BONUS: Hypertension Conversations Beyond the Guidelines

In this bonus episode of Medication Talk, join us for an extended conversation on hypertension with our expert panel. We continue the discussion from Episode 505 with additional insights on improving medication adherence, motivating patients to stay on therapy, switching blood pressure medications, laboratory monitoring, and emerging treatments in the hypertension pipeline.

**No CE Credit is available for this bonus episode.**

Special guests:

• Michael E. Ernst, PharmD; BCGP, FCCP, AHSCP-CHC
  • Clinical Professor
  • Department of Pharmacy Practice and Science, College of Pharmacy; and, Department of Family & Community Medicine, Carver College of Medicine
  • The University of Iowa
• Catherine G. Derington, PharmD, MS
  • Assistant Professor of Medicine
  • Division of Cardiology
  • University of Colorado School of Medicine

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Craig D. Williams, PharmD, FNLA, BCPS
  • Clinical Professor of Pharmacy Practice
  • Oregon Health and Science University
• Andrea Darby-Stewart, MD
  • Associate Director, Honor Health Family Medicine Residency Program
  • Clinical Professor of Family, Community & Occupational Medicine
  • The University of Arizona College of Medicine - Phoenix

This podcast is an extended conversation with our expert panel from one of TRC’s monthly live CE webinars, which originally aired in May 2026.

🏷️Use code mt1026 at checkout for 10% off a new or upgraded subscription.

The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Chart: Meds That Can Increase Blood Pressure
• Checklist: Measuring Blood Pressure Checklist
• Chart: Hypertension Goals in Adults
• Algorithm: Treatment of Hypertension
• Chart: Management of Severe Hypertension in Adults

Email us: ContactUs@trchealthcare.com.

The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

Find the show on YouTube by searching for ‘TRC Healthcare’ or clicking here.

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Transcript

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Introduction

Catherine G. Derington 0:07

Hypertension is a silent disease, and the treatment's also silent if we're doing our job, where you may not feel different, better or worse, and that's good. So that's the goal, even, and patients may not get that unless you say it out loud to them.

Michael E. Ernst 0:23

It takes time to educate patients, and I'm continually reminded by patients when they thank me for explaining things to them in this relationship between blood pressure and these different things.

Narrator 0:50

On this special bonus episode, we're bringing you something different. An extended conversation with our expert panel from our live webinar this May, an episode 505 on hypertension. Sometimes our discussions generate more valuable insights than we can fit into a single episode. So today, we're sharing some additional practical and thought-provoking conversations from our expert panel. You'll hear advice on motivating patients to stay on their blood pressure medications, strategies for improving adherence, when and how to switch hypertension therapies, recommendations for laboratory monitoring, and to look at emerging treatments that could shape the future of hypertension care. And just so you know, this bonus episode does not include continuing education credit. Our guests today are Dr. Catherine Katie Darrington, an assistant professor at the University of Colorado Division of Cardiology, Department of Medicine. She is a clinical pharmacist and investigator specializing in cardiovascular outcomes research. And Dr. Mike Ernst, clinical professor in the University of Iowa College of Pharmacy, and in the Department of Family and Community Medicine in the Carver College of Medicine. He is also a certified hypertension specialist. You'll also hear practical advice from panelists on TRC's Editorial Advisory Board, Dr. Andrea Darby Stewart from the University of Arizona College of Medicine, Phoenix, and Dr. Craig Williams from the Oregon Health and Science University. This podcast is an excerpt from one of TRC's monthly Live C webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers. Now, let's join TRC editors and clinical pharmacists, Dr. Steven Small and Sarah Clockers, and start our discussion.

Patient Motivation & Adherence

Sara Klockars 2:44

So, Craig, what are your most effective real-world strategies to help keep patients on their meds?

Craig Williams 2:50

We just had a discussion with our medicine residents recently of kind of what you do with that patient who doesn't want that first agent who's clearly at a place where they should be on it, or who clearly is just not taking medicines regularly and just dealing with compliance and in general. As you know, this like so many conditions, it's an asymptomatic condition. And we're asking patients to take medicines on a regular basis that that may have adverse effects, sometimes real adverse effects, sometimes just patients receiving adverse effects from medications. But we're asking to do something that doesn't make them feel immediately better for the long-term benefits. And so we really kind of focus on when patients aren't taking medicines as the way we think they should or we want them to, is they're clear they're not bought into the goals that we have for them. And as we lower these targets and potentially use more medications in patients, it's gonna be more of an issue for us the next uh five to ten years. So our focus really is on uh getting the patient to understand why we want them to take it, and they've they've gotta get to a point where they want to take these medications and lower the risk for themselves. So all of our residents know that what these medications do versus untreated hypertension is lower uh three major risk factors. One is isemic heart disease, so heart attack and stroke, two CKD and three CHF. But when you throw those things out broadly to patients, they that often doesn't mean a lot to them. So that's a and just briefly and then let happy to hear Mike's thoughts. We our kind of real focuses on, especially for adults over 65, most of them know someone who's had a stroke. And surviving a stroke is a pretty scary thing. And so we can like focus on, you know, stroke is a real issue here, and we know we can lower your risk of a stroke over your lifetime by probably at least 50% by treating well versus not. And the second one is CKD doesn't mean much to most of our patients either. When you work in the older population, a lot of them know someone who is on dialysis. And being on dialysis is not a fun way to spend your last few years or life. So we kind of focus on those as look, if we treat this, we can avoid your lifetime risk of need dialysis or or having a stroke, you're gonna survive. And those are things patients can really like get their mind around and start to get some buy-in for, yeah, I I want to lower my blood pressure now the way you want me to lower your blood pressure.

Michael E. Ernst 5:11

What I was gonna add, Craig, is we can now talk about lowering risk of dementia and cognitive decline. And that gets people's attention. You know, Sprint gave us early indication there, and obviously, because that study was stopped early, you know, the dementia didn't quite make statistical significance, but cognitive decline did. But now we have the Chinese rural uh blood pressure study, which showed a reduction in both dementia and uh cognitive impairment. And, you know, everybody knows somebody who's suffered from from Alzheimer's. And so I think that becomes another important talking point about the benefits of treating your blood pressure that resonates with a lot of people.

Craig Williams 5:55

Yeah, it'd be very fair. Third, very easy thing for patients to to grasp. A third thing to add is a meaningful risk reduction.

Catherine G. Derington 6:04

Yeah. I also, when I'm talking about this more with my family members, and maybe I should do this more with patients, but you don't get to pick the kind of heart attack you have. You don't get to pick the kind of stroke that you have. You just have one if you're going to have one. And we don't know if that will be a small mini stroke that you never detect, or we don't know if it'll be one that absolutely changes your life and your functionability, right? And so our, of course, you've mentioned like there's different risk takers out there, but is that something that you're willing to risk? Is the answer yes, again, or no? How do you feel about that? Uh, and that's not meant to be a scare tactic. It's the reality of what, of course, you see all the time in patients, but I don't know that people understand what it would look like for them to have a heart attack or them to look like to have a stroke.

Craig Williams 6:57

Yeah, and those very fair point. I think any of those make it much more real than just saying, I want to lower your risk of heart disease. You know, life to me for dialysis and again, stroke and dementia is certainly a very fair point as well.

Michael E. Ernst 7:08

And all the points that we're bringing up here again are are about involved time. And what I mean by that is time takes time to educate patients. And and I, you know, I'm fortunate that I I can spend that time in the clinic that my physician colleague doesn't have. But I'm continually reminded by patients when they thank me for explaining things to them and this relationship between blood pressure and these different things. I mean, it's I wish that our healthcare system allowed us, you know, more time to be able to do that. But and I realize again that the situation I practice in is not the the same as you know what everyone does. But again, it's it really comes down to a conversation that's thorough, that's that's very the participatory by the patient, and so that we're not just sort of dictating to them all this information.

Craig Williams 8:07

Yeah, it's a luxury on the inpatient side to have some of that time, but hopefully you're not meeting them because they had that stroke or that first uh seemic event. But uh, but yeah, it is it is a time-dependent process.

Steve Small 8:20

Great discussion there. Uh and Andrea,

Medication Adherence Strategies

Steve Small 8:23

how do you address adherence when patients swear they're taking meds, but their blood pressure says otherwise? Any tips there?

Andrea Darby Stewart 8:31

Yeah, well, you know, I I try to err on the side of uh believing my patients, but I also craft my questions appropriately. And so my favorite question about adherence is how many days are you able to take the medications as they're prescribed? Because when you ask a patient, are you taking your medications or you're taking all of these medicines, right? It really sets them up for a binary. They're either going to answer yes, they're taking them all and they're gonna please you, um, or they're gonna say no. And that's, you know, doesn't, you know, sometimes it's hard for people to say that. But how many days are you of the week are you able to take them gives me an idea. And if they're taking the tell me they're taking the medications maybe three or four days a week, and we can talk a little bit more about how they can adhere to that uh medication. My electronic health record will give me a fill rate so I can at least see if they're filling the medication on a regular basis. And I always have the option of, you know, myself or having one of my colleagues give a call to the pharmacy just to see if they're actually filling the medications as well. But if they're truly, you know, they're filling the medication, they say they're taking the meds six to seven days per week, then that might be an opportunity for me to talk about lifestyle. It might be an opportunity for me to consider those secondary causes of hypertension. And we may just need to layer on another medication.

Craig Williams 9:53

And I'll just reiterate, Steve, that uh increasingly EHRs are linking to pharmacy fill data, which is a wonderful thing. It's one of the greatest things I've seen EHR in the last five to six years is getting that kind of pharmacy payer level data into your system so you can see those refills. So, because in my experience, if someone's refilling the medicine, they're not being that crafty and trying to trick you and then not taking it. So if it's being refilled regularly, that's a great thing to know going in to see that patient. And increasingly, EHRs are getting much better at at pulling that data for you so you don't have to make that kind of timely call to the pharmacy.

Sara Klockars 10:24

Excellent. Thank you.

Switching Hypertension Medications

Sara Klockars 10:26

Mike, you know, if you need to switch hypertension meds, is there a best way to do it?

Michael E. Ernst 10:30

So it depends on the reason why you need to switch, right? I mean, are you switching because you need better blood pressure control? Uh, are you switching because it's a formulary issue and particular insurance prefers this generic within this class or not? So I think you know, those are sort of the first things to think about. The switch that I really want to talk about was ACE's to ARBs because I think that's a really common one. And I think sometimes people maybe fail to appreciate that you know, sort of the dose response curves for those two classes are different. And so, you know, let's say you're on an ACE inhibitor and uh, you know, either you have side effects or you know, you need to switch to an ARB. It's good to think about where you're at in the dose range. So most ACE inhibitors have roughly four to five dose steps. ARBs generally only have two, maybe three. And so if you need some additional blood pressure control, just keep in mind as you're switching across those classes that you may, you know, in terms of your equivalent dose, you may need to step up. If your blood pressure is pretty well controlled and you just you have to switch because of a formulary issue or side effects or whatever, then you would just go across at a similar dose step as opposed to to switching. So there unfortunately there aren't great, you know, comparison studies across classes that way. But I think this is also a key point here is whenever you are switching, is to make sure that um this is another opportunity for our home blood pressure monitoring to make sure that we're getting follow-up data and that we're also getting people back reasonably soon for for that follow-up, because you sort of hate to do this and then not see people for you know six or eight months down the road.

Craig Williams 12:22

I'll say, you know, briefly broadly to this question, those are those are great comments. But you know, as we say, the the best blood pressure medicine is the one that your patient will take and tolerate. So if you do notice if someone's not filling medications or they're not their numbers are consistently not what they kind of should be for the one or two medicines they're on, uh I mean the worst thing to do is to not bring it up and and to not switch. So I think in a lot of ways, there's there's not really a bad way to switch medications if it's something that the patient is not tolerating or taking and and you need to find a medication that then a class that they will tolerate. I thought maybe this conversation would go towards, you know, there's been some literature for like the really niche practices of this kind of trend of try patients on a couple different classes and find which one maybe works best. And when you switch patients between classes, you do often find a class might work better because of the pathology of that patient's hypertension. And there's some decent literature you can get another maybe three to four millimeters of mercury systolic by optimizing the class you choose. I think that's beyond certainly most busy primary care practices. But but maybe sometime down the road, we'll have some tests to help us decide. We don't just randomly pick between the three major drug classes, but we do a bit more tailoring to patients. But I think now it's a bit too much to you know switch just to see what the benefits of different classes in patients.

Michael E. Ernst 13:39

I I I would I would agree with you. The one thing, sort of related point I would just make is that in the initiate, you know, when when we've diagnosed someone with hypertension and everyone's on board, we're gonna start medication. I think it's really important to make sure the patients understand we're gonna start, you know, what we think is gonna be the medication for you, but blood pressure is regulated through multiple different pathways. And and and we have drugs that target some of these different pathways. And many people need more than one drug. And so kind of that education up front, like here's here's what this might look like as we continue down this journey, can be really helpful, I think, for buy-in. Because, you know, unfortunately, I think a lot of times patients just assume you're gonna give them a pill, it's gonna fix everything, and they're not gonna have to worry about it. And if they end up having a little bit more difficult to treat blood pressure, and you know, we've got to escalate meds, we've got to add another class, that that wears on patients. I always like to talk say the saying that you know, patients measure how sick they are by the number of medications they take. So, but helping them understand up front that blood pressure is a complex regulated pathway, and there's we don't always get it right the first time. And you know, we may need to use a combination of medications that can go a long way for buy-in later.

Catherine G. Derington 15:02

I like the vulnerability of that, Mike. Like we, in terms of adherence, we don't expect you to be perfect. We want to get somewhere close to, you know, as much as we can be to perfect, but I'll not be perfect for you, maybe. Like we may not prescribe something that works for you, but we have a plan. We can use all these other meds or whatever. We also probably underestimate or don't even think about how often patients just take themselves off of stuff when they don't feel well or when they don't see that they're responding. The more that we tell people to take home blood pressure measurements, if they're not seeing improvement in debt, that can be negative reinforcement for them and they just may stop taking it on their own. And so when you're switching, maybe it's relevant to say, did you stop? Um, are you still doing this? Or did you take it this morning, or just doing some more investigation into seeing how much actually they have in their system? Because even with the ace to ARB switch, if you've only taken one pill in the last week, I'm more comfortable switching you to an ARB today, you know, than if you had taken it every day.

Craig Williams 16:05

Yeah, uh, we're gonna try this one, but we have options approach. Works well versus here's the pill for you, go take it. Yeah, that that is a being less paternalistic about it can go a long way. I'm always surprised too to hear what people are learning about medicines. They're Googling things these days and they may not like their molided pin because Uncle Tom had some petal edema with it, and so now they're afraid of it. So yeah, you just have to be open to what patients are learning or hearing about medications and be open again to meeting them where they're at.

Michael E. Ernst 16:34

Katie, I thought you were gonna also talk about the occasional patient you run into that uh took their blood pressure medication, their blood pressure is controlled, and therefore they stopped their blood pressure medication because they were cured of the condition, right?

Catherine G. Derington 16:48

I was gonna say that like hypertension is a silent disease, and the treatment's also silent if we're doing our job, where you may not feel different better or worse, and that's good. So that's the goal, even, and patients may not get that unless you say it out loud to them.

Lab Monitoring

Steve Small 17:07

Andrew, how often do you check labs after starting or titrating an ACE inhibitor, an ARB along with a diuretic? So obviously not with set it and forget it kind of a situation. So how do you kind of go about that?

Andrea Darby Stewart 17:19

Absolutely, and I'm uh interested to hear uh what my other colleagues have to say about this as well. Typically when I start patient on a medication such as this, I'll uh recheck their BMP, their basic metabolic panel, between two and four weeks after the start of the dose. I try and get them in earlier, either with myself or with one of my ambulatory pharmacy colleagues or the nurse care coordinator that I get to work with. And so that we can rapidly escalate their blood pressure medication if we need to, but I do prefer to check labs at that two to four week point after starting or changing the dose. If they remain nice and stable, I may reassess it in about six months, just because it's a new medication for them. And I've got many patients who have stable chronic hypertension, have been on their ACE or their ARB for years, and I see them annually and I check their BMP and their uh urine for protein on an annual basis.

Steve Small 18:15

Any different approaches from the group?

Craig Williams 18:18

No, it's great. I'll just say for diuretic, my timeline is a little bit longer than an ACER, but an initial check. So just because you do want to see, make sure you don't have that uh kind of one in a thousand severe AKI from your ACER ARB. So, and interestingly, if you're seeing that patient for something else anyway, the rises in Kratin happen almost immediately with brass blocking therapy. And we see that in hospitalized patients getting daily labs when these are started. So for an ACERB timeline is a little sooner than for a diuretic, but so a week or two for an ACER ARB, I'm fine, you know, not seeing labs for a month after starting a diuretic. And as Andrew says, periodic monitoring after that, depending how stable they are in the therapies.

Emerging Therapies

Sara Klockars 19:00

And Katie, are there any new meds for hypertension in the pipeline?

Catherine G. Derington 19:05

The first is a class of oral agents called aldosterone synthase inhibitors. These are the drugs that end in drostat. Like we hear all of these different ways of remembering medications in pharmacy schools. So if you see larundrostat or baxtrostat, you'll know this is an aldosterone synphase inhibitor. They block the production of aldosterone in the adrenal glands and they're used on top of our tried and true drug classes. There's compelling data that you can lower SVP by an additional nine millimeters of mercury, roughly. And they're largely tested in patients who have resistant hypertension or uncontrolled hypertension on top of that background therapy. These are still in trials, haven't been approved by the FDA. I think the more exciting pipeline therapeutic in my mind is the silencing RNA agents or the agents that target messenger RNA. There's two. Xylbiccerin is a subcutaneous injection, works in the liver to prevent angiotensinogen from being produced at all, and nearly reduces like plasma levels of angiotensinogen to zero, basically. If you block angiotensinogen from being formed, you don't get any of its downstream products. You don't get renin, angiotensin, aldosterone. So it's really, really effective and it's really being studied to be a monotherapy agent. And we can, you know, inject patients every three to six months and see what happens. Maybe they only need one oral medicine every day. So this is still undergoing phase three testing, FDA approval, but it's super promising, super exciting. The other angiotensinogen compound is called tone lamarcin. It's actually working on the messenger RNA piece and not the silencing RNA piece, but it also blocks angiotensinogen production because it's working at a different piece of that RNA pathway. It only lowers SBP by about seven, but it could be an adjunct for patients who are just having a hard time with oral treatments, even though it is still an injection. And then the last kind of set of classes that I'm seeing pop up more in like the phase one, phase two trial world are actually working on the natriuretic peptide system. I think we learned a lot in the drug development space from entresto, this acuitralousartin piece. And there's some naturaletic peptide receptor one agonists that essentially pretend to be ANP and BNP to downregulate the RAS system. And so these trials are, you know, in their phase one, phase two phase of development. And then there's also a peptide called MANP, which is essentially an ANP analog that works the same way. What I think that's interesting about MANP is that there's data to show it also modulates lipid metabolism and insulin sensitivity. So man P could be not just a blood pressure medicine, but also thinking about dyslipidemia and potentially prediabetes and diabetes as well. The data are obviously too early. To know where it would fit in and its role in therapy, but it's a super interesting mechanism that maybe could impact that whole cardio kidney metabolic system. And I think that could be a cool, interesting thing for the future, you know?

Michael E. Ernst 22:14

Yeah, that's uh there's certainly, you know, compared to a decade ago, there's a lot of things that are, as Katie mentioned, in development and some things that are pretty close. I think the challenge for me is always, again, we actually have great drugs now. Yeah, with outcomes and and yeah, with with and so all of these drugs that are in development, while attractive in terms of their ability to have further lowering of blood pressure, they're still gonna need to be able to show outcome data. I mean, obviously, if they lower blood pressure, you would assume that they're gonna lower cardiovascular risk, but we've been burned before in approving drugs just based on surrogate endpoints. So I I think the reality is, you know, these drugs are a long ways away yet, with the exception perhaps of the aldosterone synthase inhibitors, where I think they'll find a home and it with a labeled indication, probably for you know resistant hypertension, because that's a phenotype that is well defined. But yeah, I just again I I come back to the fact that so much of our challenge in controlling blood pressure is not really about I don't have the right recipe of drugs or I just don't have the drug I need. It's really all of the other pieces of the puzzle, you know, the the social determinants that impact all of this, the it, you know, that it impact adherence, it's the other lifestyle stuff. And so, you know, while I'm excited on the one hand about always having new classes, I think the the reality of them making a big impact in the very near future, I think is is is um pretty small.

Catherine G. Derington 23:53

It's small, yeah. Well, and we have like 11 or 12 blood pressure classes, and like considering all the individual meds, we have over 60 individual medications, and all of those have their unique doses and all act differently when you combine them in different ways. Yeah. So it's just hard to look at what we have and then see what's coming and be like, okay, how much how much better are we gonna get? You know? When these are already generic, cheap, effective, safe.

Michael E. Ernst 24:21

Yeah. I and and again, I think I certainly have spent a lot of time around our medical residents. And, you know, I think sometimes we we sort of overestimate when they graduate from medical school how much they really know about using these drugs in combination and just some of the heterogeneity within class. And so again, I think I think we can do so much to also help educate our clinician colleagues that are prescribing these drugs, you know, mid-level providers as well, on how to use these drugs effectively in combinations, which again, having fixed dose combinations is helpful. But many of the clinicians I work with will tell me, you know, it's hard to break old habits, you know, it's hard to break old habits. And but yeah, I just I again I'm excited about, I'm always excited about drug development, but being present in the here and now, I think that we can improve our blood pressure control rates just as easily with uh, you know, probably better utilization of the drugs we have and the uh addressing many of the other, you know, sort of the social barriers and just all of the other pieces that we know affect blood pressure.

Narrator 25:38

We hope

Conclusion

Narrator 25:39

you enjoyed and gained practical insights from listening to this discussion. And just a note that Baxtrostat was FDA approved under the trade name Baxfendi days after this recording. Now that you've listened, you can log in to your pharmacist letter, pharmacy technician's letter, or prescriber insights account and access and print out additional materials on this topic, like charts and other quick reference tools. We've linked directly to a few relevant ones right in the show notes. If you're not yet a pharmacist letter, pharmacy technician's letter, or prescriber insights subscriber, now's the time. Sign up today to stay ahead with trusted, unbiased insights and continuing education. And as a listener, you can save 10% on a new or upgraded subscription with code MT1026 at checkout. Be sure to follow or subscribe, rate, and review this show in your favorite podcast app. Or find the show on YouTube by searching for TRC Healthcare or clicking the link in the show notes. You can also reach out to provide feedback or make suggestions by emailing us at contactus at trchealthcare.com. Thanks for listening to Medication Talk.