What is the recommended blood pressure treatment for a patient on Zejula (niraparib)?

Blood Pressure Management for Patients on Zejula (Niraparib)

For patients on Zejula (niraparib), ACE inhibitors or ARBs are recommended as first-line therapy for hypertension management, with a blood pressure target of 120-129/70-79 mmHg if tolerated.

Understanding Hypertension in Patients on Zejula

Zejula (niraparib) is a PARP inhibitor used as maintenance therapy in patients with advanced ovarian cancer. While the primary evidence doesn't specifically address hypertension management in patients taking Zejula, we can apply general hypertension management principles with consideration of the patient population.

First-Line Medication Selection

Recommended Approach:

1. First-line agent: ACE inhibitor or ARB

   • Particularly beneficial for patients with:
     • Coronary artery disease 1
     • Chronic kidney disease 2, 1
     • Diabetes with albuminuria 2, 1

2. Second-line agent (if needed): Add a dihydropyridine calcium channel blocker (CCB)

   • The combination of an ARB and a dihydropyridine CCB is well-supported for non-Black patients 1

3. Third-line agent (if needed): Add a thiazide-like diuretic

   • Consider if BP remains uncontrolled on ARB + CCB combination 1

Special Considerations:

• For patients of African descent, a thiazide-like diuretic plus CCB may be more effective 1
• ARBs may be preferred over ACE inhibitors due to lower risk of cough and angioedema 1

Blood Pressure Targets

The recommended target blood pressure for patients on Zejula is 120-129/70-79 mmHg if tolerated 2, 1. This target is consistent with current guidelines that emphasize more intensive blood pressure control for optimal cardiovascular risk reduction.

For patients who cannot tolerate this target (e.g., due to symptoms of hypotension), a more lenient target may be considered, but blood pressure should always be maintained below 140/90 mmHg 2, 1.

Monitoring Recommendations

1. Initial monitoring:

   • Check blood pressure, renal function, and electrolytes within 2-4 weeks of starting antihypertensive therapy 1
   • Continue regular monitoring, particularly when adding or adjusting medications

2. Home blood pressure monitoring:

   • Encourage home BP monitoring to guide treatment adjustments 1
   • This is particularly important for patients on Zejula to detect any treatment-related hypertension early

Lifestyle Modifications

In addition to pharmacological treatment, lifestyle modifications should be recommended:

1. Dietary approaches:

   • Sodium restriction (<1500 mg/day) 1
   • DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy 1
   • Increased dietary potassium (3500-5000 mg/day) 1

2. Physical activity:

   • 90-150 minutes/week of aerobic or dynamic resistance exercise 1
   • Alternatively, isometric resistance 3 sessions/week 1

3. Weight management:

   • Weight loss if overweight or obese (approximately 1 mmHg SBP reduction per 1 kg weight loss) 1

4. Alcohol moderation:

   • ≤2 drinks/day for men, ≤1 drink/day for women 1

Potential Pitfalls and Caveats

1. Medication interactions: Monitor for potential interactions between antihypertensive medications and Zejula

2. Thrombocytopenia risk: Zejula can cause thrombocytopenia 3, which may influence the choice and dosing of antihypertensive medications that might affect platelet function

3. Fatigue consideration: Since fatigue is a common side effect of Zejula 4, choose antihypertensive medications that minimize additional fatigue when possible

4. Avoid treatment resistance: If blood pressure remains ≥130/80 mmHg despite adherence to ≥3 antihypertensive medications at optimal doses (including a diuretic), consider evaluation for resistant hypertension 1

By following these evidence-based recommendations, clinicians can effectively manage hypertension in patients receiving Zejula while minimizing cardiovascular risk and optimizing treatment outcomes.