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Quality of Life in the Management of Hypertension

Quality of Life in the Management of Hypertension. Joel Handler MD Director, Kaiser Permanente Orange County Hypertension Program. Quality of Life Issues. What is health related quality of life (QOL)? Is hypertension an asymptomatic disease?

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Quality of Life in the Management of Hypertension

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  1. Quality of Life in the Management of Hypertension Joel Handler MD Director, Kaiser Permanente Orange County Hypertension Program

  2. 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?

  3. 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

  4. Quality of Life Components • Physical capabilities • Emotional status • Social interactions • Intellectual functioning • Economic status • Self-perceived health status

  5. Health Related Quality of Life Measures in Chronic Disease • Alzheimer’s • Parkinson’s • Heart failure • HIV • MI recovery • Asthma • Cancer

  6. Bulpitt et al BHJ 1976;38:121-128

  7. Percentage of Subjects in NHANES Survey Reporting Symptoms Related to Systolic Blood Pressure Weiss NS NEJM 1972;287:631-633

  8. 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.

  9. 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.

  10. Effects of HTN Labeling on Illness Absenteeism Haynes et al. NEJM 1978;299:741-744

  11. Effect sizes in quality of life trials comparing angiotensin-converting enzyme inhibitors with other treatments:measures of overall wellbeing Fletcher A. Cur Opinion Neph Hypertens 1995;4:538-542

  12. Losartan HCTZ N=2085 N=271 Any Adverse Experience (AE) 46.8% 48.3% Drug Related (AE) 15.3% 18.1% Asthenia/ Fatigue 3.8% 5.5% Cough 3.1% 4.1% Dizziness 4.1% 4.1% Headache 14.1% 14.0% Insomnia 1.1% 1.1% Losartan Compared to HCTZ: Merck Data Goldberg et al. Am J Card 1995; 75: 193-795

  13. Adverse Effect Placebo HCTZ 12.5mg N=168 N=173 Abnormal Urination 3 3 Asthenia 4.9 2.3 Dizziness 1.2-11.8 1-5.9 Fatigue 6 3 Headache 7-17.6 5.9-10.3 Rash 1 1 Stress Reaction 1 3 Frequency (%) of Adverse Effects Weir et al. Am J Med 1996; 101: 835-925

  14. ALPINE Study: Subjective Symptoms Assessment Profile, Sex Life (n=392, 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 N=190 N=196 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)

  15. 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

  16. 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

  17. 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 don’t work: iron, NSAIDs, cromolyn Consider rechallenge

  18. 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

  19. 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 JAMA 2002; 288: 2868-2869

  20. 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

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