1. European Strategies for Blood Pressure Control Prepared for RCI by Helen Ann Halpin, PhD October 1, 2010 Professor, SPH, UC Berkeley Deputy Editor, Public Health Reviews, Sorbonne, Paris

2. Introduction Evidence-based hypertension treatment guidelines E.U. every 2 years; 7 year gap in U.S. 1.Compare E.U. to U.S. 2.Compare A.L.L. to E.U. 3.Role of community pharmacists in E.U.

3. Major Hypertension Drugs Major Hypertensions Drugs Most Prescribed: generic (Brand) Thiazide-diuretics (TD)hydrochlorothiazide (Tagamet) Beta Blockers (BB)propanolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL, Inderal) Ace Inhibitors (ACEI)captopril (Capoten), lisinopril (Prinivel, Zestril), enalapril (Vasotec), benzapril(Lotesnin) Calcium Channel Blockers (CCB) nifedipine (Procardia), diltiazem (Cardizem), verapamil (Calan, Isoptin) Angiotension receptor blockers (ARB) losartan (Cozaar), losartan HCTZ (Hyzaar

4. Hypertension Guidelines: U.S. vs E.U. RecommendationsUS DHHSEU Last Update20042009 (2007) Next Update2011 (Fall )2011 Treatment by StageYesNo Initial TreatmentThiazide-diuretic (T-D)Two-combination drugs Drug CombinationsSilentT-D with ACEI, ARB or CCB OR ACEI with CCB Or ARB with CCB If 3rd: add T-D, ARB or CCB

5. Hypertension Guidelines: U.S. vs E.U. RecommendationsUS DHHSEU Treatments to AvoidNone specifiedBeta Blockers (BB) BB/T-D combinations ACEI/ARB combinations Fix-dose/single pillRecommended Low does aspirinAs an adjunct only after BP is controlled Only for patients with a previous cardiovascular event PolypillSilentNot supported Lifestyle risksWeight, sodium, activity, alcohol, smoking, fat, blood glucose

6. BP RCTs Published Since 2004 (40) 20052006200720082009 ACTION ALLHAT ASCOT BBLTTC EDIC FEVER IDNT LIFE MOSES PROGRESS SCOPE SHEP VALUE CAFÉ DREAM ELSA FEVER HYVET INVEST MOSES PHARAO STAR Steno 2 TROPHY UKPDS VALUE ACCORD ACTION ADVANCE CAPRAF COMET INVEST JIKEY HEART LIFE PROGRESS SENIORS ACCOMPLISH ACCORD ADVANCE DIRECT HYVET I-PRESERVE JUPITER LIFE ONTARGET PROFESS TRANSCEND ADVANCE CHHIPS ELSA FEVER GISSI-AF ONTARGET PAMELA UADT VALUE

7. A.L.L. Protocol* vs E.U. Guidelines** Kaiser A.L.L. Protocol E.U. Blood Pressure Guidelines aspirinRecommended only following first cardiovascular event. (Serious side effects include serious bleeding from the stomach/intestine and increased risk of hemorrhagic stroke) lisinopril (ace inhibitor) Recommended in combination with Thiazide- Diuretic or CCB only Lovastatin (statin) Not recommended unless lipids are elevated. (Serious side effects include rhabdomylysis and kidney failure, peripheral neuopathy, memory loss, and delirium) 3 pills/day1 pill/day Fixed doses for allMedicate based on individual risk *for diabetic patients at risk of cvd mortality ** for treatment of high blood pressure

8. Community Pharmacists in E.U. Use of pharmacists as part of primary care team –Primary prevention –Detection –Management Advantages –Access –Evidence of increased compliance and improved BP control Challenges –Education and training (beyond Rx filling) –Legal duty to perform (Denmark, Spain, Belgium, France) –Contractual relationship with and payment by insurers (FFS; little evaluation) –Cooperation between physicians and pharmacists –Lack of time

9. Recent Policy Innovation France has established a national pharmaceutical electronic record –All community pharmacists must participate –Goal: to prevent adverse drug reactions and redundant treatments