January 25, 2016
The well designed, run, and reported Systolic Blood Pressure Intervention Trial (SPRINT) is a landmark trial as it sets a target level for systolic blood pressure (SBP) for all patients independent of demographics, concomitant disease states, or SBP at baseline (difficult to treat patients were excluded). SPRINT enrolled 9,361 people with SBP of ≥130 mmHg and an increased cardiovascular risk (not including diabetes mellitus) to a target SBP of ≤ 120 mmHg (intensive treatment)or a target < 140 mmHg (standard treatment).1 Both groups were well matched without statistical or clinical differences. The mean blood pressure at baseline was 139.7/78.0 mmHg in the treatment groups. The mean pressure at one year was 121.4/68.7 mmHg in the intensive-treatment group and 136.2/76.3 mmHg in the standard-treatment group and maintained throughout the 3.26 years of follow-up. The mean number of blood pressure drugs was 2.8 and 1.8, respectively. The trial was stopped due to a 25% lower risk of major cardiovascular events (95% CI: 11-36) with consistent results across age, sex, race, medical history, and baseline blood pressure. The intensive-treatment group had a 27% lower risk of all-cause mortality. Serious events were higher in the intensive-treatment group, including hypotension, syncope, acute renal injury or failure, and electrolyte abnormalities, but the rate of events was relatively similar between groups at 38.3% compared to 37.1%, and injurious falls were similar.
So, what does this mean for clinical pharmacists? A tremendous opportunity to actively participate in lowering SBP across all patient populations now exists. Currently there are 13 billion annual visits or 530-570 visits daily to the 67,000 community pharmacies across the United States.2-3 Ninety-two percent of patients live within 1.6 miles of a pharmacy.3 Substantial effort and resources must be applied to implement these results across the United States to the 70 million+ persons with hypertension. Pharmacists can assume monitoring of blood pressure, medication therapy, and adverse events across the country. Monthly visits will be needed while patients are up-titrating their blood pressure—especially important with combination therapy, which was the norm in SPRINT. Pharmacists can provide consistent blood pressure monitoring and close monitoring of adverse effects, including point of care chemistry values. Pharmacists will be able to form relationships with their patients by having discussions about hypotension, tolerance to medications, and especially adherence to their regimens. Setting up practice agreements with prescribing practitioners to monitor their patients will offer an opportunity for advanced clinical practice opportunities with the potential to reimburse for services.
Wow, what an opportunity! Let’s take advantage of a landmark trial to implement clinical pharmacy practice.
Mark A. Munger, PharmD, FCCP, FACC, is a Professor of Pharmacotherapy and Adjunct Professor of Internal Medicine, at the University of Utah, where he also serves as the Associate Dean, Academic Affairs for the College of Pharmacy.
1. SPRINT Research Group, Wright JT Jr, Williamson JD, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103-2116.
2. Department of Health and Human Services. The adequacy of pharmacist supply: 2004 to 2030. bhpr.hrsa.gov. Accessed January 25, 20016.
3. Retail clinics 2015: growth of stores, consumer opinion, leading competitors, sales of products to clinics (diagnostic tests, pharmaceuticals, vaccines), clinic sales forecasts and trends. www.kalorainformation.com. Accessed January 25, 2016.