In a video posted in December 2018, , of Georgetown University and Director of MedStar Heart & Vascular Institute's Cardio-Oncology Program and Medical Director of the Cardiac Rehabilitation Program there, discussed chemotherapeutic-related hypertension, including which types of therapies are causing hypertension and how to manage patients. In this new video, Barac continues to offer insight on hypertension-related concerns, when to treat, and the best agents for management.
Following is a transcript of her remarks:
Management of hypertension in a cancer patient starts with realizing how does hypertension present? It presents very early. It presents more in patients who have preexisting diagnosis of hypertension, and it's directly related to the drug. For example, if a patient has a known diagnosis of hypertension, the patient will get, for example, sunitinib for renal cell carcinoma, which is an oral drug. We can expect that within the first week when they start sunitinib, blood pressure is going to go up by anywhere between 20 mmHg and 30 mmHg. Clinicians need to know this. The patient needs to know and the patient often does and is warned.
The treatment of hypertension needs to start right there and then. Therefore, in 2 or 3 weeks, the patient goes off of the drug for a week, blood pressure will go down, so we need to follow the patient.
With respect to the choice of antihypertensive agent, that has not been systematically studied. These are very challenging patients, who are primarily at risk for bad outcomes because of the aggressive cancer. Hypertension-related concerns have been mostly related to the need of stopping the drug if hypertension is difficult to control. Sometimes the blood pressure is going to 180, 190.
In clinical trials, the drug would be stopped and frequently so in clinical practice if we just cannot control it, it becomes unsafe. The risk of intracerebral hemorrhage with high blood pressure ... risk of heart failure grows with high blood pressure. It's important to try to preemptively manage.
Now regarding which medications to give, there is small evidence, mostly from mechanistic trials, that ACE inhibitors and angiotensin receptor inhibitors may be the first class of drugs to try in these patients, specifically in patients with renal cell carcinoma. There was a small benefit, and this is a retrospective analysis of clinical trials. There was a small benefit in patients who were treated with ACE or ARBs, or angiotensin receptor blockers, compared to patients who were treated with calcium channel blockers and beta blockers. Again, retrospective, look with all limitations, but that would be the first, perhaps, class of drugs to continue.
In this specific group, which often tried to avoid thiazide diuretics because of the risk of hypercalcemia in volume to the patient, a lot of it depends on the specific patient. Amlodipine would be, perhaps, the preferred calcium channel blocker as opposed to diltiazem, which is less favored because of the drug and drug interaction for the cytochrome P450.
These are sort of broad concepts to the patient, but ultimately, the most important thing is what we do know right now. Look for it, look for it early, diagnose it, tell the patient. The patients will often have sheets and go home with a blood pressure cuff with strict instructions that if the blood pressure goes, so increase the dose. Try to, perhaps, use ACE inhibitors, angiotensin receptor blockers, as a first line. If limited by kidney function or intolerance, amlodipine may be a second choice, also carvedilol.
Nebivolol has been speculated that it could be a good option based on the mechanistic aspects, so nitric oxide, but that has not been clinically tested.