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Antihypertensives in Children and Adolescents. Curr Hypertens Rep 2022; 24:581-587. [PMID: 36114998 DOI: 10.1007/s11906-022-01220-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To review target organ outcomes and current pharmacologic treatment options for children and adolescents with hypertension. RECENT FINDINGS There is an increased prevalence of pediatric hypertension. Following the 2017 AAP clinical practice guidelines, there is a growing body of literature illustrating the association between pediatric hypertension and end organ damage, though few studies looking at long-term outcomes. There is also new data to support the use of n-of-1 trials to identify the best antihypertensive therapy for an individual. Pediatric hypertension is increasing in prevalence and is associated with end organ damage. Treatment of hypertensive children has been shown to reverse end organ damage. Due to the lack of large, randomized trials assessing antihypertensive classes against one another, n-of-1 studies may serve as a viable and safe option to optimize patient care.
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Stergiou G, Stambolliu E, Bountzona I, Ntineri A, Kollias A, Vazeou A, Soldatou A. Home Blood Pressure Monitoring in Children and Adolescents: Systematic Review of Evidence on Clinical Utility. Curr Hypertens Rep 2019; 21:64. [PMID: 31240404 DOI: 10.1007/s11906-019-0967-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW For the accurate diagnosis and management of hypertension, out-of-office blood pressure evaluation using ambulatory (ABPM) or home monitoring (HBPM) is currently recommended. In children, there is considerable evidence on the clinical utility of ABPM, whereas the evidence on HBPM is limited. This systematic review presents (i) the benefits of HBPM in children; (ii) the evidence on normal range, diagnostic accuracy, and relationship with preclinical organ damage; and (iii) guidance for devices, monitoring schedule, and interpretation. RECENT FINDINGS HBPM is a useful adjunct to the conventional office measurements for the evaluation of children with suspected or treated hypertension. HBPM is feasible in children and has good reproducibility, diagnostic accuracy and acceptability by users, and relatively low cost. Thus, it has greater potential for widespread and long-term use than ABPM, which is more expensive and often not available or not tolerated. Automated monitors that have been clinically validated specifically in children should be used with appropriate cuff size. HBPM for 7 days (minimum 3) with duplicate morning and evening measurements (minimum 12 readings) should be performed in children with suspected or treated hypertension before each office visit. Until more data become available, in case of diagnostic disagreement between office blood pressure and HBPM, treatment decisions should be based on ABPM. HBPM is clinically useful in children with hypertension. More research is needed on its clinical application, and more automated devices need to be clinically validated in this population.
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Affiliation(s)
- George Stergiou
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece.
| | - Emelina Stambolliu
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Ioanna Bountzona
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Angeliki Ntineri
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Anastasios Kollias
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Andriani Vazeou
- First Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece
| | - Alexandra Soldatou
- Second Department of Pediatrics, National and Kapodistrian University of Athens, School of Medicine, P&A Kyriakou Children's Hospital, Athens, Greece
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Baker-Smith CM, Flinn SK, Flynn JT, Kaelber DC, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Diagnosis, Evaluation, and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2018; 142:peds.2018-2096. [PMID: 30126937 DOI: 10.1542/peds.2018-2096] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED Systemic hypertension is a major cause of morbidity and mortality in adulthood. High blood pressure (HBP) and repeated measures of HBP, hypertension (HTN), begin in youth. Knowledge of how best to diagnose, manage, and treat systemic HTN in children and adolescents is important for primary and subspecialty care providers. OBJECTIVES To provide a technical summary of the methodology used to generate the 2017 "Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents," an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." DATA SOURCES Medline, Cochrane Central Register of Controlled Trials, and Excerpta Medica Database references published between January 2003 and July 2015 followed by an additional search between August 2015 and July 2016. STUDY SELECTION English-language observational studies and randomized trials. METHODS Key action statements (KASs) and additional recommendations regarding the diagnosis, management, and treatment of HBP in youth were the product of a detailed systematic review of the literature. A content outline establishing the breadth and depth was followed by the generation of 4 patient, intervention, comparison, outcome, time questions. Key questions addressed: (1) diagnosis of systemic HTN, (2) recommended work-up of systemic HTN, (3) optimal blood pressure (BP) goals, and (4) impact of high BP on indirect markers of cardiovascular disease in youth. Once selected, references were subjected to a 2-person review of the abstract and title followed by a separate 2-person full-text review. Full citation information, population data, findings, benefits and harms of the findings, as well as other key reference information were archived. Selected primary references were then used for KAS generation. Level of evidence (LOE) scoring was assigned for each reference and then in aggregate. Appropriate language was used to generate each KAS based on the LOE and the balance of benefit versus harm of the findings. Topics that could not be researched via the stated approach were (1) definition of HTN in youth, and (2) definition of left ventricular hypertrophy. KASs related to these stated topics were generated via expert opinion. RESULTS Nearly 15 000 references were identified during an initial literature search. After a deduplication process, 14 382 references were available for title and abstract review, and 1379 underwent full text review. One hundred twenty-four experimental and observational studies published between 2003 and 2016 were selected as primary references for KAS generation, followed by an additional 269 primary references selected between August 2015 and July 2016. The LOE for the majority of references was C. In total, 30 KASs and 27 additional recommendations were generated; 12 were related to the diagnosis of HTN, 13 were related to management and additional diagnostic testing, 3 to treatment goals, and 2 to treatment options. Finally, special additions to the clinical practice guideline included creation of new BP tables based on BP values obtained solely from children with normal weight, creation of a simplified table to enhance screening and recognition of abnormal BP, and a revision of the criteria for diagnosing left ventricular hypertrophy. CONCLUSIONS An extensive and detailed systematic approach was used to generate evidence-based guidelines for the diagnosis, management, and treatment of youth with systemic HTN.
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Affiliation(s)
- Carissa M Baker-Smith
- Division of Cardiology, Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland;
| | | | - Joseph T Flynn
- Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - David C Kaelber
- Division of General Internal Medicine, Departments of Pediatrics and Population and Quantitative Health Sciences, Case Western Reserve University and Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, Ohio
| | - Douglas Blowey
- University of Missouri-Kansas City, Children's Mercy Kansas City, Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | | | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Samuel S Gidding
- Cardiology Division, Nemours Cardiac Center, A. I. duPont Hospital for Children and Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, Morehouse School of Medicine, Atlanta, Georgia
| | | | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern School of Medicine, University of Texas, Houston, Texas
| | - Madeline Simasek
- Department of Pediatrics, UPMC Shadyside Family Medicine Residency, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Molecular Genetics, Department of Pediatrics, Columbia University Irving Medical Center, Columbia University, New York, New York.,Broad Institute, Cambridge, Massachusetts; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Wells TG, Blowey DL, Sullivan JE, Blumer J, Sherbotie JR, Song S, Rohatagi S, Heyrman R, Salazar DE. Pharmacokinetics of olmesartan medoxomil in pediatric patients with hypertension. Paediatr Drugs 2012; 14:401-9. [PMID: 22880942 DOI: 10.2165/11631450-000000000-00000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND The prevalence and importance of hypertension in younger patients is becoming increasingly recognized; however, only a limited number of clinical trials have been conducted in the pediatric population. OBJECTIVE The aim of this study was to characterize the pharmacokinetics and short-term safety of olmesartan medoxomil in children and adolescents with hypertension. METHODS An open-label, multicenter, single-dose study was conducted in children and adolescents aged 12 months-16 years who were receiving treatment for hypertension or, if not currently treated for hypertension, had either a systolic blood pressure (SBP) or diastolic blood pressure (DBP).≥95th percentile, or SBP or DBP ≥90th percentile if diabetic or with a family history of hypertension. Patients were stratified by age: 12-23 months (Group 1; none enrolled), 2-5 years (Group 2; n = 4), 6-12 years (Group 3; n = 10), and 13-16 years (Group 4; n = 10). All patients received a single oral dose of olmesartan medoxomil based on the individual's age and bodyweight. Patients aged <6 years received an oral suspension of olmesartan medoxomil at a dose of 0.3 mg/kg of bodyweight (not to exceed 20 mg), those aged ≥6 years who weighed ≥35 kg received olmesartan medoxomil 40 mg tablets, and those who weighed <35 kg received olmesartan medoxomil 20 mg tablets. RESULTS In Groups 2, 3, and 4, the weight-adjusted apparent total body clearance (CL/F) of olmesartan medoxomil was 0.100 ± 0.034, 0.062 ± 0.020, and 0.072 ± 0.022 L/h/kg, respectively, and the weight-adjusted apparent volume of distribution (Vd/F) was 0.32 ± 0.16, 0.33 ± 0.14, and 0.49 ± 0.23 L/kg, respectively. CL/F and Vd/F in Groups 3 and 4 were not significantly different. Statistical comparisons between Groups 3 or 4 and Group 2 were not performed due to the small sample size of Group 2 (n = 4). Plasma elimination half-life and time to maximum plasma concentration were similar across the three groups. In Groups 3 and 4, considerable interindividual variability was seen in maximum plasma concentration (C(max)), area under the curve (AUC) from time zero to the last measurable concentration, and apparent clearance, with AUC and C(max) approximately 30% greater in Group 3. Four of 24 (16.7%) patients experienced treatment-emergent adverse events that were all mild in severity and considered not drug-related. No deaths, serious adverse events, or discontinuations due to adverse events occurred in the study. CONCLUSIONS Olmesartan medoxomil was well tolerated and demonstrated a pharmacokinetic profile in pediatric patients similar to that of adults when adjusted for body size. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00151814
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Affiliation(s)
- Thomas G Wells
- Arkansas Childrens Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Meyers RS, Siu A. Pharmacotherapy Review of Chronic Pediatric Hypertension. Clin Ther 2011; 33:1331-56. [DOI: 10.1016/j.clinthera.2011.09.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 08/31/2011] [Accepted: 09/05/2011] [Indexed: 12/16/2022]
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Rocchini AP. Angiotensin receptor blockers for the treatment of hypertension in children. Clin Pediatr (Phila) 2011; 50:791-6. [PMID: 21127084 DOI: 10.1177/0009922810388514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Albert P Rocchini
- Department of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA.
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Jadhav PR, Kern SE. The need for modeling and simulation to design clinical investigations in children. J Clin Pharmacol 2011; 50:121S-129S. [PMID: 20881225 DOI: 10.1177/0091270010376968] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent legislation in the United States and Europe has resulted in an increased number of clinical trials of pharmaceutical agents in children. Creating a well-designed clinical trial that can be successfully completed is a challenging task, particularly as the study population includes younger and smaller children. Although there are some established principles for initially estimating appropriate doses of pharmaceutical agents in children based on known effective doses in adults, these rules are inadequate as the sole basis for designing a clinical trial in children. Factors such as maturation of metabolizing enzymes, relative physical maturation of the child, and altered absorption because of physiological differences in adults and children may contribute to alterations in the dose-exposure relationship. To account for the impact of these potential factors on a clinical trial, the use of modeling and simulation is necessary to anticipate the influence these variables can have on the desired clinical question to be addressed. The examples presented in this article highlight the principle that modeling and simulation is critical for adequately designing pediatrics trials.
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Affiliation(s)
- Pravin R Jadhav
- Division of Pharmacometrics, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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Efficacy and safety of angiotensin II receptor type 1 antagonists in children and adolescents. Pediatr Nephrol 2010; 25:801-11. [PMID: 19936798 DOI: 10.1007/s00467-009-1346-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 08/07/2009] [Accepted: 09/02/2009] [Indexed: 12/30/2022]
Abstract
Our purpose was to evaluate the effects of angiotensin II receptor type 1 antagonists (ARAs) in children and adolescents with hypertension or/and several kinds of nephropathies on blood pressure (BP) and proteinuria and to evaluate related safety issues. Data sources were Medline, Embase, The Cochrane Library, BIOSIS Previews, contact with investigators and manufacturers, personal bibliography of the lead author, and manual searches. We selected randomized controlled trials (RCTs), uncontrolled trials, and case series investigating ARAs in children and adolescents, as well as case reports about adverse events and the embryotoxic effects of ARAs in children. In four RCTs with 698 individuals, mean systolic blood pressure (BP) decreased by 10.5 mmHg [95% confidence interval (CI) 9.8-11.2] and mean diastolic BP by 6.4 mmHg (95% CI 5.8-7.0). Proteinuria decreased by 30-64% (range) in two RCTs and four case series. Safety data were comparable with adult safety data. ARAs can be considered effective and safe in lowering BP and proteinuria in the pediatric age group. The correlation between the surrogate parameters BP and proteinuria with clinical endpoints is documented to a large degree. The evidence is based on RCTs and also on lower evidence levels, such as case series. In some conditions, RCTs in children are not feasible. Registers could provide more evidence in the future.
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Hazan L, Hernández Rodriguez OA, Bhorat AE, Miyazaki K, Tao B, Heyrman R. A double-blind, dose-response study of the efficacy and safety of olmesartan medoxomil in children and adolescents with hypertension. Hypertension 2010; 55:1323-30. [PMID: 20385971 DOI: 10.1161/hypertensionaha.109.147702] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The current study investigated the efficacy and safety of olmesartan medoxomil in children with hypertension, defined as systolic blood pressure measured at or above the 95th percentile (90th percentile for patients with diabetes, glomerular kidney disease, or family history of hypertension) for age, gender, and height while off any antihypertensive medication. The active treatment phase was conducted in 2 periods, with 2 cohorts in each period (cohort A, 62% white; cohort B, 100% Black). In period 1, patients stratified by weight received low-dose (2.5 or 5 mg) or high-dose (20 or 40 mg) olmesartan medoxomil daily for 3 weeks. In period 2, patients maintained their olmesartan medoxomil dose or initiated placebo washout for an additional 2 weeks. Period 1 efficacy results showed a dose-dependent, statistically significant reduction in seated trough systolic and diastolic blood pressure for both cohorts, with mean blood pressure reductions numerically smaller in cohort B than in cohort A. The olmesartan medoxomil dose response remained statistically significant when adjusted for body weight. In period 2, blood pressure control decreased in those patients switching to placebo, whereas patients continuing to receive olmesartan medoxomil therapy maintained consistent blood pressure reduction. Adverse events were generally mild and unrelated to study medication. Olmesartan medoxomil was safe and efficacious in children with hypertension, resulting in significant blood pressure reductions.
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Affiliation(s)
- Lydie Hazan
- Impact Clinical Trials, Los Angeles, Calif, USA
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Trachtman H, Hainer JW, Sugg J, Teng R, Sorof JM, Radcliffe J. Efficacy, safety, and pharmacokinetics of candesartan cilexetil in hypertensive children aged 6 to 17 years. J Clin Hypertens (Greenwich) 2009; 10:743-50. [PMID: 19090875 DOI: 10.1111/j.1751-7176.2008.00022.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This 4-week randomized, double blind, placebo-controlled study (N=240), 1-year open label trial (N=233), and single-dose pharmacokinetic study (N=22) evaluated candesartan cilexetil (3 doses) in hypertensive children aged 6 to 17 years. Seventy-one percent were 12 years of age or older, 71% were male, and 47% were black. Systolic (SBP)/diastolic (DBP) blood pressure declined 8.6/4.8-11.2/8.0 mm Hg with candesartan and 3.7/1.8 mm Hg with placebo (P<.01 compared to placebo for SBP and for the mid and high doses for DBP; placebo-corrected 4.9/3.0-7.5/6.2 mm Hg). The slopes for dose were not, however, different from zero (P>.05). The response rate (SBP and DBP <95th percentile) after 1 year was 53%. The pharmacokinetic profiles in 6- to 12- and 12- to 17-year-olds were similar and were comparable to adults. Eight candesartan patients discontinued treatment because of an adverse event. Candesartan is an effective, well-tolerated antihypertensive agent for children aged 6 to 17 years and has a pharmacokinetic profile that is similar to that in adults.
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Affiliation(s)
- Howard Trachtman
- Division of Pediatric Nephrology, Schneider Children's Hospital, New Hyde Park, NY, USA
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