Patient Case

Mr. Engle, a 70-year-old patient, comes to the pharmacy with his wife to fill a new prescription. The pharmacist notices that the prescription is for the same antihypertensive agent that Mr. Engle has been taking, but now he will be taking a higher strength. As the pharmacist is entering the prescription information into the computer, she chats with Mr. Engle and his wife, asking how they are feeling and how their grandchildren are doing.

Mr. Engle comments that they are feeling well, while Mrs. Engle pulls out pictures of all of their grandchildren. After discussing each picture with the pharmacist, Mrs. Engle asks if the pharmacist could provide them with some advice. Mrs. Engle asks if the pharmacist knows of any place she and her husband can get more information on controlling his high blood pressure. They realize the importance of controlling his blood pressure but feel that they “just don’t know enough.” She explains that they have a difficult time reading due to failing eyesight but would like to better understand what to do for him. They also mention that their memories are not as good as they used to be, and their doctor has a tendency to talk a little fast. So even though he does explain some things, they really feel they need more information and a better understanding of hypertension. Mr. Engle’s physician schedules appointments for him every six months. They are looking for a way to have more frequent interaction with someone who can better educate them, along with checking to see that they are successful in reducing his blood pressure.

Discussion

Who could be better to accomplish this than the pharmacist? The pharmacist interacts with these patients on a monthly basis when they refill their prescriptions. When the Engles come to the pharmacy to pick up their prescriptions, the pharmacist can spend a few minutes with them to evaluate their situation. He or she can evaluate Mr. Engle’s adherence to his medication therapy. Since the Engles admit that they have a difficult time retaining information, he or she can remind them about lifestyle modifications that can reduce blood pressure. He or she can also check Mr. Engle’s blood pressure to determine if it has improved. The pharmacist also can encourage them to practice home blood pressure monitoring and select a monitor that will be a good match for their needs.

lifestyle modifications are essential. The use of multiple lifestyle modifications has been shown to improve the likelihood of achieving blood pressure goals. ¹¹

Although the pharmacist may wish the patient to implement all of these modifications at once, the initial goal should be to work with the patient to make small changes. Setting impossibly high expectations for the patient will not be realistic, setting the patient up for failure. Examples of realistic goals may include reducing cigarettes smoked per day, walking 15 minutes, switching to lower-salt versions of their favorite foods or adding one to two servings of fruits or vegetables per day. At each visit, the pharmacist can re-evaluate how well the patient has done with these modifications. The pharmacist and patient can work to add new ones if successful. If the patient was unable to achieve those goals, the pharmacist and patient should work together to problem solve on how to overcome barriers or, if necessary, develop new goals that the patient believes are achievable.

harmful in many older individuals and those with kidney disorders because the kidneys become less able to remove potassium from the blood.

The JNC- 7 guidelines also recommend reduction of daily sodium intake to less than 2. 4 grams, compared with the average intake of 3. 5 grams. Reductions in sodium intake have been shown to reduce systolic blood pressure by 2 to 4 mmHg. When combined with the DASH diet, the reductions in blood pressure are even greater.

with patients to help improve their health outcomes. To accomplish this, pharmacists should make sure pharmacy technicians know what kinds of situations warrant pharmacist counseling and have a system for tagging prescriptions to alert the technician that the pharmacist wants to speak to a patient when he or comes in to pick up the medication. Pharmacists also should help technicians regarding how to initiate communication with patients. Asking patients a “closed” question such as “Do you have any questions?” is likely to result in a yes or no answer—and in this case most likely a no. Instead, a question such as “What were the directions your physician gave you for taking this medication?” is more likely to lead to conversation and, at a minimum, establish whether the patient understands the directions. Patients also should be encouraged to call back if they have any questions when they get home. This is important, as some patients may not think of their questions until later, and others may be hesitant to talk in public, either due to a desire for privacy or concern that others are waiting for their medications.

The pharmacist should remember that patient-centered services do not have to be offered without reimbursement. Under medication therapy management (MTM) services, the pharmacist can receive payment for evaluations of patients with multiple medications. The pharmacist should be familiar with and prepared to participate in the MTM services being offered through his or her store.

 

IMPORTANCE OF

LIFESTYLE MODIFICATIONS

Lifestyle modifications play an important role in the prevention and treatment of hypertension. The pharmacist should recommend these modifications to patients who have prehypertension or hypertension. For patients with prehypertension, these lifestyle modifications may help delay or prevent the progression to stage 1 hypertension. For patients with hypertension, lifestyle modifications are utilized in combination with medications to control blood pressure. The pharmacist should reiterate to patients that medication alone often will not control blood pressure, so these

Dietary changes

A key element of blood pressure control is diet. Studies involving the DASH (Dietary Approaches to Stop Hypertension) diet have shown beneficial effects on reducing blood pressure.¹² The DASH diet is rich in fruits, vegetables, fat-free or low-fat milk and milk products, whole grain foods, fish, poultry, beans, seeds and nuts. The diet also contains less salt and sodium, sweets, added sugars, sugar-containing beverages, fats and red meats. This diet was shown to reduce blood pressure in virtually all subgroups regardless of sex, age, race, body mass index, alcohol intake or hypertension status. It is particularly effective in lowering blood pressure in African-Americans and individuals who already have hypertension. The DASH diet typically reduces the systolic blood pressure by 8 to 14 mmHg. ¹³

The DASH study also found that increased potassium intake may help lower blood pressure, but this should only be done as part of other dietary changes. The pharmacist should recommend a daily intake of potassium of approximately 3,500 mg. Foods high in potassium include fruits, vegetables, dairy foods and fish. The pharmacist should be aware, however, that too much potassium can be

Weight loss and exercise

As mentioned earlier, obesity is a risk factor for hypertension. To control or prevent hypertension, the pharmacist can recommend weight loss. The pharmacist does not need to recommend the loss of exorbitant amounts of weight, because the loss of 10 pounds can reduce or prevent hypertension. The loss of 20 pounds can reduce systolic blood pressure by as much as 20 mmHg. ¹⁴

Even if patients do not want or need to lose weight, aerobic exercise also should be recommended for the reduction of blood pressure. On average, individuals will reduce systolic blood pressure by 8 to 9 mmHg with aerobic exercise. ¹⁵

 

Smoking and alcohol intake

The pharmacist should inquire about the patient’s smoking or alcoholic drinking habits. Smoking increases the risk of cardiovascular events, especially stroke and peripheral vascular disease. This is particularly true in individuals with hypertension, another risk factor for these conditions.

As a controllable risk factor for hypertension, heavy alcohol should be discouraged. The JNC- 7 guidelines recommend limiting daily alcohol intake to two drinks for men and one drink for women. One alcoholic drink is equivalent to 12 ounces of beer, 5 ounces of wine or 1. 5 ounces of 80-proof liquor. This can reduce systolic blood pressure by 2 to 4 mmHg. ¹⁶

 

BLOOD PRESSURE SCREENINGS

AND MONITORING

A simple, yet important, service that pharmacists can offer in their pharmacy is blood pressure screenings. These either can be done whenever a patient comes to the pharmacy, as a scheduled blood pressure screening clinic or as part of medication therapy management services.

12 • May/June 2008