexi-Com, 2005.
  • 6. Luma, GB and Spiotta, RT. Hypertension in
    Children and Adolescents. AAFP 2006 73
    1158-68.

46
Questions
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