It was in final year clinical class and Prof. Mrs. C.V Ukwe was taking us on hypertension. She concluded by saying we should look into JNC 7 report and its recommendations. I actually thought she had said GNC 7 but was proved wrong when I typed into Google search and what popped out was “search results for JNC 7”. Going through it, I was excited about this guideline as it improved my knowledge base and was hoping JNC 8 would be released soon as the amiable professor had said it was about time. This was in 2011.
For those still at sea, JNC 7 simply refers to the report of the 7th joint national committee on the prevention, detection, evaluation and treatment of high blood pressure. This means that there have been previous ones, that is, JNC 1-6. Experts are nominated to a panel to brainstorm on meta-analyses of clinical researches and studies carried out within a time frame, review previous guidelines and make recommendations. The JNC 7 was published in 2003 and so all expected that by 2010, JNC 8 should be out. It was not to be and it was not long before people started referring to the yet to be published guideline as “JNC late”. However, Dr. Smith who was a member of the JNC 8 expert panel explained that the delay was due to unprecedented prerelease review by numerous government agencies.
When finally it was published online on December 18, 2013, it didn’t meet a soft landing. The fact that it was not endorsed by the National Heart Blood Lung Institute(NHBLI), the American Heart Association and other health authorities was a real cause for concern. Infact, AHA stated that it still stands on the recommendations of JNC 7 and a new guideline should be expected in 2015 from them. The crux of the matter is that the JNC 8 committee declined to partner with AHA ab initio and AHA has some undisclosed reservations about the report. We leave them to settle their matter. More worrisome was a post by Dr. David K. Cundiff titled “A call to retract JNC 8 hypertension guideline” and the comments that followed on Kevinmd.com. He had co-authored a systematic review in the Cochrane Database of Systematic Reviews that found no evidence supporting drug treatment for patients of any age with mild hypertension ( SBP 140-159; DBP 90-99) with no previous cardiovascular disease, diabetes or renal disease. Comments that trailed the post instigated that drug companies might be up to making profits again alleging that the panel members’ financial obligation to drug companies had compromised the review by still leaving general target bp at below 140/90 and above which drug therapy should be instituted.
If you are a lippincott student, you may want to see a truth in this. Chapter 8 as written by Janet Fleetwood dwelt on contemporary bioethical issues in pharmacology and pharmaceutical research. In it we were made to understand that “the pharmaceutical industry combines a desire for discovery and development with profit-motivated marketing and sales goals. Although scientists and physicians share the desire for drug discovery and development and are motivated by the desire to contribute to scientific advancement and improved patient care, pharmaceutical companies are simultaneously under strong commercial pressures. Pharmaceutical companies are therefore willing to offer financial incentives to physician–researchers who conduct studies, recruit patients, or are helpful in product development and testing. In some cases, this financial support may compromise professional judgment in conducting, analyzing, or reporting researches.”2 Fleetwood went on to educate us that “the principle of nonmaleficence asserts that professionals have an obligation to prevent harm or if harm is unavoidable, minimize that harm. This principle plays an important role in clinical research, as it entails an obligation to minimize risks to each participant”.2 In this context, if I were to belong to David’s school of thought, the harm is that patients with BP range of 140/90-159/99 are made to take antihypertensive drugs when lifestyle modification can suffice predisposing them to the adverse effect of these drugs unnecessarily.
Though I may not be knowledgeable about the goings on in the American healthcare system, my candid opinion is that the allegation by Dr. David was unfounded. His research was one out of many that had to be reviewed and probably the only one supporting higher threshold for initiation of therapy. It was enough that they increased the Bp target and initiation of therapy for patients older than 60yrs to ‹150/90 and that for diabetics and CKD pts to ‹140/90 as research showed no additional benefit with lower BP targets. For the AHA to stick with JNC 7 having lower targets, it means probably that that study bore no weight. Let’s be honest with ourselves, even at the prehypertensive stage of 121-139 SBP, how many patients can boast of bringing down their Bp with exercise and DASH diet? Just how many have that discipline? Most actually end up being hypertensive and needing drugs. Despite the drug therapy, lifestyle modifications are still advised. Besides, the “Panel members disclosed any potential conflicts of interest including studies evaluated in the report and relationships with industry. Those with conflicts were allowed to participate in discussions as long as they declared their relationships, but they recused themselves from voting on evidence statements and recommendations relevant to their relationships or conflicts. Four panel members (24%) had relationships with industry or potential conflicts to disclose at the outset of the process. In January 2013, the guideline was submitted for external peer review by NHLBI to 20 reviewers, all of whom had expertise in hypertension, and to 16 federal agencies. Reviewers also had expertise in cardiology, nephrology, primary care, pharmacology, research (including clinical trials), biostatistics, and other important related fields. Sixteen individual reviewers and 5 federal agencies responded. Reviewers’ comments were collected, collated, and anonymized. Comments were reviewed and discussed by the panel from March through June 2013 and incorporated into a revised document”.1 Despite all these, the recommendations came with a caveat that although “this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient”.1 So, Dr. David is free to base his clinical judgement on his own study.
Among the panelists for the JNC 8 was a medical practitioner by name Olugbenga Ogedegbe, a Nigerian-American. We are proud of you and Barry L. Carter, PharmD., the pharmacist in the team. While health workers in this country are busy wasting their talents on salary and allowance squabbles, others are seeing to the good of their patients and actually having contentions over their patients’ welfare. Not even the health minister could give a public statement on what should be our stand on the JNC 8 report or do we need a surgeon general to do that? Better still, are we not supposed to generate our own research questions, set up our panelists and make recommendations based on indigenous clinical trials? We can’t continue to rely on JNC reports which are largely American to solve hypertension issues in Nigeria. The British have theirs and even in the same America many other guidelines coexist with the JNC making one have plethora of options to choose from.
PHARMACISTS, have you read the report?
Pharmacist uchenna Maduka writes in from lagos
1.Paul A. James 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. doi:10.1001/jama.2013.284427,Published online December 18, 2013.
2. Janet Fleetwood; contemporary bioethical issues in pharmacology and pharmaceutical research, in Lippincott modern pharmacology, 5th edition.