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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

Quality of Life in the Management of Hypertension

Joel Handler MD

Director, Kaiser Permanente Orange County Hypertension Program

quality of life issues
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?
what is health related quality of life hrqol
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

quality of life components
Quality of Life Components
  • Physical capabilities
  • Emotional status
  • Social interactions
  • Intellectual functioning
  • Economic status
  • Self-perceived health status
health related quality of life measures in chronic disease
Health Related Quality of Life Measures in Chronic Disease
  • Alzheimer’s
  • Parkinson’s
  • Heart failure
  • HIV
  • MI recovery
  • Asthma
  • Cancer
percentage of subjects in nhanes survey reporting symptoms related to systolic blood pressure
Percentage of Subjects in NHANES Survey Reporting Symptoms Related to Systolic Blood Pressure

Weiss NS NEJM 1972;287:631-633

case study
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.

case study16
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.

effects of htn labeling on illness absenteeism
Effects of HTN Labeling on Illness Absenteeism

Haynes et al. NEJM 1978;299:741-744

slide19

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

losartan compared to hctz merck data

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

frequency of adverse effects

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

alpine study subjective symptoms assessment profile sex life
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)

thiazide related gout
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
beta blocker therapy and symptoms of depression fatigue and sexual dysfunction meta analysis
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

ace inhibitor cough
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

angioneurotic edema on ace inhibitors
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

slide38

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

conclusions
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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