February 2017 Newsletter
Call for Nominations for GSHP offices


The Committee on Nominations-2017 is pursuing members who wish to get or stay active and involved in GSHP. These candidates should exhibit qualities of leadership, vision and professional awareness that will sustain the enterprising and pioneering spirit that has characterized GSHP.
 
WHO: Any pharmacist member of GSHP.
 
WHAT: Submit your name or another GSHP member's name to the Committee on Nominations for consideration as a candidate for the following offices:
 
President-Elect
 
District Directors-elect for:
Chattahoochee (Columbus, LaGrange area)
NE Georgia (Athens, Gainesville area)
NE Georgia Metro (Dekalb Co, N Fulton Co.)
 
Functions:
President Elect: The President-elect serves as a member of the Executive Committee, Finance Committee, Board of Directors and as a non-voting ex-officio member of all standing committees and ad hoc bodies of the GSHP Board. Perform the duties of the President in the President's absence. Monitor progress of committees and individuals in addressing issues identified and charges assigned from the planning retreats. Succeeds to the offices of President and Chairman of the Board. Your term of office would be from August 2017 to August 2018 as President-elect; August 2018 to August 2019 as President and August 2019 to August 2020 as Chair of the Board.
 
District Directors: In addition to representing membership from the local district as a voting member of the Board, the District Directors serve as membership liaison and coordinate local continuing education programming for GSHP. You would serve as district director elect from August 2017 to August 2018, and District Director from August 2018 to August 2020. 
WHERE: Submit names for consideration to: The Committee Nominations - 2017, c/o Jennifer Sterner-Allison jennifer.sterner-allison@choa.org
 
 
When: Before March 31, 2017
 
WHY: The future of our profession needs the participation and contribution of its leaders.

Legislative Update

The Georgia General Assembly has been in session since January 10th and is approaching the half-way point for the 2017 session.  As of this writing, the GSHP Legislative Committee is tracking 15 house and senate bills relating to medication use, pharmacy practice, and/or hospitals and health systems.  A summary of the individual bills and links to review the proposed legislation via The General Assembly website is available via GSHP by clicking on this link: http://www.gshp.org/issues_state.aspx .  Topics under consideration this year include but are not limited to: regulation and licensure of PBMs; requirements for both prescribers and dispensers and controlled substances prescriptions, e.g. limiting new first time prescriptions to 5 days; as well revisions to medical cannabis regulations and indications for use. 
 
Please address any questions to our committee co-chairs, Rondell Jaggers (rjaggers@gmh.edu) or Megan Freeman (megan.freeman@northside.com)

Illuminated waterfront Savannah Historic District at night
Save the Date

GSHP Spring Meeting

March 24-26, 2017
Marriott Riverfront
Savannah, GA

Agenda

Hotel Reservations 


A wall calendar with tear-away pages, and words that read Save the Date
Call for Resolutions for the
2017 ASHP House of Delegates
 
 
The Call for Resolutions for the 2017 House of Delegates Session is open. Deadline for submissions is March 6, 2017.
 
The ASHP policy development process allows professional policies to originate in three ways:
  • from ASHP councils, which meet in July, September and February;
  • from executive committees of sections and forums; and
  • directly from ASHP members via Resolutions.
 
ASHP's Resolution process offers a mechanism for ASHP members to have input into the House of Delegates. Resolutions require sponsorship by two active members, who need not be delegates. All Resolutions must be submitted 90 days in advance of the House session, which is March 6, 2017. Resolutions must be submitted via the online Resolutions Submission Form.
 
Before submitting a Resolution, members are encouraged to familiarize themselves with the Guidelines for Submitting Resolutions and existing ASHP policy on the proposed topic. New policy recommendations that resulted from September's ASHP Policy Week and are currently under Board consideration are available on the ASHP Connect House of Delegates Community site.
 
We appreciate your interest and participation in the policymaking process of ASHP. If you have any questions about the process for submitting a Resolution, you are encouraged to contact the Chair of the House of Delegates at hodchair@ashp.org .


Call for Posters - GSHP Spring Meeting-Sign up NOW!

This is your opportunity to share your results with pharmacy colleagues from around Georgia at the GSHP Spring Meeting Poster Session in Savannah on Saturday, March 25, 2017. Posters highlighting innovative services, evaluations and pharmacy practice model change initiatives are especially encouraged. Encore presentations from national meetings (ASHP, ACCP, etc.) are accepted.  Presenting a peer-reviewed poster is an ideal professional development activity for preceptors, both seasoned and new practitioners, residents and students. The primary (first) poster presenter must be a GSHP member and results must be included on abstract to be accepted.  Research-in-progress abstracts with background and methods only will not be accepted for the poster awards but can present.  Pharmacy students and residents are especially encouraged to participate.   Students and residents presenting posters will receive free meeting registration if they are the primary (first author) on the poster.  Please let us know if you are able to attend the entire program or Saturday only).

The GSHP Education Committee will be evaluating ALL posters submitted for recognition and designation as "Outstanding GSHP Poster".   There will be three categories recognized: 1) Best Pharmacy Student Poster; 2) Best Pharmacy Resident Poster; 3) Best Pharmacy Practitioner Poster based on the credentials of the primary (first) author.  The  scoring rubric by which the posters will be judged will be available on the GSHP website.    
The deadline for submission of abstracts is at 12:00 Noon on March 1st.

To submit your poster abstract, or for questions, contact Marjorie Phillips, GSHP Poster Session Coordinator at:  mphillip@augusta.edu

Each abstract email submission must be entered on the  abstract form (attached) and contain the following:

1)    Brief descriptive title (use title case)
2)    Author information. Include full name, professional credentials and institutional affiliation (i.e., health care organization or college name) author(s), email address for corresponding author/presenter.
3)    Body of the abstract with the following headings: Purpose, Methods, Results and Conclusions.  
4)   The submitted abstract must fit on the attached form and be no more than 300 words.
5)    Abstract should be written using calibri font and should be 11-point font.  Do not include tables, graphs, or illustrations in abstract.  Spell out all pharmaceutical acronyms and special symbols (e.g., < or >).  
6)    Include which poster category applies (should be based only on first author's credentials)
  • Pharmacy Student Poster
  • Pharmacy Resident Poster
  • Pharmacy Practitioner Poster
7)    Include submission type
  • Descriptive report - describes new, improved, or innovative roles or services in pharmacy practice, or case report.
  • Evaluative study report - describes original research including clinical research, drug effects in humans, drug use evaluations, and evaluations of clinical pharmacy services
Clinical Articles

High Dose Loperamide Can Result in Serious Heart Complications

Authors: Neil Patel, Student Pharmacist Mercer University, and Kendra Manigault, PharmD., BCPS, BCACP, CDE, Clinical Assistant Professor, Mercer University

Opioid abuse is a major problem in the United States. In 2014, 4.3 million Americans aged 12 and older admitted to current, nonmedical use of prescription pain relievers. [1] Opioid abuse can lead to accidental overdose death, increased healthcare, crime involvement, and additional addiction (i.e. heroin).2,3 Several medications (i.e. methadone, buprenorphine, naltrexone) are available to help wean patients off of opioids; however, costs and/or enrollment in specialized monitoring programs may deter patients from obtaining these prescription medications. Additionally, opioid medications are becoming harder to obtain, likely due to prescriber education and abuse-deterrent formulations.4 As a result, individuals addicted to opioid medications may seek alternative remedies to ease withdrawal symptoms despite potential health repercussions. [2], [3] 
Loperamide (Imodium®) is an antidiarrheal and peripheral µ-opioid receptor agonist available over the counter. After its approval, loperamide was classified as a Schedule V controlled substance due to its mechanism action. This restriction was later removed because it was considered to have "extremely low abuse potential" due to its poor central nervous system (CNS) penetration and low bioavailability.5 Major side effects reported are constipation, dizziness, abdominal cramps and nausea. At therapeutic doses, this drug is considered safe and well tolerated. At supratherapeutic doses, however, loperamide is able to cross the blood by way of P-glycoprotein (Pgp) saturation and/or inhibition.6 Higher than normal loperamide levels may also result due to interactions with the cytochrome P450 isozymes, CYP3A4 and CYP2C8, because these isozymes play an important role in its metabolism.5 Because loperamide is easy to obtain, cheap, and unregulated, it has been referred to as the "poor man's methadone."7 Online posts discussing loperamide's use to alleviate opioid withdrawal symptoms has been evaluated in a web-based review of the extra-medical use of loperamide. This review highlights the increased discussions relating to the illicit use of loperamide by the often hard-to-reach population of drug abusers.7 The national poison control center reported a 71% increase in the number of calls related to intentional loperamide overdose between the years of 2011 and 2014.8,9 These calls involved case reports which led to serious cardiac issues. The mechanism behind this cardiotoxicity is not yet completely understood, however there are some theories. One proposed mechanism deals with the chemical structure of the compound. Loperamide is a piperidine derivative. These drugs have been shown to increase the action potential duration and the effective refractory period in animal studies.10 At large doses, piperidines can act as sodium channel blockers. Additionally, the ability of loperamide to block L-type Ca2+ channels at high doses has been shown in previous studies.10 Supratherapeutic concentrations are required for these hypothetical mechanism to result in cardiotoxicity.
Several cases have been reported in the literature detailing the potential risks of supratherapeutic doses of loperamide. A 25-year-old woman with a prior history of substance abuse first visited the emergency department due to abdominal pain and was admitted to the hospital on two separate occasion weeks later, first due to a syncope episode while driving and later due to nausea and vomiting.10 Electrocardiograms (ECGs) taken during the patient's hospital visits showed abnormalities at each visit. During the second admission, the patient experienced multiple episodes of ventricular tachycardia. The patient denied use of over-the-counter medications or illicit substances and her toxicology report was negative for drugs of abuse. Upon investigation, multiple empty bottles of loperamide were found at her house, and her blood level of loperamide was found to be markedly elevated. The physicians reported this patient case was a classic example of substitutive behavior in which the loperamide was abused in place of stronger opioids. 10 Two months after her second discharge, the patient was readmitted for cardiopulmonary arrest attributed to continued loperamide abuse, from which she died 18 hours post admission.Another case involved a 54-year-old woman who reported taking loperamide for diarrhea.11 The patient reported two episodes of syncope prior to hospital admission. Upon arrival to the hospital, she presented with multiple episodes of sinus pauses up to 5 seconds and intermittent ventricular tachycardia. Her past medical history was significant for a cholecystectomy resulting in severe chronic diarrhea. The patient reported self-medicating her diarrhea with loperamide since her surgery 8 years prior. Over the course of a couple years, the patient titrated herself from the recommended maximum dose of loperamide (16 mg/day) to 72 capsules (144 mg) per day in two divided doses and maintained the regimen for around 2 years. During this time, the patient took nine times the maximum recommended dosage. 5 The patient received an implantable cardioverter-defibrillator and was discharged after six days. The patient was instructed to avoid loperamide and was placed on cholestyramine for her symptoms. Two months post discharge the patient had no ventricular tachycardia or bradycardia requiring intervention.11
As a result of multiple case reports, the FDA announced the potential of loperamide to cause serious heart problems in individuals misusing and/or abusing high doses of loperamide.12 These problems may manifest in the form of unexplained QT prolongation, Torsades de Pointes, ventricular tachycardia, cardiac arrest, or syncope. Since this is a relatively new discovery and because loperamide testing is not included in routine toxicology testing, the suspected loperamide death toll is higher than reported. Healthcare professionals should be aware of the potential serious cardiac adverse events involving loperamide. Patients should be advised of the signs and symptoms associated with cardiotoxicity including fainting, irregular heartbeats, or faster than normal heartbeat. Pharmacists can educate other healthcare practitioners about this new warning and review medications for potential drug-drug interactions involving CYP3A4, CYP2C8, and Pgp substrates.5 It is important that healthcare providers are aware of potential issues involving medications, especially common ones patients consider safe.

References:
1. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Surveyon Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration.
2. Stotts AL, Dodrill CL, Kosten TR. Opioid dependence treatment: options in pharmacotherapy. Expert Opin Pharmacother. 2009;10(11):1727-40.
3. Cameron D, Smith GA, Daniulaityte R, Sheth AP, Dave D, Chen L, Anand G, Carlson R, Watkins KZ, Falck R. PREDOSE: a semantic web platform for drug abuse epidemiology using social media. J Biomed Inform. 2013 Dec;46(6):985-997. doi: 10.1016/j.jbi.2013.07.007.
4. Ensuring Appropriate Opioid Management in a Community Pharmacy Setting. Pharmacist's Letter. Vol. 2016 Course No. 214. Self-study Course #160214.  
5. Loperamide [Package Insert]. Morgantown, WV: Mylan Pharmaceuticals Inc, 2006.
6. Crowe A, Wong P. Potential roles of P-gp and calcium channels in loperamide and diphenoxylate transport. Toxicol Appl Pharmacol. 2003;193(1):127-37.
7. Daniulaityte R, Carlson R, Falck R, et al. "I just wanted to tell you that loperamide WILL WORK": a web-based study of extra-medical use of loperamide. Drug Alcohol Depend. 2013;130(1-3):241-4.
8. Bronstein AC, Spyker DA, Cantilena LR, et al. 2011 Annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 29th annual report. Clin Toxicol (Phila). 2012;50:911-1164.
9. Mowry JB, Spyker DA, Brooks DE, et al. 2014 Annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd annual report.  Clin Toxicol (Phila). 2015;53: 962-1147.
10. Enakpene EO, Riaz IB, Shirazi FM, Raz Y, Indik JH. The long QT teaser: loperamide abuse. Am J Med. 2015;128(10):1083-6.
11. Spinner HL, Lonardo NW, Mulamalla R, Stehlik J. Ventricular tachycardia associated with high-dose chronic loperamide use. Pharmacotherapy 2015;35:234-8.
12. FDA Drug Safety Communication: FDA warns about serious heart problems with high doses of the antidiarrheal medicine loperamide (Imodium), including from abuse and misuse. http://www.fda.gov/Drugs/DrugSafety/ucm504617.htm  . Accessed July 20, 2016. 
 
 
A SPRINT to lower blood pressure goals:An evaluation of current guidelines and updated findings
 
Authors: Heather Corbo, Pharm.D. Candidate Class of 2017, Jaina Patel, Pharm.D. Candidate Class of 2017 and Maria Miller Thurston, Pharm.D., BCPS
 
Corresponding Author: Maria Miller Thurston, Pharm.D., BCPS, Clinical Assistant Professor, Mercer University College of Pharmacy, 3001 Mercer University Drive Atlanta, GA 30341, T: (678) 547-6253, F: (678) 547-6384, E: thurston_mm@mercer.edu
 
Introduction
Hypertension is a common medical condition in the United States and the prevalence increases with age.1 Hypertension can be a silent disease, which causes many people to go undiagnosed for years. This under diagnosis can lead to further complications such as stroke, myocardial infarction, and other renal and cardiac problems.  In 2014, The Eighth Joint national Committee Report (JNC 8) provided new goals and recommendations in the updated guideline.2 However, experts in the field have mixed reviews about these updated recommendations because of the less stringent goals for control of hypertension.  Clinical trials such as ACCORD, JATOS, HYVET, and most recently, SPRINT focus on blood pressure control and offer insight into evidenced-based goals of therapy.3,4,5,6  
 
Current Guideline Recommendations: JNC 8
The 2014 JNC 8 guideline is an evidence-based guideline used by clinicians in the management of hypertension. The emphasis was to evaluate and include randomized controlled trials as supporting evidence behind the JNC 8 recommendations. The guideline sought to answer three key clinical questions in adults with hypertension: 1) Does initiating antihypertensive pharmacologic therapy at specific blood pressure (BP) thresholds improve health outcomes? 2) Does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? 3) Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?2
 
The guideline raised the threshold on BP goals for certain populations and encourages use of agents with the most robust evidence of reducing cardiovascular risk. Treatment goals are based on patient age and the presence or absence of chronic kidney disease (CKD) or diabetes. The guideline recommends that pharmacologic treatment be initiated in patients age ≥ 60 with a diastolic BP ≥ 90 mmHg or systolic BP ≥ 150 mmHg, to achieve the goal BP of < 150/90 mm Hg. Furthermore, the BP goal is < 140/90 for patients who are < 60 years, have CKD and/or diabetes.2
 
In comparison to other guidelines, JNC 8 goal BP recommendations are either similar or less stringent. Comparing the changes from JNC 7 to JNC 8, JNC 7 did not have higher BP goals for older patients whereas JNC 8 creates a higher systolic BP threshold for those ≥ 60 years, without diabetes or CKD. The American Society of Hypertension/International Society of Hypertension (ASH/ISH) guideline also recommends a BP goal of < 150/90 mmHg in older patients, but this applies to patients ≥ 80 years as opposed to ≥ 60 years, as in JNC 8. Furthermore, JNC 8 does not make a distinction between patients with CKD based on presence or absence of albuminuria in regards to their goal BP, whereas other guidelines do. The ASH/ISH, European Society of Hypertension and of the European Society of Cardiology (ESH/ESC), and the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines all target a lower BP goal of < 130/80 to 90 mmHg based on presence of albuminuria.7,8,9,10
 
Clinical Trials that Influence Current and Future Guidelines
There are numerous clinical trials that were reviewed in developing the JNC 8 recommendations, including but not limited to, ACCORD, JATOS, and HYVET.4,5,6
 
Effects of Intensive Blood-Pressure Control in Type 2 Diabetes (ACCORD)
This was a randomized, controlled, open-label trial that investigated the effect of two systolic BP targets, < 120 or < 140 mmHg, on cardiovascular events among high-risk patients with type 2 diabetes mellitus (T2DM).4
 
Patients included in this trial were patients with T2DM who had a hemoglobin A1c ≥ 7.5% and were ≥ 40 years of age with cardiovascular disease or ≥ 55 years with evidence of atherosclerosis, albuminuria, left ventricular hypertrophy (LVH) or at least two additional risk factors for cardiovascular disease. Patients were excluded if they if they had a BMI of ≥ 45 kg/m2, serum creatinine > 1.5 mg/dL, and other serious illness. A total of 4,733 patients were randomized to either intensive treatment targeting a SBP < 120 mmHg (n=2362) or standard treatment targeting a SBP <140 mmHg (n=2371).4
 
The primary outcome was a composite of nonfatal myocardial infarction, nonfatal stroke or cardiovascular death. The rate of the outcome was 1.87% per year in the intensive treatment group compared to 2.09% in the standard treatment group (HR 0.88 [95% CI, 0.73-1.06], p=0.20), with fewer patients in the intensive treatment group experiencing the outcome; however, there was not a statistically significant difference noted. More serious adverse events attributed to antihypertensive treatment were evident in the intensive treatment group (3.3%) compared to the standard treatment group (1.27%). Therefore, the authors concluded that in patients with T2DM, intensive treatment targeting a SBP of < 120 mmHg did not significantly reduce the primary cardiovascular outcome.4
 
The Japanese Trial to Assess Optimal Systolic BP in Elderly Hypertensive Patients (JATOS)
The purpose of this study was to compare the effect of two years of strict versus mild antihypertensive treatment in elderly patients with hypertension. It was a prospective, randomized, open-label study. Approximately 4,418 patients were randomized to either strict treatment to maintain SBP < 140 mmHg (n=2,212) or mild treatment, SBP between ≥140 mmHg and < 160 mmHg (n=2,206). The majority of the participants were between 65-85 years of age and had a persistent SBP of 160 mmHg or higher. The baseline drug used was efonidipine hydrochloride (Landel®), a long-acting dihydropyridine calcium channel blocker approved in Japan.5,11 Participants received efonidipine plus other agents to achieve the strict and mild targets. The primary composite outcome was stroke, cardiac disease, vascular disease and renal failure. Although there was a significant difference in the lowering of BP, 9.7 mmHg and 3.3 mmHg in the strict and mild treatment groups respectively (both p<0.001), the incidence of the primary outcome was similar in both groups (p=0.99). Additionally, there was no significant difference in the rate of the primary outcome over two years of follow-up. Overall, this trial supports the JNC 8 recommendation to target SBP at 150 mmHg in patients ≥ 60 years of age.5
 
Hypertension in the Very Elderly Trial (HYVET)
This study investigated the effects of antihypertensive treatment in hypertensive patients ≥ 80 years of age. This study was a multicenter, randomized, double-blind, placebo-controlled study examining patients who were 80 years of age or older with persistent hypertension. Patients were excluded if they had a contraindication to any medications used in the trial, accelerated hypertension, secondary hypertension, or a hemorrhagic stroke in the previous 6 months. Patients were also excluded they had heart failure requiring treatment with antihypertensive medication, a serum creatinine >1.7 mg/dL, gout, clinical dementia or if they required nursing care.6
 
A total of 3,845 participants with a baseline SBP of > 160 mmHg were randomized to indapamide and placebo (n=1,912) or indapamide and perindopril (n=1,933), treated to a target BP of < 150/80 mmHg. The mean duration of follow-up was 1.8 years. The primary endpoint was any stroke, fatal or nonfatal. The rate of the primary outcome in the active and placebo treatment group was 12.4 vs. 17.7 per 1000 person-years, respectively. Although that reveals a 30% lower stroke rate in the intervention arm, the results were not statistically significant (p=0.06). In conclusion, indapamide and perindopril lowered BP further than indapamide and placebo. Furthermore, the combined active treatment reduced stroke-related deaths by 39%, cardiovascular-related deaths by 27% and heart failure rates by 64%. The improved outcomes in this trial are paramount behind the recommendation made by JNC 8 to achieve a SBP of < 150 mmHg in adults ≥ 60 years.6
 
Holes in Literature
Although many studies have been done in the past related to hypertension and effective management with medications, the target systolic BP goals were still debated by many healthcare professionals, even at the time of JNC 8 publication. A large clinical trial was needed to assess systolic values associated with cardiovascular outcomes in order to further evaluate which goals are most appropriate for certain patient subgroups.3,13
 
A Randomized Trial of Intensive versus Standard BP Control (SPRINT)
A recent study: A Randomized Trial of Intensive versus Standard BP Control (SPRINT) provided additional insight on BP control related to systolic BP values.  The SPRINT trial was a multicenter, randomized, controlled, open-label trial with the goal to determine if stricter systolic BP control would be more beneficial than the current recommendations provided by JNC 8. The inclusion criteria for the study is as follows: a systolic BP ranging from 130-180 mmHg with the exact value/range dependent upon the number of current anti-hypertensive medications the patient was taking.  Patients were also required to have at least one of the following: clinical or subclinical cardiovascular disease, chronic kidney disease in the past 6 months, a 10 year ASCVD risk of 15% or greater, or be 75 years of age or older. Patients with diabetes mellitus, known secondary causes of hypertension, history of stroke, symptomatic heart failure within the past six months, polycystic kidney disease, and/or a one minute standing systolic BP of less than 110 mm Hg were excluded from the trial.3  
 
The primary outcome was any major cardiovascular event (MI, non-MI acute coronary syndrome, stroke, heart failure, or death attributed to CVD).  9,361 participants were enrolled in the study with 57.7% of the study population being white, 31.1% black, and an age range of 58.5-84 years old.  The participants were assigned to either the intensive group (systolic BP target of < 120 mm Hg) or the standard group (systolic BP target of < 140 mm Hg).  The primary outcome was seen in 5.2% of patients in the intensive group and 6.8% in the standard group (p <0.001). The most common adverse events (intensive vs. standard) percentages are as follows: hypotension (2.4 vs. 1.4, p=0.001), syncope (2.3 vs. 1.7, p=0.05), electrolyte abnormalities (3.1 vs. 2.3, p=0.02), and acute kidney injury (4.1 vs. 2.5, p<0.001).3
 
The SPRINT trial was terminated early due to positive benefit with stricter control.3, 12 The authors of this trial concluded that targeting a SBP of < 120 mm Hg, compared to less than 140 mm Hg, in patients that were at risk for cardiovascular events, but did not have diabetes, resulted in lower rates of both fatal and non-fatal events.3
 
Implications for Clinical Practice
Most clinicians currently utilize JNC 8 in practice, but expert consensus regarding guideline-direct BP goals in lacking. Experts in the field of medicine and pharmacy, for the most part, agree that the SPRINT trial was a well-designed and executed study that will have major implications in the future of hypertension management.  However, one weaknesses of the study stems from the exclusion criteria; patients with diabetes and/or history of stroke were excluded. This leads some practitioners to feel that problems could arise when applying the results in real-life practice.9 Additionally, the ACCORD trial and the SPRINT trial demonstrated confounding results.  However, the study designs were different and ACCORD included diabetic patients. The ACCORD trial also had a smaller study population than SPRINT.  Overall, most experts found the results of the SPRINT trial significant due to the number needed to treat associated with the primary outcome.  Also, many of the patients that were older than 75 years old and had cardiovascular risk showed benefit from stricter SBP goals, which could impact future guidelines. Clinicians likely plan to apply these stricter SBP goals to appropriate patient populations, and experts are currently deciding how to update the hypertension guidelines for such patient populations.13
 
References
  1. Yoon SS, Fryar CD, Carroll MD. Hypertension prevalence and control among adults: United States, 2011-2014. NCHS data brief, no 220. Hyattsville, MD: National Center for Health Statistics. 2015. Retrieved from: http://www.cdc.gov/nchs/products/databriefs/db220.htm. Accessed on September 24, 2016.
  2. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High BP in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
  3. The SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015; 373:2103-16
  4. Beckett NS, Peters R, Fletcher A, et al. Treatment of hypertension in patients 80 years of age or older. The New England Journal of Medicine. 2008. 358(18):1887-1898.
  5. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension. Eur Heart J 2013:31:1925-38. DOI: 10.1093/eurheartj/eht.151
  6. Gerstein HC, Miller M, Byington R, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575-85. DOI: 10.1056/NEJMoa1001286.
  7. Goto Y, Ishii M, Saruta T, et al. Principal results of the Japanese trial to assess optimal systolic BP in elderly hypertensive patients (JATOS). Hypertens Res. 2008;31(12):2115-2127.
  8. Kovell LC, Ahmed HM, Misra S, et al. US hypertension management guidelines: a review of the recent past and recommendations for the future. J Am Heart Assoc. 2015;4(12):e002315. doi:10.1161/JAHA.115.002315
  9. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community. A statement by the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH). J Clin Hypertens. 2014;16(1):14-26.
  10. Kidney Disease: Improving Global Outcomes (KDIGO) BP Work Group. KDIGO clinical practice guideline for the management of BP in chronic kidney disease. Kidney Int Suppl. 2012;2:337-414.
  11. Tanaka H, Shigenobu K. Efonidipine hydrochloride: a dual blocker of L- and T-type Ca(2+) channels. Cardiovascular Drug Reviews.2002. 20:81-92.
  12. MacLaughlin, Eric J. Pulling Ahead After a SPRINT - Evidence for Lower BP Goals. Retrieved from: http://www.iforumrx.org/node/318. Accessed on September 24, 2016 
  13. Eagle, Kim. The SPRINT trial: Implications for your practice. American College of Cardiology. Retrieved from: http://www.acc.org/latest-in-cardiology/features/sprint-trial-hub?w_nav=S. Accessed on September 24, 2016.

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