Pharmacist-Driven Prescribing Significantly Lowers Blood Pressure vs Usual Care

June 17, 2015

EDMONTON, AB ( updated June 22 ) — Results from a new randomized, controlled trial suggests that pharmacists might play an expanded role in treating and managing patients with elevated blood pressure[1].

Individuals receiving "enhanced" pharmacist care, which authorized pharmacists to independently prescribe antihypertensive drug therapy and to titrate medications, if necessary, had significantly larger reductions in systolic and diastolic blood pressure at 6 months when compared with physician-directed usual care.

Those randomized to the enhanced pharmacist-treatment arm were also two times more likely than those treated conventionally to achieve the Canadian Hypertension Education Program (CHEP) recommended blood-pressure targets.

Led by Dr Ross Tsuyuki (University of Alberta, Edmonton), the study, which is published online June 10, 2015 in Circulation, "supports recent efforts to expand pharmacists' scope of practice to include medication-management activities in an effort to address clinical inertia in hypertension management."

To heartwire from Medscape, Tsuyuki said they were excited by the results and the public-health implications of the findings. The degree of blood-pressure lowering observed in the study—a between-group difference of 6.6 mm Hg vs usual care—would be expected to reduce the risk of stroke by approximately 40%, said Tsuyuki. "For policymakers who are serious about tackling the burden of hypertension, it's exciting that you could have 290,000 [pharmacist] allies in the US and 40,000 in Canada," he said.

Pharmacist Prescribing in Canada

In Alberta, where the study was performed, pharmacists are allowed to prescribe antihypertensive medication for patients. Two other Canadian provinces—Manitoba and New Brunswick—have also followed suit with independent pharmacist prescribing. In the UK, pharmacists have independently prescribed a broad range of medications for different conditions since 2006.

The study, known as RxACTION, included 248 patients, with 181 randomized to the intervention arm and 67 to usual care, from 23 community pharmacies. The intervention arm consisted of the pharmacist's assessment of the patient's cardiovascular risk and allowed the pharmacist to review all antihypertensive medications and prescribe new therapies/titrate dosages if necessary. In both the usual-care and enhanced-pharmacist-intervention arms, patients were counseled about lifestyle and given written information about hypertension developed by CHEP.

At baseline, the mean blood pressure was 150/84 mm Hg, and 78% of patients were currently taking antihypertensive medications. Those who were already taking blood-pressure medication were older and were significantly more likely to have other cardiovascular comorbidities, such as a prior history of MI, atrial fibrillation, and dyslipidemia, among others.

Over the 6-month period, systolic blood pressure was reduced 18.3 mm Hg in the intervention arm and 11.8 mm Hg in the usual-care arm, a statistically significant difference (P=0.0006). Similarly, diastolic blood pressure was reduced 8.0 mm Hg in the pharmacist-directed-care arm and 4.9 mm Hg in the usual-care arm, a difference of 3.2 mm Hg that was also statistically significant (P=0.01). Regarding the CHEP blood-pressure targets, 58% in the intervention arm and 37% treated with usual care were considered to have their blood pressure adequately controlled (P=0.02).

The pharmacists initiated 103 new antihypertensive medications in the patients, made 94 dose changes, the vast majority being increases in dose, and stopped 76 antihypertensive medications. Another 12 patients were prescribed low-dose aspirin, and a statin was started by the pharmacist in 14 subjects.

To heartwire , Tsuyuki said there is some "understandable angst about pharmacists taking on patient care roles, but most of it is poorly informed." Pharmacist prescribing in Alberta is not done in a vacuum, he said, and prescribing pharmacists are in contact with all other healthcare professionals involved in the patient’s care. In doing so, the pharmacist explains the rationale for the prescribing activity and where appropriate, can send the patient to their family physician for follow-up. "Indeed, we were also careful to engage family physicians in each community to let them know what we were doing," said Tsuyuki. "This is a collaboration."

In an editorial[2], Dr Theresa Shireman (University of Kansas School of Medicine, Kansas City) notes that 30% of North Americans have hypertension, of whom half are uncontrolled. Over the past 20 years, however, there has been a "substantial body of evidence" documenting the effectiveness of a team-based approach incorporating pharmacists to manage hypertension. "Across the variety of interventions tested, the results have generated a rather consistent and compelling pattern of significant reductions in systolic and diastolic blood pressures when pharmacists are deployed to help manage blood pressure," she writes.

With the consistent signal of benefit, Shireman said the next steps should involve translating the findings to pharmacies throughout the US and beyond.

"Walk into nearly any community pharmacy in North America, and you will find an automated blood-pressure machine, usually parked in sight of the prescription department," she writes. "There is tremendous scale here if pharmacists will step out, review the numbers with the patient, and follow up on reducing our hypertension burden. What we really need to know is how to make this happen."

RxACTION was supported by grants from the Canadian Institutes of Health Research, Alberta Innovates—Health Solutions, Merck, the Canadian Foundation for Pharmacy, and the Cardiovascular Health and Stroke Strategic Clinical Network of Alberta Health Services. Tsuyuki has received research funds for investigator-initiated trials from AstraZeneca, Sanofi, and Merck and has provided consulting for PharmaSmart International and Boehringer Ingelheim. Disclosures for the coauthors are listed in the article. Shireman has reported she has no relevant financial relationships.

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