HTN-LIPID-Protocol

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Chamberlain University College of Nursing *

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565

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Medicine

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Jan 9, 2024

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NR565 HTN Lipid Protocol 1 HYPERTENSION PROTOCOL: INITIAL VISIT 1) RATIONALE a) This protocol will assist in the differentiation between essential hypertension and renal artery stenosis to aid in the identification of patients in need of referral to nephrology to prevent further renal damage from an unidentified renal artery stenosis. The design of the protocol for UTI encompasses these principles. 2) SYMPTOMS a) HYPERTENSION i) Blood pressure >140/90 mmHg ii) Other possible subjective symptoms (1) Headache (2) Visual changes (3) Dyspnea (4) Chest pain (5) Sensory or motor deficit b) RENAL ARTERY STENOSIS i) Onset of hypertension age >55 years or <30 years ii) History of accelerated, malignant, or resistant hypertension iii) History of unexplained kidney dysfunction iv) History of multivessel coronary artery disease v) History of other peripheral vascular disease vi) Abdominal bruit vii)Sudden or unexplained recurrent pulmonary edema viii) Other possible factors (1) Absence of family history of hypertension (2) Other bruits (3) History of acute kidney injury after administration of ACE inhibitor or angiotensin II receptor antagonist (ARB) 3) HISTORY a) Continue with treatment of hypertension but consult supervising physician if patient has: i) History of accelerated, malignant, or resistant hypertension ii) History of unexplained kidney dysfunction iii) History of multivessel coronary artery disease iv) History of other peripheral vascular disease v) Abdominal bruit vi) Sudden or unexplained recurrent pulmonary edema 4) PHYSICAL EXAM a) Perform the following examinations: i) Vital Signs (blood pressure, pulse) ii) Auscultation for bruits (carotid, abdominal, and femoral)

NR565 HTN Lipid Protocol 2 iii) Palpation of thyroid iv) Cardiac v) Respiratory vi) Lower extremities for edema and pulses vii)Neurological b) Consult supervising physician if findings of: i) Abdominal bruit ii) Another bruit 5) LAB TESTS a) Metabolic panel i) Cholesterol ii) Blood sugar iii) Uric acid level b) Glomerular filtration rate c) Consult supervising physician if: i) GFR indicates chronic kidney disease (CKD) or renal failure 6) PHARMACOLOGICAL TREATMENT a) List the hypertension drug classifications and examples you would prescribe in order of treatment according to clinical practice guidelines without consideration of race or ethnicity: (Provide generic names for examples. Doses are not needed or required.) Drug Category/ Classification Example 1 Example 2 Example 3 Example 4 ACE Inhibitor (ACEI) Lisinopril Benazapril Fosinopril Quinapril Angiotensin Receptor Blocker (ARB) Candesartan Valsartan Losartan Olmesartan Thiazide Diuretic HCTZ Clorthalidone Indapamide Triamterene Calcium Channel Blocker (CCB) Amlodipine Nifedipine Diltiazen Verapamil Citation (Provide (Author, year) and not full reference): James et al., 2014 b) 1 st line pharmacological treatment if warranted in a non-African American patient after a thiazide diuretic has been given and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe to either add to existing treatment or replace a thiazide.) i) Drug: Amlodipine ii) Dose: 5mg iii) Route: Oral iv) Frequency: Once a day v) Instructions to provide patient: Take one tablet by mouth once daily vi) Caution/Precautions: Edema

NR565 HTN Lipid Protocol 3 vii)Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? Estimated cost for 5mg Amlodipine for 30-days at Walmart would cost $9.00 (GoodRX, 2023). viii) What patient education is needed for this drug? Take medication as prescribed at the same time each day. Avoid fast positional changes such as from a sit to stand position, may cause light headedness. If a dose is missed take it as soon as possible but if >12 hours late skip the dose. Citation (Provide (Author, year) and not full reference): Epocrates, 2023 c) 1 st line pharmacological treatment if warranted in an African American patient after a thiazide diuretic has been given and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe to either add to existing treatment or replace a thiazide.) i) Drug: Lisinopril ii) Dose: 5mg iii) Route: Oral iv) Frequency: Once a day v) Instructions to provide patient: Take one tablet my mouth once daily vi) Caution/Precautions: Cough, Angioedema vii)Using a source such as GoodRX, what is an estimated cost of this drug for a 30-day supply? 30 day supply of Lisinopril 5mg tablet is $4.00 at Walmart (GoodRX, 2023) viii) What patient education is needed for this drug?If pregnancy is suspected stop taking this medication and notify your provider. Lisinopril cannot be taken within 36 hours of medications containing sacubitril. Do not take lisinopril if you have a history of angioedema. Citation (Provide (Author, year) and not full reference): Epocrates, 2023 d) When should ACEIs be used in African Americans according to the course textbook? Include a citation with matching reference in the reference section. i) Type I diabetes with proteinuria ii) Hypertensive nephrosclerosis iii) BP is uncontrolled with (single drug) thiazide diuretic + ACEI, or CCP + ACEI. Citation (Provide (Author, year) and not full reference): Rosenthal, L & Burcham, J., 2021BP e) Prescribe statin therapy according to the prescription table which follows: Complete the following table to indicate which drug at which dose would be used for different intensity statin therapies to treat high low-density lipoprotein (LDL) as noted in the course textbook. Each drug listed in each column should be a different drug with a specific dose or dose rans as indicated in your course textbook. High-Intensity Therapy Moderate-Intensity Therapy Low-Intensity Therapy

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NR565 HTN Lipid Protocol 4 Daily dose lowers LDL-C on average by >=50% Daily dose lowers LDL-C on average by 30% - <50% Daily dose lowers LDL-C on average by <30% Drug/Dose 1: Atorvastatin: 40- 80mg Drug/Dose 2: Rosuvastatin: 20mg Drug/Dose 1: Atorvastatin: 10mg Drug/Dose 2:Rosuvastatin 10mg Drug/Dose 3:Simvastatin 20-40mg Drug/Dose 4:Pravastatin 40mg Drug/Dose 5:Lovastatin 40mg Drug/Dose 1: Simvastatin 10mg Drug/Dose 2:Pravastatin 10-20mg Drug/Dose 3:Lovastatin 20mg What patient education is needed when prescribing statins? Consider any patient counseling points and adverse effects they may need to be aware of or report if experienced. Cholesterol levels should be monitored- checked once a month Should not be used if pregnant or suspected pregnancy or in individuals with viral or alcoholic hepatitis. Muscle pain or tenderness should be reported immediately to provider due to risk of rhabdomyolysis. Citation (Provide (Author, year) and not full reference): Rosenthal, L. & Burcham, J., 2021 7) TREATMENT MONITORING a) How long until a follow up appointment should be done with patient? 4 weeks b) Monitoring needs for blood pressure medication prescribed: (Include physical assessments as well as lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.) i) Physical Assessments: Chest pain, dizziness, vision changes, lightheaded ii) Labs/Diagnostics: CMP, Renal function, liver function Citation (Provide (Author, year) and not full reference): (Grundy, S., et al., 2018) c) Monitoring needs for statin medication prescribed: (Include physical assessments as well as lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.) i) Physical Assessments: Myalgias ii) Labs/Diagnostics: Lipid panel, liver function (CMP/LFTs) Citation (Provide (Author, year) and not full reference): Grundy, S., et al., 2018 8) TREATMENT FAILURE

NR565 HTN Lipid Protocol 5 a) How will you know if the treatment is not working or needs to progress? Include a citation with matching reference in the reference section. BP is uncontrolled (<140/90), and no improvement in LDL/HDL as levels continue to be outside of normal limits. LDL would continue to high, and HDL would remain low. Citation (Provide (Author, year) and not full reference): Grundy, S., et al., 2018 References

NR565 HTN Lipid Protocol 6 Epocrates. (2023). Amlodipine. https://www.epocrates.com/online/drugs/1052/amlodipine Epocrates. (2023). Lisinopril. https://www.epocrates.com/online/drugs/1133/lisinopril#black- box-warnings GoodRX. (2023). Amlodipine. https://www.goodrx.com/amlodipine?c=homepage-lander-sem- 7&optly_audience=%257bnextbestaction %257d&utm_campaign=127243741&utm_content=121594327805&utm_source=google &utm_medium=cpc&utm_term=kwd- 1302066403591&gclid=EAIaIQobChMIr8LbgrzRggMVaiitBh2hsQNsEAAYASAAEgLr 7PD_BwE&gclsrc=aw.ds&ajs_prop_experiment_name=NFD%2520Promo %2520Drawer&ajs_prop_variation_name=Variation_1&ajs_prop_path=%2Fgo %2Fhomepage-lander-sem-7-tl- 2&form=tablet&dosage=5mg&quantity=30&label_override=amlodipine GoodRX. (2023). Lisinopril. https://www.goodrx.com/lisinopril?c=homepage-lander-sem- 7&optly_audience=%257bnextbestaction %257d&utm_campaign=127243741&utm_content=7699746781&utm_source=google&utm_ medium=cpc&utm_term=kwd- 54255549541&gclid=EAIaIQobChMInsT1oM3RggMVEwd9Ch29AAZsEAAYASAAEgLbh fD_BwE&gclsrc=aw.ds&ajs_prop_experiment_name=NFD%2520Promo %2520Drawer&ajs_prop_variation_name=Variation_1&ajs_prop_path=%2Fgo %2Fhomepage-lander-sem-7-tl- 2&ppid=1&form=tablet&dosage=5mg&quantity=30&label_override=lisinopril Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A.,

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NR565 HTN Lipid Protocol 7 Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., … Yeboah, J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology , 73 (24), 3168–3209. https://doi.org/10.1016/j.jacc.2018.11.002 James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., Lackland, D. T., LeFevre, M. L., MacKenzie, T. D., Ogedegbe, O., Smith, S. C., Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T., Narva, A. S., & Ortiz, E. (2014). 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA : The Journal of the American Medical Association , 311 (5), 507–520. https://doi.org/10.1001/jama.2013.284427 Rosenthal, L. & Burcham, J. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2 nd ed.). Elsevier.

HTN-LIPID-Protocol

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