Which drugs for which patients?
Pharmacologic management is indicated for pediatric patients with stage 1 or stage 2 hypertension, secondary hypertension, and those with evidence of target-organ damage.12 The goal of therapy is to reduce BP to <95th percentile. In patients with target organ damage, renal disease, or diabetes mellitus, the goal is <90th percentile.12,15,28 Intensive management of BP (≤50th percentile) in children with chronic kidney disease has been shown to delay progression to renal failure,29 but it is uncertain if lower BP goals can slow or prevent additional subclinical target organ damage.
Pharmacotherapy for hypertensive children or adolescents can be challenging because recommendations of which medication to use are based upon expert opinion and extrapolation from randomized trials of adults. The length of therapy (often lifelong), potential adverse effects, and unproven direct mortality benefit complicate this decision. Medication choice usually is based on physician preference or experience.12 The most common antihypertensive drugs prescribed are angiotensin-converting enzyme (ACE) inhibitors (26%), followed by diuretics (20%), and beta-blockers (17%).30,31 The starting doses and other details of medications commonly used to treat pediatric hypertension are listed in TABLE 3.28,32-34
One approach to choosing an antihypertensive drug for children is to measure the patient’s ambulatory plasma renin activity (PRA) level before initiating therapy. Those with high PRA levels (>0.65 ng/mL/h), presumably due to peripheral vasoconstriction, may benefit more from ACE inhibitors, angiotensin receptor blockers (ARBs), or beta-adrenergic antagonists.35 Individuals with low PRA levels (<0.65 ng/mL/h) maintain higher volume/sodium excess and may benefit more from diuretics or calcium channel blockers.35
Ethnicity also may guide medication selection. African American adults do not respond well to ACE inhibitor monotherapy due to decreased PRA and increased salt hypersensitivity.36 One meta-analysis found that African American children and adolescents had inadequate BP response to 6 individual ACE inhibitors, even at higher doses compared with white children and those of other ethnicities, who showed significant improvement in BP.37 ARBs may be a more effective alternative for this population.
Most experts recommend initiating a single agent at a low dose.12 A systematic review found that except for African American children, pediatric patients experienced comparable reductions in BP with ACE inhibitors (10.7/8.1 mm Hg), ARBs (10.5/6.9 mm Hg), and calcium channel blockers (9.3/7.2 mm Hg).38 In addition, ACE inhibitors and ARBs significantly reduced proteinuria by 49% and 59%, respectively.38
Schedule follow-up visits for 2 to 4 weeks (or sooner for patients with stage 2 hypertension) after initiating pharmacotherapy. If BP response is suboptimal, consider increasing the dose before adding a second agent. If the patient experiences significant adverse effects or has an inadequate BP response, changing to a drug from a different class is recommended.39 Patients who do not adequately respond to these approaches may require combination therapy; in such cases, strongly consider consultation with pediatric nephrologist or cardiologist.39 Medication compliance should be verified (eg, by pill counting, parental supervision) in patients who do not respond to therapy. Once BP control has been achieved, visits every 3 to 4 months are appropriate, with periodic laboratory monitoring, especially for children taking diuretics, ACE inhibitors, or ARBs or who have underlying renal disease.
Recommend exercise, but carefully monitor athlete's BP
Encourage obese and overweight children and adolescents to lose weight to maintain a BMI <95th percentile. Current guidelines based on expert opinion recommend that children and adolescents should engage in 60 minutes of daily physical activity.12 A meta-analysis found physical activity led to a 1% and 3% reduction in systolic and diastolic BP, respectively, although these results were not statistically significant.40
Be aware, however, that children and adolescents with hypertension who engage in certain competitive sports can significantly increase their BP and may be at risk for complications.41 According to the AAP guidelines, patients with stage 2 hypertension should not engage in high-static sports (eg, gymnastics, weightlifting, wrestling, boxing, cycling, decathlon, triathlon) until BP is well controlled.41 Patients with target-organ damage, uncontrolled hypertension, or symptomatic hypertension should not participate until BP is well controlled. Patients with prehypertension and stage 1 hypertension without target-organ damage are eligible to participate in competitive athletics. Reassess BP every 6 months in patients who are prehypertensive and every one to 2 weeks for those with stage 1 hypertension. When the patient’s BP remains <90th percentile, routine surveillance every 3 to 6 months is recommended.
