Considerations in Managing Hypertension in Men

Hypertension is a major risk factor for the development of cardiovascular disease in the United States. Based on data from the National Health and Nutrition Examination Survey 1999-2004, an estimated 72 million Americans aged 20 years and older have hypertension. Of this total estimate, 33 million (45.8%) are men. Additionally, the deaths of 22,795 men in 2004 were attributed to high blood pressure.1Recognizing the large number of Americans who are at increased risk for heart disease, the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) has developed guidelines to provide a framework to aid health care providers in the management of patients with hypertension. In its most recent update, JNC 7, a new classification of prehypertension has been identified to allow for earlier detection of individuals who are likely to progress to hypertension.Prehypertension is defined as a systolic blood pressure reading of 120 to 139 mm Hg or a diastolic blood pressure reading of 80 to 89 mm Hg.2Nonadherence to Therapy

• Cost of the medication
• Lack of patient inclusion in the treatment decision-making process
• Inadequacy of patient counseling
• Length of therapy
• Need for behavioral modifications
• Complexity of the regimen

Forgetfulness3

Nonadherence also may be attributed to the fact that patients with hypertension often are asymptomatic. In addition, many antihypertensives are associated with adverse drug reactions that make patients feel ill. Although these barriers exist for all patients, special considerations in the management of hypertension in men may be particularly important in increasing patient adherence to therapy and ultimately reducing the risk for heart disease.

Erectile Dysfunction and Treatment

• Aldosterone antagonists (spironolactone)
• Thiazide diuretics
• Central-acting sympatholytics (methyldopa and clonidine)

Peripheral-acting sympatholytics (reserpine)5

Given the personal and intimate nature of the topic, patients and health care providers alike may be reluctant to initiate or discuss signs and symptoms of ED. Patient counseling and follow-up, however, should include appropriate questions to determine whether the patient is experiencing side effects?such as difficulty achieving and/or maintaining erections?from antihypertensive therapy. Additionally, patient referral to a physician can be helpful to men who present with signs and symptoms of ED to determine the underlying cause(s) of the condition (ie, other medications, stress, disease) and to assess their risk for cardiovascular disease. In the event that a patient is experiencing ED resulting from antihypertensive therapy, a dosage reduction or a change in the drug class may resolve the problem. In some cases, however, such as with the use of a ?-blocker in heart failure, dosage reductions or discontinuation may not be feasible, because the risks will exceed the benefits. Counseling regarding nonpharmacologic options for ED may be warranted.

ED frequently is managed through the use of phosphodiesterase type 5 inhibitors, such as sildenafil, tadalafil, and vardenafil. Reductions in blood pressure may occur with the administration of these agents, based on their mechanism of action, and patients should be aware of this side effect. Studies have shown, however, that phosphodiesterase type 5 inhibitors may be given safely to patients receiving antihypertensive therapies.6,7Treatment with a-Blockers

Men with benign prostatic hyperplasia (BPH) may receive treatment with a-adrenergic blockers?such as terazosin, doxazosin, and tamsulosin?to reduce symptoms caused by an enlarged prostate. Treatment with a-blockers once was considered potentially favorable for the management of hypertension in patients with BPH to target both blood pressure and BPH symptoms.^{8 Results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), however, determined that patients treated with doxazosin, when compared with those treated with chlorthalidone, had an increased risk for stroke and heart failure.}9,10Thus, JNC 7 no longer recommends that hypertension be managed with an a-blocker. In men with BPH and elevated blood pressure, hypertension should be treated according to evidence-based recommendations, such as with a thiazide diuretic. BPH symptoms should be managed separately. Patients receiving a-blocker therapy should be counseled regarding the potential for first-dose syncope and orthostatic hypotension. The risk for orthostatic hypotension increases in patients receiving a-blockers in combination with antihypertensives such as diuretics.2Alcohol Use and Other Lifestyle Modifications

JNC 7 also recommends minimizing alcohol consumption to lower systolic blood pressure by 2 to 4 mm Hg. Moderate alcohol consumption in men is considered to be no more than 2 drinks per day, where 1 drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz of 80-proof liquor. Other lifestyle modifications?including weight reduction, increased physical activity, restricted sodium intake, and a diet consisting of fruits and vegetables with limited saturated fat intake?should be an integral part of appropriately managing hypertension.2Analgesic Use

The risk for hypertension in men receiving commonly used OTC analgesics? including acetaminophen, ibuprofen, and aspirin?has received recent attention. Inhibition of vasodilatory prostaglandins by acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and aspirin results in elevations in blood pressure. Additionally, NSAIDs can promote sodium and water retention, and acetaminophen increases cellular oxidative stress to cause hypertension.Data from the ongoing prospective cohort Health Professionals Follow-up Study suggest that all 3 agents, given at least 6 to 7 times each week, were associated with a moderate increase in the risk for hypertension.11 Thus, pharmacists may suggest routine monitoring of blood pressure in men who are taking analgesics frequently.Summary

Pharmacist involvement in the care of men patients with hypertension can potentially improve adherence. Appropriate patient counseling about the importance of therapy can reduce the risk for heart disease and help in the management of adverse drug reactions.References

1. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics?2007 update. Circulation. 2007;115:e69-e171.

2. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA. 2003; 289: 2560-2572.

3. Patel RP, Taylor SD. Factors affecting medication adherence in hypertensive patients. Ann Pharmacother. 2002;36:40-45.

4. Doumas M, Tsakiris A, Douma S, et al. Factors affecting the increased prevalence of erectile dysfunction in Greek hypertensive compared with normotensive subjects. J Androl. 2006;27:469-477.

5. Miller TA. Diagnostic evaluation of erectile dysfunction. Am Fam Physician. 2000;61:95-104.

6. Webb DJ, Freestone S, Allen MJ, Muirhead GJ. Sildenafil citrate and blood-pressure-lowering drugs: results of drug interaction studies with an organic nitrate and a calcium antagonist. Am J Cardiol. 1999;83:21C-28C.

7. Zusman RM, Prisant LM, Brown MJ. Effect of sildenafil citrate on blood pressure and heart rate in men with erectile dysfunction taking concomitant antihypertensive medication. J Hypertens. 2000;18:1865-1869.

8. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;157:2413-2446.

9. Davis BR, Cutler JA, Furberg CD, et al. Relationship of antihypertensive treatment regimens and change in blood pressure to risk for heart failure in hypertensive patients randomly assigned to doxazosin or chlorthalidone: further analyses from the Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial. Ann Intern Med. 2002;137:313-320.

10. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT). JAMA. 2000;283:1967-1975.

11. Forman JP, Rimm EB, Curhan GC. Frequency of analgesic use and risk of hypertension among men. Arch Intern Med. 2007;167:394-399.