Evidence-based practice has patients’ values and preferences as one of its 3 pillars. To properly elicit this pillar, health professionals need to do shared decision making (SDM). To do SDM, clinicians need to be provided with information that would allow them to discuss with patients the risks of their medical condition, the different treatment options and the potential benefits and harms associated with these treatments. Hopefully, most pharmacists would wish to practise in this way.
The decisions around the treatment of high blood pressure (HBP) are an ideal opportunity for SDM. There is solid evidence that some HBP treatments reduce cardiovascular disease (CVD) risk. However, it is important to remember that HBP for the good majority of patients is an asymptomatic risk factor that does not progress to morbidity, and most people, despite a lifetime of treatment, will not derive a CVD benefit.1 In addition, all HBP pharmacologic treatments are associated with the potential for adverse effects, and all incur an inconvenience and cost that an individual patient would have to balance against the possibility of benefit.
In their recent article in the January/February 2018 issue of CPJ,2 the authors presented what they felt were the update highlights and the important elements from the most recent 2017 Hypertension Canada guidelines.3 I read their article with the eye of seeing if one could extract information from this update that would help pharmacists engage in SDM.
It was disappointing to find that within the 9 pages of this article, there was not a single mention of the following key aspects/treatment information:
Patient values and preferences—There was no mention of patient values and preferences, and in fact, a number of phrases used by the authors, such as “Antihypertensive therapy should be provided to all patients,” “Antihypertensive therapy should be strongly considered,” “All patients should be treated to achieve a SBP target” and “strongly recommend antihypertensive therapy for most patients,” seem to fly in the face of a SDM concept.
Lifestyle recommendations (nutrition and physical activity)—No mention was made of any lifestyle recommendations despite the importance of these issues not only for HBP but also for overall health.
Adverse effects of HBP medications—There was no mention of any potential adverse effects or their magnitude and nothing about what to monitor or what to do if adverse effects occur.
Cost issues, inconvenience of treating, pill burden, concern for labeling—All of these aspects are important when it comes to making decisions around HBP but were not mentioned in the update.
Starting with very low doses of medications and titrating up slowly based on tolerability and response—Most side effects are dose related, and titrating up slowly can potentially reduce the chance of a patient developing adverse effects.4
Discontinuing or reevaluating treatment—No mention of this aspect of therapy or when or how to do it.
Risk calculation tools—No mention of how to use these tools or their advantages/disadvantages/limitations. While the authors suggest “CVD risk should be assessed in all patients,” there is no discussion as to what to do with these risk calculations other than advise patients of their CVD risk. Obviously, providing patients with an estimate of their potential individualized treatment benefit is required for SDM.
In my opinion, the above (both evidence and approaches to treatment) would be useful and, I would say essential, to have when it comes to SDM. I realize this article was not intended to be an exhaustive discussion of HBP treatment, but surely if the authors felt any of the above issues were important to pharmacists, they would have at least been mentioned somewhere within the 9 pages, almost 4000 words, 1 box and 1 figure of their article. Unfortunately, in hindsight, it isn’t completely surprising that these aspects were missing because the actual 2017 Hypertension Canada guidelines are also mute on many of these aspects.3 Both the guidelines and this update seem to be very much focused on improving adherence and blood pressure control. While these 2 concepts are not unimportant, they are very medication and threshold centric.
Pharmacists are ideally suited to help people make decisions about HBP treatment, but if the “experts” don’t promote SDM or provide the necessary information to do SDM, pharmacists will continue to play the role of target shooters versus evidence-based practitioners.
—James McCormack, BSc(Pharm), PharmD
Faculty of Pharmaceutical Sciences
University of British Columbia, Vancouver, BC
james.mccormack@ubc.ca
References
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