Treating Hypertension in Haiti
in the aftermath of the earthquake
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HypertensionRxHaiti.com     Eric Roehm, M.D.

                 Treating Hypertension in Haiti-  a cardiologist's perspective

                           Including hypertension RX when laboratory tests are not available.

Lab available protocol      Lab not available protocol        BP Treatment protocols with           Cost Effective Therapy-   10¢/day for 3 drugs

Table of Contents

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Medical problems in Haiti are no longer primarily the problems of acute trauma, but rather the medical needs of a displaced population.  Many patients are presenting to medical clinics in Haiti with blood pressures of 200/115 who have never been on medication or who no longer have medication available following the earthquake.

Many of the medical clinics throughout Haiti are currently without facilities to run blood work, including electrolytes. The following is a perspective on treating hypertension in Haiti by a United States cardiologist who volunteered in Haiti the first week of March 2010. I had the privilege of working in Port-au-Prince with the Dorsainvil Foundation at one of their clinics during that time. 

                                        
Tent city in Port-au-Prince                                     
     

Table of Contents:                Top of Page

1.  What medications used for treating hypertension are particularly cost effective?

2.  What are a few of the medications previously used for treating hypertension in Haiti?

3. What is the way to tell a Haitian patient blood pressure results in a way that is understandable to the patient?

4.  What are some general considerations for treating hypertension in Haiti?

5. What are some specific medications to consider using, including therapeutic considerations and equivalent dosages of other medications in the same therapeutic class?

6.  Frequency of medication translated into English, French, & Kreyol.

7.  What are some cost effective drug combinations for treating hypertension? 

8. High Blood Pressure Treatment Protocol: If Lab unavailable

9. High Blood Pressure Treatment Protocol: Lab monitoring available

10. Why were verapamil, diltiazem, and clonidine not used as primary drugs in this protocol?

CAVEAT: All recommendations made here are with the understanding that the final  determination of therapy is made by the clinician seeing the patient and based on their own individual clinical judgment.                                                             

1. What medications used for treating hypertension are particularly cost effective for clinics to purchase? (Since blood pressure medications are continued long term, cost issues become quite important.)

Medication                     dosage             Quantity        Cost to a hospital
                                                                                       pharmacy-USA         

amlodipine                       10 mg              1000 pills               $25.00 
atenolol                            50 mg              1000 pills               $20.00
hydrochlorothiazide         25mg               1000 pills               $10.00 
                   (HCTZ) 
lisinopril                           20mg               1000 pills               $50.00 

       (amlodipine 2.5¢/pill, atenolol 2¢/pill, HCTZ 1¢/pill, lisinopril 5¢/pill)  
    

                                                                           

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2. What are a few of the medications previously used for treating hypertension in Haiti?

Hydrex is hydrochlorothiazide (HCTZ)
 (This same brand name is used for different medications throughout the world.)
Hydrex-terene  is HCTZ/triamterene (often 25mg/50mg)
enalapril (an ACE inhibitor) , metoprolol (a beta blocker)  

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3.  What is the way to tell a Haitian patient about their blood pressure results in a way that is understandable to the patient?     

 Blood pressure values are not recognized by patients in Haiti if they are told their blood pressure is 152/101. For the Haitian patient, the blood pressure nomenclature for this blood pressure is 15/10.

Similarly, if a BP is 178/92, the nomenclature recognized by the non medical Haitian population is 18/9. If a patient is informed that the blood pressure is 178/92 there will be no comprehension of what is said. If that same patient is told that their blood pressure is 18/9, the patient may well say on their own, “Oh, that blood pressure is too high.”  
 
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4. What are some general considerations in treating hypertension in Haiti?

1. All patients should be told to decrease salt intake and increase fruit and vegetable intake, if possible.

2. For patients started on hydrochlorothiazde (HCTZ), advise the following.
-Eat at least one piece of fruit daily: 
Either a banana, tomato, or citrus fruit (such as an orange).
(When a daily banana was initially recommended, many of the patients seen did not have access to bananas or did not like bananas, so the recommendation was broadened.)
(HCTZ is an effective BP medication which is a very mild diuretic and causes potassium-K+ loss and hence the above recommendation.)                                
                                    
3. Consider giving each medication in a separate plastic container with a label attached to the outside of the container detailing medication, dose, and frequency. (Plastic bags may be used as containers.)
Ask the patient to bring all containers of medication back with them to the clinic approximately 5 days before the medication runs out. This ensures that the doctors will know what medications the patient has been taking and be able to give appropriate additional medications.

4. If ½ pills are used, consider having someone at the clinic split the pill for the patient and place them in the plastic bag or other container to increase compliance. (Though some crumbling of the pills occurs, the expected increase in patient compliance outweighs this concern.) 

5. Tell the patient that if they develop an infectious gastroenteritis with either profuse diarrhea or sustained nausea and vomiting, they should hold the diuretic therapy (HCTZ) and ACE inhibitor therapy (lisinopril), until the gastroenteritis resolves.  Other blood pressure medicines may need to be held, but this issue is particularly important with HCTZ and ACE inhibitors.                   _                                                        Home

5.  What are some specific medications to consider
     using?  
(Includes therapeutic considerations and equivalent dosages of other medications in the same therapeutic class)  
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Amlodipine is a calcium channel blocker.  There is no need for laboratory monitoring with amlodipine.
Amlodipine is very similar in effects and side effects to extended release nifedipine. Both medications are the same type of calcium channel blockers.

Side effects: 
-Can cause lower extremity swelling (noncardiac) in a dose related fashion. A small amount of swelling is common and acceptable if not bothersome to the patient. Usually, swelling occurs during the first week. Swelling resolves if the medication is stopped.
-Can increase heart rate and provoke angina.  

Amlodipine 5mg qd is the therapeutic equivalent to nifedipine  (extended release) 30mg qd. (Amlodipine 10mg qd is the approximate therapeutic equivalent to nifedipine XR 60mg qd.) Amlodipine and extended release nifedipine are different medications but with similar efficacy and similar side effect profiles. The preferred agent is whichever is drug is cheaper. (Nifedipine that is not an extended release is not an equivalent agent.) If  both drugs are similar in price, obtain amlodipine, since there are more clinical trials documenting benefit.   
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Atenolol is a beta blocker. There is no need for laboratory monitoring with beta blockers.
Atenolol and metoprolol are in the same class of medications with similar efficacy.
Side effects: Can cause excessively slow heart rate, fatigue, and bronchospasm (asthma)- usually in individuals who already have this tendency. If patient has a pulse less than 60 beats per minute, would not prescribe this type of medication. Side effects of beta blockers are apparent through either history or physical exam. Beta blockers slow the heart rate to some degree in all patients and this is an expected effect. Beta blockers can also cause impotence.

Beta blockers can be less effective for treatment of hypertension in blacks.  However, there is so much mixed ancestry in Haiti that it is unclear whether this concern has significant general applicability to Haiti.

Atenolol 50 mg qd is the therapeutic equivalent of metoprolol 25mg bid. Atenolol 100mg qd is the therapeutic equivalent of metoprolol 50mg bid. (Atenolol has a longer half life and is cheaper for an equivalent therapeutic effect.)  

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Hydrochlorothiazide (HCTZ) is a blood pressure medication and a very mild diuretic. HCTZ can cause low potassium. Infrequently, HCTZ can cause decrease renal function. Usually, this is not a problem when used in low dosages. Older patients are more at risk, though HCTZ is usually tolerated even in this population, at low dosages. HCTZ is ideally used with laboratory monitoring.
HCTZ tends to increase the effectiveness of other blood pressure medication when used in combination with other medications.

Recommendations: Consider using HCTZ, even without laboratory, in very low dosages. (HCTZ 12.5mg or ½ of 25mg pill). The higher the dosage, the more likely that low potassium will result.
When HCTZ is used, recommend that the patient eat foods high in potassium.                                                   

HCTZ/triamterene tablets would be an option. Pills that can be split (rather than capsules), which allow for lower dosages of HCTZ to be used, are recommended. (The potassium losing characteristics of HCTZ are usually only partially made up by the weaker potassium sparing effects of triamterene.) However, HCTZ/triamterene combinations are considerably more expensive than HCTZ.    
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Lisinopril is an ACE inhibitor.  Lisinopril is ideally used with  laboratory monitoring.
Side effects: Can raise potassium levels excessively in some patients. Lisinopril can cause a significant decrease in renal function in some patients.  Risk for adverse renal effects greatly increases with age. Highest risk is for a patient with bilateral renal stenosis which most commonly occurs in the older patient with diffuse atherosclerosis.

Side effects:
Excessively elevated potassium. 
Decreased renal function.
Non productive cough.  Occurs in approximately 1 out of 20 patient and begins 1-2 weeks after starting the medication. The cough is annoying but will resolve approximately one week after the medication is stopped.
Not to be used in pregnancy.

Recommendations: Lisinopril can be considered for patients less than 55 years of age even if lab is not available, if needed in addition to other medication to control severe hypertension. The risks and benefits for each individual patient need to be considered, but severe hypertension that is not well controlled has major risks.

If a patient has recently previously taken enalapril without a problem in a lab monitored setting, then lisinopril can usually be restarted regardless of age.   

Lisinopril is in the same class of medication as enalapril.  Lisinopril 10mg qd is the therapeutic equivalent of enalapril 5mg bid. Lisinopril 20mg qd is the therapeutic equivalent of enalapril 10mg bid. (Lisinopril has a longer duration of action.) Enalapril is equally good for hypertensive control, but to achieve an equivalent effective dose, the expense of enalapril tends to be significantly more, at least in the United States. 
Captopril is also an ACE inhibitor and has the shortest half life. Captopril is similarly more expensive than lisinopril, with captopril 25mg bid being the approximate equivalent of lisinopril 10mg qd.
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Cost effective combinations of medications for hypertension (when laboratory monitoring available):

            Amlodipine/ HCTZ
            Amlodipine/Lisinopril
            Lisinopril/HCTZ
            Amlodipine/Lisinopril/HCTZ

(A beta blocker can be used with any of the above combinations.)
                                                                                                               

Angiotensin receptor blockers: As a footnote, there is a good deal of relatively small amounts of various angiotensin receptor blockers at some of the volunteer clinics in Haiti (as a result of samples given to doctors that were subsequently brought into the country).                           

Angiotensin receptor blockers have essentially the same effects as ACE inhibitors on the patient in regards to therapeutic effects. Angiotensin receptor blockers also have the same side effect profile except no problem with cough and a somewhat decreased risk of rare allergic reactions compared to ACE inhibitors.

Currently, there are no generic versions of these in the United States.  When they initially become available, these generic versions will tend to be much more expensive than lisinopril. Except for using up the samples of angiotensin receptor blockers as a temporary equivalent to lisinopril, they do not have much of a role in Haiti because of the cost. 

In order to allow the identification of these sample medications that are at some of the volunteer clinics, the following names are provided.

Brand names/(generic): Atacand/(candesartan), Avapro/(irbesartan), Diovan/(valsartan), Micardis/(telmisartan), Teveten/(eprosartan). (These are often combined with low dose hydrochlorothiazide--HCTZ.)

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Addendum:   Frequency of Medication
Translation into English, French, & Kreyol

English:  Take one pill a day-   qd
French:   Prendre une pilule(comprimé) par jour
Kreyol:   Pran yon grenn chak jou

English:  Take one pill twice a day-  bid
French:   Prendre une pilule(comprimé) deux fois par jour
Kreyol:   Pran yon grenn de fwa pa jou

English:  Take one pill three times a day-  tid
French:   Prendre une pilule(comprimé) trois fois par jour
Kreyol:   Pran yon grenn twa fwa pa jou

English:  Take one pill four times a day- qid
French:   Prendre une pilule(comprimé) quatre fois par jour
Kreyol:   Pran yon grenn kat fwa pa jou

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            Protocols for Treating the 
          Hypertensive Patient in Haiti

There are a number of ways to approach the treatment of the patient with high blood pressure when laboratory testing is not available. The following is one approach. 

Naturally, the particular circumstances of the individual patient and the experience and clinical judgment of the individual medical practioner will lead to modifications of this protocol or even a different treatment protocol altogether. However, in the hope of providing concrete and usable information to the volunteer medical health care provider working in Haiti, the following treatment protocol is offered as a potential starting point. 

The medications that are used in this protocol are very cost effective increasing the feasibility of making a sustainable effort to treat blood pressure in this setting.  (At wholesale prices, the cost of a 3 drug regimen is 10 cents/day.)                                                                                                   Home

HIGH BLOOD PRESSURE TREATMENT PROTOCOL 
WHEN LAB MONITORING NOT AVAILABLE 

             -      If a patient has a contraindication or a significant side effect develops with a medication, delete that medication from the protocol.                Home

-          The prescribing health care provider must be personally knowledgeable about the complete side effect profile of every medication prescribed. Final treatment decisions are to be made by the health care provider in the context of the particular conditions that exist for the individual patient.
 
-          All patients treated for hypertension should be advised to decrease salt intake and increase fruit and vegetable intake.

-          If the patient develops profuse diarrhea or sustained nausea and vomiting, hold diuretic (HCTZ) and ACE inhibitor therapy (lisinopril) until gastroenteritis resolves. (May need to hold other blood pressure medications as well.)                                                          
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   HTN TREATMENT FLOW CHART- IF NO LAB AVAILABLE:

  If systolic BP 140-149  or diastolic BP 90-95:

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         If  P > 80 or angina symptoms:

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          If   P ≤ 80 :

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         If  P > 80 or angina symptoms : 

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        If  P ≤ 80 : 

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       If  2 medications used with persistent hypertension:

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       If  3 medications used with persistent hypertension:  

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Atenolol¹ use can be limited by the development of bronchospasm or excessive slowing of heart rate, particularly if accompanied by lightheadness. (Atenolol always slows heart rate.) Beta blockers can also can impotence.

Beta blockers can be less effective for the treatment of hypertension in blacks. However, there is so much mixed ancestry in Haiti, that it is unclear whether this concern has significant general applicability to Haiti.

Verapamil² can not routinely be combined with atenolol (a beta blocker) or amlodipine. The slow release formulation of verapamil which is needed for hypertension is relatively much more expensive than the other medications in this protocol. Verapamil can cause excessive slowing of heart rate, constipation, and GI upset.

Amlodipine³ can at times cause the development of increased heart rate and angina.

HCTZ⁴ (hydrochlorothiazide) use in the unmonitored lab setting should be limited to a maximum dose of 25mg ½ pill qd. HCTZ use should always be accompanied by the advice to eat 1 additional piece of fruit daily (banana, tomato, or citrus fruit) to minimize potassium loss.

Lisinopril⁵ in this setting should not be used in patients with cachexia or dehydration because of the increased risk of renal dysfunction. Lisinopril tends to increase potassium levels. Lisinopril (as well as any other ACE inhibitor) is not to be used during pregnancy.

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