Blood Pressure Monitoring and Checkup Frequency
According to 2017 hypertension guidelines from the American College of Cardiology and American Heart Association (ACC/AHA), patients started on blood pressure-lowering medication should return for a follow-up appointment monthly until blood pressure goals are met [Strong Recommendation (Level B-R)].1 The experts also found strong evidence to support the recommendation of promoting other strategies to improve control of blood pressure in patients on antihypertensive therapy to include the use of home blood pressure monitoring, team-based care, and telehealth strategies [Strong Recommendation (Level A)].1 The evidence in these studies demonstrated the benefits of a combination of home blood pressure monitoring, telehealth, and team-based (e.g., nurse case manager, pharmacist, doctor) care over just office based follow-up.2-6 At the follow-up checkup, the doctor will measure blood pressure and assess for adverse effects.1,7 Patients with more severe hypertension (≥160 systolic blood pressure or ≥100 diastolic blood pressure) or complicating comorbid conditions, such as heart failure (HF), diabetes, or chronic kidney disease (CKD) need more frequent visits. At this checkup, the doctor will measure blood pressure and assess for adverse effects. Doctors must assess blood tests of electrolytes and renal function within two to four weeks after starting therapy for people who are taking a renin-angiotensin system inhibitor, such as an angiotensin receptor blocker (ARB), or diuretic therapy. Once the BP goal is met and stable, visits can be at three- to six-month intervals.
Renal Function Monitoring Details
Periodic renal function monitoring is recommended for patients taking ARBs.8-15 Drugs that inhibit the renin-angiotensin system, such as ARBs, can cause changes in renal function including acute renal failure. Patients whose renal function may depend on the activity of the renin-angiotensin system include those with renal artery stenosis, CKD, severe HF, or volume depletion. They may be at higher risk of developing oliguria, progressive azotemia, or acute renal failure when taking an ARB. Doctors should consider withholding or discontinuing treatment in patients who develop a clinically significant decrease in renal function on an ARB.
The 2017 ACC/AHA Hypertension Guidelines say that angiotensin converting enzyme inhibitors (ACEIs) are a reasonable antihypertensive treatment for adults with CKD to slow kidney disease progression [Moderate recommendation (Level B-R)].1 This guideline recommends ARBs as an alternative if ACEIs are not tolerated. [Weak recommendation (Level C-EO)]. The previous 2014 Eighth Joint National Committee (JNC8) guidelines recommend that adults with CKD should include an ARB or an ACEI as part of their antihypertensive treatment to improve kidney outcomes [Moderate recommendation (Grade B)].16 This guideline gave more detail on monitoring patients using an ARB. Since an ARB can increase serum creatinine and may produce other metabolic effects such as hyperkalemia, the guideline recommends people with CKD have their electrolyte and serum creatinine levels tested regularly.
Serum Potassium Monitoring Details
Manufacturers recommend monitoring serum potassium periodically in patients receiving an ARB.8-15 Drugs that inhibit the renin-angiotensin system can cause hyperkalemia. Patients at risk of developing hyperkalemia include those:
- with renal insufficiency
- with diabetes mellitus
- who also use potassium-sparing diuretics, potassium supplements, and/or potassium-containing salt substitutes
A 2010 meta-analysis reviewed 39 studies for the effects on serum potassium levels of ARBs, ACEIs, aldosterone receptor antagonists, and direct renin inhibitors, alone and in combination, in patients with hypertension, HF, or CKD.17 In patients on ARB monotherapy with hypertension and no risk factor for hyperkalemia, the incidence of hyperkalemia was very low (≤2%). Patients with risk factors, such as HF or CKD, had a higher incidence of hyperkalemia (5% to 10%).
A 2003 meta-analysis of 354 randomized double-blind placebo controlled trials of hypertension treatment with thiazides, beta blockers, ARBs, calcium channel blockers, and ACEIs looked at the rate of side effects at the standard dose.18 The study found potassium increased by 2%, or 0.07 mmol/L with ARBs (95% confidence interval [-0.04 – 0.18 mmol/L], five trials, eight treatment arms).
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a reportof the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017.
- Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA 2013; 310 (1): 46-56.
- Bosworth HB, Powers BJ, Olsen MK, et al. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Arch Intern Med 2011; 171 (13): 1173-1180.
- Brennan T, Spettell C, Villagra V, et al. Disease management to promote blood pressure control among African Americans. Popul Health Manag 2010; 13 (2): 65-72.
- Bosworth HB, Olsen MK, Grubber JM, et al. Two self-management interventions to improve hypertension control: a randomized trial. Ann Intern Med 2009; 151 (10): 687-695.
- Green BB, Cook AJ, Ralston JD, et al. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. JAMA 2008; 299 (24): 2857-2867.
- Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42 (6): 1206-1252.
- Diovan [package insert] East Hanover, NJ: Novartis Pharmaceuticals Corp; 2017.
- Edarbi [package insert] Atlanta, GA: Arbor Pharmaceuticals, LLC; 2016.
- Atacand [package insert] Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2016.
- Avapro [package insert] Bridgewater, NJ: Sanofi-Aventis U.S. LLC; 2016.
- Cozaar [package insert]. Whitehouse Station, NJ: Merck Sharp & Dohme Corp; 2015.
- Teveten [package insert]. North Chicago, IL: AbbVie Inc.; 2014.
- Micardis [package insert] Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; 2014.
- Benicar [package insert] Parsippany, NJ: Daiichi Sankyo, Inc; 2009.
- James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA 2014; 311 (5): 507-520.
- Weir MR, Rolfe M. Potassium homeostasis and renin-angiotensin-aldosterone system inhibitors. Clin J Am Soc Nephrol 2010; 5 (3): 531-548.
- Law M, Wald N, Morris J. Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy. Health Technol Assess 2003; 7 (31): 1-94.