/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/delegationpractice-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/ambulatory-delegation-protocols/,

/clinical/cckm-tools/content/delegationpractice-protocols/ambulatory-delegation-protocols/name-122197-en.cckm

20180103

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Ambulatory Delegation Protocols

Primary Care Expanded Antihypertensive Medication Management - Adult - Ambulatory [164]

Primary Care Expanded Antihypertensive Medication Management - Adult - Ambulatory [164] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 164

Delegation Protocol Title:
Primary Care Expanded Antihypertensive Medication Management - Adult - Ambulatory

Delegation Protocol Applies To:
UW Health Primary Care Clinics

Target Patient Population:
Adult patients (> 18 years old) with a diagnosis of hypertension

Delegation Protocol Champions:
Jeffrey Huebner, MD – Department of Family Medicine
Matthew Anderson, MD – Department of Internal Medicine
James Stein, MD – Department of Medicine (Cardiology Division)

Delegation Protocol Reviewers:
Kate Hartkopf, PharmD, BCACP –Department of Pharmacy
Caroline Van Horn, PharmD, BCACP –Department of Pharmacy
Kristina Bennwitz, PharmD, BCACP –Department of Pharmacy
April Weaver, PharmD, BCACP –Department of Pharmacy
Julie Cable, PharmD, BCPS – Department of Pharmacy
Jessica Norman, PharmD – Department of Pharmacy

Responsible Department:
Department of Pharmacy

Purpose Statement:
To delegate authority from the provider managing the patient’s hypertension to clinic-based
pharmacists to initiate, titrate, and discontinue antihypertensive medications and enter orders for labs
to monitor therapy.

Who May Carry Out This Delegation Protocol:
1. UW Health pharmacists practicing as part of the health care team in UW Health clinics and/or
practicing at a UW Health retail pharmacy location trained in the use of this delegation protocol.
1.1. Training will include, but is not limited to the following:
1.1.1. Mentorship and training side-by-side with current pharmacist including:
• Validation of blood pressure measurement
• Validation of clinical competency
• Review of guidelines, any guideline updates, and current evidence-based medicine
2. Licensed trainee pharmacists (i.e. pharmacy resident) may conduct protocol activities under the
direct supervision of an experienced pharmacist who has completed the above requirements
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Guidelines for Implementation:
1. This protocol is initiated when patients have had a visit with the primary care provider within the
last 12 months and the provider has signed an order for “Pharmacist Antihypertensive Medication
Management Protocol”.
2. Contraindications to this protocol include:
2.1. Patients with Stage 4-5 Chronic Kidney Disease
2.2. Patients on dialysis
2.3. Pregnancy
2.4. Patients with congestive heart failure or LV ejection fraction ≤40%
3. Prescribing Provider Consultation
The supervising provider will be consulted for the presence of any potentially serious consequences
of hypertension or its treatment, including, but not limited to the following:
3.1. Symptoms of cerebral infarct or TIA
3.2. Patient experiences significant side effects/adverse reactions, such as significant edema, chest
pain, dyspnea, headache, vision changes, dizziness/lightheadedness
3.3. Any acute and/or potentially serious manifestations of atherosclerotic disease
3.4. Electrolyte abnormalities
3.4.1. Creatinine increase by > 0.3 mg/dL from baseline
3.4.2. Potassium > 5.1 or < 3.5 mmol/L
3.4.3. Sodium < 135 mmol/L
3.5. Abnormal vitals
3.5.1. Systolic blood pressure > 180 mmHg or < 100 mmHg
3.5.2. Diastolic blood pressure > 110 mmHg or < 60 mmHg
3.5.3. Heart rate consistently < 55 beats per minute or > 100 beats per minute
3.6. Any acute illness apparent at visit
3.7. Suspected undiagnosed secondary causes of hypertension
3.8. Other questions/issues as needed
4. Treatment Goals
4.1. Antihypertensives will be initiated and/or titrated to the patient-specific blood pressure goal
documented in the delegation order by the provider
4.2. Blood pressure goal will be documented in problem list by pharmacist when order is signed
5. Antihypertensive Management
5.1. Upon protocol activation, the pharmacist may initiate, titrate, and/or discontinue
antihypertensive therapy as clinically appropriate to attain and maintain goal blood pressure
5.1.1. Medications that may be initiated, titrated or discontinued by the clinic pharmacist are
included in Table 1
5.1.2. Patients will not be excluded from delegation protocol if they are taking medications
outside of those listed in Table 1
• Medications not included in Table 1 may be initiated, titrated, or discontinued by the
clinic pharmacist after consultation with the primary provider (e.g. vasodilators, non-
dihydropyridine calcium channel blockers, alpha blockers, alpha agonists, and
potassium-sparing diuretics).
5.1.3. Treatment decisions and medication adjustments will be made according to the UW
Health Diagnosis and Management of Hypertension – Adult – Ambulatory Clinical Practice
Guideline and Table 1
• Initiating Therapy
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

o Two medications may be initiated for patients with blood pressure
measurements greater than 20/10 mmHg above goal if patient is less than 80
years old
o The starting dose will be initiated according to the UW Health Diagnosis and
Management of Hypertension – Adult – Ambulatory Clinical Practice Guideline
and Table 1 unless completing a therapeutic interchange
o Pharmacist to take into consideration drug interactions, concomitant disease
states and previous history with antihypertensives, side effects or intolerances
o Treatment decisions will be based on insurance coverage and/or patient
preferences
• Adjusting Therapy
o Up to three medications may be independently initiated and modified by the
pharmacist, up to the maximum dose listed in Table 1 or maximally tolerated
dose
i. If patient requires more than 3 antihypertensive medications to achieve
blood pressure goal, the provider will be consulted. The provider will
initiate further medication therapy and the pharmacist may then
independently modify the antihypertensive medications up to the maximum
dose listed in Table 1 or maximally tolerated dose.
o Pharmacist will order and obtain labs according to the UW Health Diagnosis
and Management of Hypertension – Adult – Ambulatory Clinical Practice
Guideline and as indicated in Table 1
6. Patient counseling
6.1. Pharmacist will counsel patient on therapeutic lifestyle behaviors, including the DASH/DASH
sodium diet, and pharmacotherapy
7. Documentation
Pharmacist will log into department of the patient’s primary care provider and document:
7.1. Pertinent subjective and objective information, clinical assessment, and ultimate plan agreed
upon with patient
7.2. Follow-up plan, including next patient outreach and required labs in accordance to 5.1.3 above
8. Follow-up and Monitoring
8.1. The patient will return to clinic within 4 weeks (optimally 1-2 weeks) after antihypertensive
initiation and after each dose adjustment for a blood pressure reading and any needed labs in
accordance to 5.1.3 above
8.2. Pharmacist will refer patient back to primary care provider once patient has achieved blood
pressure goal
8.3. Patient will be referred back to primary care provider if patient is not engaged in care

Order Mode:
Medications: Protocol/Policy, Without Cosign
Laboratory Orders: Cosign Required, Protocol/Policy

References:
1. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High
Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Committee (JNC 8). JAMA. 2014;311:507-20.
http://jama.jamanetwork.com/article.aspx?articleid=1791497
2. UW Health. Hypertension – Adult – Clinical Practice Guideline (CPG). 2015.
https://uconnect.wisc.edu/clinical/cckm-tools/content/delegationpractice-protocols/ambulatory-
delegation-protocols/name-97398-en.cckm.
3. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High
Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National
Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.
4. National Institute for Health and Care Excellence. 2011 Hypertension: Clinical Management of
Primary Hypertension in Adults. CG127. London: National Institute for Health and Care Excellence.
5. American Diabetes Association. 2014 Clinical Practice Recommendations. doi: 10.2337/dc14-S014
Diabetes Care January 2014 vol. 37 no. Supplement 1 S14-S80
6. KDOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney
Disease. National Kidney Foundation 2004
7. Izzo, Joseph L; Sica, Domenic A, et al. Hypertension Primer. 4th Edition. American Heart Association
2008
8. VA/Dod Clinical Practice Guideline for Diagnosis and Management of Hypertension in the Primary
Care Setting. Version 2.0b- 2004
9. University of Cambridge Addenbrooke’s Hospital Guidelines for the Management of Hypertension.
2010.
10. Gerin, W; Schwartz, A., et al. Limitations of Current Validation Protocols for Home Blood pressure
Monitors for Individual Patients. Blood Pressure Monitoring 2002. Vol 6(6) ISSN: 1359-5237
11. Guiding Principles for the Care of Older Adults with Multimorbidity. Journal of the American
Geriatrics Society. 2012

Collateral Documents/Tools:
UW Health Diagnosis and Management of Hypertension – Adult - Ambulatory Clinical Practice Guideline

Approved By:
UW Health Ambulatory Protocol Committee: July 2017
UW Health Laboratory Practices Committee: August 2017
UWHC Pharmacy & Therapeutics Committee: September 2017
UWHC Medical Board: October 2017
UW Health Chief Medical Officer: October 2017

Effective Date: October 2017

Scheduled for Review: October 2020






Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Table 1. Medication‐Specific Dosing and Monitoring
Medication
Class
Drug (Trade
Name)
Starting
Dose
(mg)
Usual
Dose
(mg)
Max
Dose
(mg)
Laboratory
Orders
Special Considerations
ACE
Inhibitors
Benazepril
(Lotensin)
5-10 mg
daily
10-40
mg
daily
40 mg
daily
Monitor
plasma
creatinine and
potassium
within 4
weeks
(optimally 1-2
weeks) after
initiation and
dose change


Adjust dose every 1-2
weeks

Consider lower starting
dose when receiving
concomitant diuretics

Creatinine increase of
30% acceptable (repeat
creatinine in 2-4 weeks
to confirm stability).
Often reversible upon
dose reduction or
discontinuation

Contraindicated at
conception/during
pregnancy, bilateral renal
artery stenosis,
angioedema

Hyperkalemia is dose
dependent; all other
ADRs not dose
dependent
Enalapril
(Vasotec)
2.5-5
mg daily
10-20
mg
daily
OR 5-
10 mg
BID
40 mg
daily
OR 20
mg
BID
Lisinopril
(Prinivil,
Zestril)
2.5-10
mg daily
10-40
mg
daily
40 mg
daily
Quinapril
(Accupril)
5-20 mg
daily
10-80
mg
daily
80 mg
daily
Fosinopril
(Monopril)

10 mg
daily

10-40
mg
daily
80 mg
daily

Perindopril
(Aceon)
2-4 mg
daily
4-8 mg
daily
16 mg
daily
Trandolapril
(Mavik)

1-2 mg
daily
2-4 mg
daily
8 mg
daily
Ramipril
(Altace)
2.5 mg
daily
5-10
mg
daily
20 mg
daily
ARB
Losartan
(Cozaar)

25-50
mg daily
25-50
mg BID
50 mg
BID
Monitor
plasma
creatinine and
potassium
within 4
weeks
(optimally 1-2
weeks) after
initiation and
dose change

Adjust dose every 1-4
weeks

Consider lower starting
dose when receiving
concomitant diuretics
Creatinine increase of
30% acceptable (repeat
creatinine in 2-4 weeks
to confirm stability).
Often reversible upon
dose reduction or
discontinuation

ARBs are alternatives for
patients with ACE-I
associated cough or
Valsartan
(Diovan)

80-160
mg daily

80-320
mg
daily
320
mg
daily

Candesartan
(Atacand)
8 mg
daily
8-32
mg
daily
32 mg
daily
Irbesartan
(Avapro)
75-150
mg daily
150-
300 mg
daily
300
mg
daily
Olmesartan
(Benicar)
10-20
mg daily
20-40
mg
daily
40 mg
daily
Telmisartan 20-40 40-80 80 mg
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

(Micardis) mg daily mg
daily
daily angioedema

Contraindicated at
conception/during
pregnancy, bilateral renal
artery stenosis,
angioedema

ADRs are not dose
dependent

Azilsartan
(Medoxomil
)
40 mg
daily
80 mg
daily
80 mg
daily
Dihydropyri
dine
Calcium
Channel
Blockers
Amlodipine
(Norvasc)
2.5-5
mg daily
5-10
mg
daily
10 mg
daily
Adjust dose every 1-2
weeks

Peripheral edema is dose
dependent

Reflex tachycardia with
nifedipine

May also be useful for
Raynaud syndrome

Prioritize use over non-
dihydropyridine CCBs
(more effective, fewer
side effects and drug
interactions)

Not recommended in HF
patients; although
amlodipine can be
considered
Nifedipine
long acting
(multiple
brands)

30-60
mg daily

30-90
mg
daily

120
mg
daily

Felodipine
ER
(Plendil)
2.5-5
mg daily
5-10
mg
daily
10 mg
daily
Thiazide
Diuretics
Chlorthalido
ne
(Thalitone)
12.5-25
mg daily
12.5-25
mg
daily
25 mg
daily
Monitor
plasma
creatinine,
potassium,
and sodium
within 4
weeks
(optimally 1-2
weeks) after
initiation and
dose change


Chlorthalidone use
should be favored over
hydrochlorothiazide,
though should be
monitored more closely
for metabolic side effects
as it is more potent and
has a longer duration of
action

Higher doses may
increase triglycerides
and/or LDL and worsen
insulin resistance
Hydrochloro
thiazide
(Microzide)
12.5-25
mg daily
12.5-25
mg
daily
25 mg
daily
Indapamide
(Lozol)
1.25 mg
daily

1.25-
2.5 mg
daily
5 mg
daily
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org


ADRs are dose
dependent

Contraindicated with
anuria; use with caution
with gout

Hydrochlorothiazide and
chlorthalidone are
usually ineffective with
CrCl <30 ml/min unless in
combination with a loop
diuretic




Beta-
Blockers
Atenolol
(Tenormin)
25 mg
daily
25-100
mg
daily
100
mg
daily
No longer recommended
as first-line agents unless
there is a compelling
indications (e.g.,
coronary artery disease,
LV systolic dysfunction,
atrial fibrillation rate
control, etc)

Caution with severe
bronchospastic disease

Caution with concurrent
treatment with verapamil
and diltiazem

Combined alpha-beta-
blockers (i.e., carvedilol,
labetalol) are much more
effective and less likely to
cause metabolic
disturbances than high
dose pure beta-blockers
(i.e., atenolol,
metoprolol)

Can worsen insulin
resistance and
dyslipidemia in
susceptible individuals,
Metoprolol
tartrate
(Lopressor)
12.5 mg
BID
50-100
mg BID
200
mg
BID
Metoprolol
succinate
(Toprol XL)

25-50
mg daily

50-100
mg
daily

200
mg
daily

Nadolol
(Corgard)

40 mg
daily

40-120
mg
daily

320
mg
daily

Propranolol
(Inderal,
Inderal LA)

IR: 40
mg BID
LA: 80
mg daily

IR: 40-
160 mg
BID
LA: 80-
320 mg
daily
IR:
160
mg
BID
LA:
320
mg
daily

Bisoprolol
(Zebeta)
2.5-5
mg daily
5-10
mg
daily
20 mg
daily
Carvedilol
(Coreg)
6.25 mg
BID
12.5-50
mg BID
50 mg
BID
100 mg 200- 400
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Labetalol
(Trandate)
BID


400 mg
BID
mg
BID
such as those with
diabetes mellitus or
metabolic syndrome

Use cautiously in patients
with type 1 diabetes
mellitus because of the
potential to mask
hypoglycemia

Metoprolol and
bisoprolol: agents with
evidence for CAD

Beta-blockers,
particularly propranolol,
have been associated
with impotence but at a
very low incidence; this is
less likely to happen with
atenolol. Lowering BP
has been associated with
best quality of life,
including sexual function.

Contraindicated in
sinoatrial or
atrioventricular (AV)
node dysfunction,
decompensated HF,
severe bronchospastic
disease, severe hepatic
dysfunction

May also be useful for
migraine prophylaxis

Teach patient to monitor
HR, patient to call if HR
less than 60 bpm
Aldosteron
e-receptor
blockers
Spironolacto
ne*
(Aldactone)

12.5-25
mg daily

12.5-25
mg
daily

25 mg
daily

Monitor SCr, K, and Na
within 4 weeks (optimally
1-2 weeks) after initiation
and dose change

*If patient is on an ACE-
inhibitor, ARB, NSAID or
moderate CYP3A4
Eplerenone
*
(Inspra)
25-50
mg
daily**
100 mg
daily
OR 50
mg BID
100
mg
daily
OR 50
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

mg
BID
inhibitor (eplerenone
only), SCr/K should be
monitored within 3 days
and 7 days within
initiation or dose change
and periodically
thereafter as clinically
indicated. Patients with
heart failure may need
more frequent
monitoring

Effective third or fourth
line agent, especially in
overweight patients and
patients with
hypokalemia

Less ADRs associated
with eplerenone

Gynecomastia and sexual
dysfunction less common
with lower dose
spironolactone or with
eplerenone

Risk of hyperkalemia may
be increased with renal
impairment, proteinuria,
diabetes, or when used in
combination with
ACE/ARBs or NSAIDs

**Initial dose 25 mg with
moderate CYP3A4
inhibitors, max dose 50
mg daily

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org