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Hypertension

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Background

Hypertension (HTN) is one of the most common side effects of antiangiogenic therapy, including bevacizumab. The incidence of HTN (> 150/100 mm Hg) in patients receiving bevacizumab with a 5-FU–based regimen ranged from 60% to 67%, compared with 43% in the control arm not receiving bevacizumab. The incidence of severe HTN (National Cancer Institute Common Toxicity Criteria [NCI CTC] grade 3/4; ≥ 200/110 mm Hg) was 7% to 10%, compared with 2% in patients not receiving bevacizumab.1 The incidence of severe HTN increased in patients receiving bevacizumab compared with controls. Across clinical studies, the incidence of NCI-CTC grade 3 or 4 HTN ranged from 8% to 18%.1 The presence of HTN during bevacizumab therapy is statistically associated with proteinuria, although a causative relationship has not yet been established. No temporal relationship between HTN and proteinuria was found in an observational study by Martel and colleagues, who noted that half the patients developed HTN first and the other half, proteinuria.2

In the presence of HTN, careful monitoring of blood pressure (BP) prior to each chemotherapy treatment or more frequently is warranted.3,4 Patients who develop HTN during therapy should be advised to purchase a home BP monitoring system. BP should be checked at home at least once daily, and patients should be advised to contact the clinic if they note either intermittent elevated BP levels or a trend toward an increase.

Bevacizumab-related HTN should be treated with standard oral antihypertensive therapy, titrated to effect. If BP control is less than optimal, the patient should be referred to a cardiologist or to an internist specializing in HTN management. Standard oral antihypertensive agents used to manage bevacizumab-related HTN include1,5:

  • Angiotensin-converting enzyme (ACE) inhibitors
  • Beta blockers
  • Calcium channel blockers
  • Diuretics

Treatment with bevacizumab should be temporarily suspended in patients with severe HTN that is not controlled with medical management and permanently discontinued in patients with hypertensive crisis. HTN can persist after discontinuation of bevacizumab.1

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Assessment Tools

Table 1. Comparison of JNC 7 Blood Pressure Classification and Common Terminology Criteria for Adverse Events Grading of Hypertension

JNC7 Blood Pressure Classification
Blood Pressure Classification
Systolic Blood Pressure, mm Hg
Diastolic Blood Pressure, mm Hg
Normal
< 120
< 80
Prehypertension
120-139
80-99
Stage 1 hypertension
140-159
90-99
Stage 2 hypertension
≥ 160
≥ 100

JNC = Joint National committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Data from Chobanian et al.6

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Common Terminology Criteria for Adverse Events (v3.0) Grading of Hypertension
Grade
Adverse Event
0
None
1
Asymptomatic, transient (≤ 24 h) increase by > 20 mm Hg (diastolic) or to > 150/100 mm Hg if previously within normal limits; intervention not indicated
2
Recurrent or persistent (≤ 24 h) or symptomatic increase by > 20 mm Hg (diastolic) or to > 150/100 mm Hg if previously within normal limits; monotherapy may be indicated
3
Requiring more than one drug or more intensive therapy than previously
4
Life-threatening consequences (eg, hypertensive crisis)
5
Death

Data from NCI CTEP.7

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An algorithm for treating hypertension by Rosiak and Sadowski,8 can be accessed at http://www.ons.org/publications/journals/CJON/Volume9/Issue4/pdf/0904407.pdf

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References

  1. Avastin (bevacizumab) full prescribing information. Available at: http://www.gene.com/gene/products/information/oncology/avastin/insert.jsp. Accessed August 27, 2006.
  2. Martel CL, Presant CA, Ebrahimi B, et al. Bevacizumab-related toxicities: association of hypertension and proteinuria. Community Oncol. 2006;3:90-93.
  3. Knoop T. Nursing management of patients receiving angiogenesis inhibitors [monograph]. In: Current Topics in Colorectal Cancer: Targeting VEGF. Miami, Fla: Institute for Medical Education and Research; 2005.
  4. Wilkes GM. Therapeutic options in the management of colon cancer: 2005 update. Clin J Oncol Nurs. 2005;9:31-44.
  5. Miles JS. Hypertension therapy for the oncology patient. Community Oncol. 2006;3:94-99.
  6. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA. 2003;289:2560-2572. [Pub Med]
  7. National Cancer Institute Cancer Therapy Evaluation Program. Common terminology criteria for adverse events v3.0. Available at: http://ctep.cancer.gov/reporting/ctc.html. Accessed August 27, 2006.
  8. Rosiak J, Sadowski L. Hypertension associated with bevacizumab. Clin J Oncol Nurs. 2005;9:407-411.

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This page was last modified on 3/27/2007, at 11:17:51 am ET.