Updates to Hypertension, Migraine, and pharmacogenetics

07 Sep Updates to Hypertension, Migraine, and pharmacogenetics

All TreatGx users now have access to the updated treatment algorithms for Hypertension and Migraine. As always, these updates include the TreatGx standard of providing personalized dosing based on pharmacogenetics, kidney function, liver function, and drug interactions.

General updates: a scope message has now been added to each TreatGx condition to clarify what is included in the condition and what is excluded, for clarity and transparency. Look for these below each condition’s medication options.

Hypertension

This comprehensive update reviewed medication options based on current guidelines including ACC/AHA 2017 guideline [1], ESC/ESH 2018 guideline [2], Hypertension Canada’s 2020 guideline [3], and VA/DoD 2020 guideline [4].

Key updates include:

• All medication options are now shown regardless of current medications, including options for resistant hypertension in last line. This allows clinicians to see the full range of options for their patient, including other options within the same class and optimized dosing for a current medication.
• The algorithm accounts for the presence of factors affecting therapy choices including: heart failure, coronary artery disease, chronic kidney disease, diabetes, or Black African or Caribbean family origin
• Drug inclusion was reviewed based on guidelines: carvedilol, nebivolol, propranolol, and torsemide dosing was added. Triamterene and terazosin were removed due to being last-line options in the same class as other medications with more robust evidence and guideline support.
• Updated information on combination products available in Canada or the United States (single pill combos)

Migraine

This comprehensive update includes information from the latest clinical guidelines, including the American College of Physicians 2017 [5], American Academy of Family Physicians 2018 [6], Kaiser Permanente Washington 2018 [7], and the New England Journal of Medicine 2020 [8].

Key updates include:

• Filter function to display non-oral formulations for patients who are unable to swallow tablets or capsules due to nausea or vomiting
• Half-life profiles for all triptans, to help clinicians select the most appropriate triptan based on migraine presentation and frequency
• Information on -ditans and -gepants, the newest drug classes being used in migraine therapy

Pharmacogenetics updates

• Beta-blocker pharmacogenetics added to TreatGx for carvedilol, nebivolol, and propranolol for CYP2D6 poor metabolizer status per FDA Table of Pharmacogenetic Associations. This was updated in Hypertension, Heart Failure – Chronic, Migraine Prophylaxis, Post-Myocardial Infarction, and Atrial Fibrillation – Rate Control.
• KCNIP4 rs1495509 pharmacogenetics for ACE Inhibitors (increased risk of ACEI-induced cough for C/T or C/C) were removed from TreatGx due to PharmGKB level of evidence now being downgraded to Level 3. This was updated in Hypertension, Post-Myocardial Infarction, Heart Failure – Chronic, and Migraine Prophylaxis.
• Metoclopramide pharmacogenetics for CYP2D6 poor metabolizer status were added to TreatGx for Migraine and Dyspepsia per FDA Table of Pharmacogenetic Associations
• Tamoxifen CYP2D6 ultrarapid metabolizer status information was updated in TreatGx for Bipolar 1 Disorder based on He et al. 2021 [9]

References

1. Whelton PK, Carey RM, Aronow WS, Casey DE, Jr., Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW et al: 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018, 71(6):1269-1324.
2. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A et al: 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. Journal of Hypertension 2018, 36(10).
3. Rabi DM, McBrien KA, Sapir-Pichhadze R, Nakhla M, Ahmed SB, Dumanski SM, Butalia S, Leung AA, Harris KC, Cloutier L et al: Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children. Can J Cardiol 2020, 36(5):596-624.
4. Department of Veterans Affairs/Department of Defense: VA/DoD Clinical Practice Guideline for the Diagnosis and Management of Hypertension in the Primary Care Setting. 2020.
5. Migraine. Annals of Internal Medicine 2017, 166(7):ITC49-ITC64.
6. Mayans L, Walling A: Acute Migraine Headache: Treatment Strategies. Am Fam Physician 2018, 97(4):243-251.
7. Kaiser Permanente Washington (KPWA): Migraine and Tension Headache Guideline. 2018.
8. Ashina M: Migraine. N Engl J Med 2020, 383(19):1866-1876.
9. He W, Eriksson M, Eliasson E, Grassmann F, Bäcklund M, Gabrielson M, Hammarström M, Margolin S, Thorén L, Wengström Y et al: CYP2D6 genotype predicts tamoxifen discontinuation and drug response: a secondary analysis of the KARISMA trial. Ann Oncol 2021.