Hypertension Treatment in Spina Bifida
For patients with spina bifida and hypertension, treatment should follow standard hypertension guidelines with special attention to renal function monitoring, as renal scarring is strongly associated with hypertension in this population. 1
Epidemiology and Risk Assessment
- Hypertension appears to be more prevalent in spina bifida patients compared to the general population, with studies showing high blood pressure in 27% of patients aged 18-29, increasing to 67% in those 50 years or older 2
- Renal scarring on DMSA scans is significantly associated with hypertension (46% of patients with scarring had hypertension) and decreased estimated glomerular filtration rate (eGFR) in spina bifida patients transitioning to adulthood 1
- Obesity, present in 43% of older spina bifida patients, is a common comorbidity that contributes to hypertension risk 3
Initial Evaluation
- Comprehensive screening for secondary causes of hypertension is recommended in young adults with spina bifida, particularly given their higher risk of renal dysfunction 4, 2
- Consider DMSA renal scanning to detect renal scarring, which is strongly associated with hypertension in this population 1
- Evaluate for common comorbidities in spina bifida patients that may contribute to hypertension, including:
Treatment Approach
Lifestyle Modifications
- Weight management should be a priority, as obesity affects 43% of older spina bifida patients and contributes to hypertension 3
- Recommend dietary approaches such as DASH diet with sodium restriction to less than 2,300 mg/day 4
- Encourage regular physical activity adapted to the patient's mobility capabilities 4
- Advise moderation or avoidance of alcohol consumption 4
- Recommend smoking cessation for tobacco users (38% of hypertensive spina bifida patients use tobacco) 4, 2
Pharmacological Treatment
- For confirmed office BP ≥140/90 mmHg, initiate prompt pharmacological treatment alongside lifestyle measures 4
- For patients with diabetes and confirmed BP ≥130/80 mmHg, initiate pharmacological treatment 4
- First-line medications should include:
- For most patients, combination therapy is recommended as initial treatment, preferably as a single-pill combination to improve adherence 4
- Preferred combinations include a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or diuretic 4
- If BP is not controlled with a two-drug combination, increase to a three-drug combination (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic) 4
Blood Pressure Targets
- Target systolic BP to 120-129 mmHg if tolerated 4
- In patients with chronic kidney disease, target systolic BP to 130-139 mmHg 4
- In patients with diabetes, target systolic BP to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 4
Special Considerations for Spina Bifida
- Regular monitoring of renal function is crucial, as renal scarring is associated with hypertension in this population 1
- Consider antihypertensive treatment for patients with renal scarring even if blood pressure is borderline, to protect renal function 1
- Be vigilant for deterioration in ambulatory function, which typically begins around age 40 in >80% of spina bifida patients and may impact ability to exercise 3
- Monitor for and address pain, which is a common issue in spina bifida patients and may affect adherence to lifestyle modifications 3
- Consider the impact of executive dysfunction and nonverbal learning disability on self-management and treatment adherence 5
Follow-up and Monitoring
- Regular monitoring of serum creatinine/eGFR and potassium levels is recommended, especially for patients on ACE inhibitors, ARBs, or diuretics 4
- Regular follow-up with specialists in urology, neurosurgery, and physiatry is beneficial for almost all adults with spina bifida 5
- Maintain lifelong BP-lowering treatment if well tolerated 4
- Consider comprehensive spina bifida-specific health evaluations throughout adulthood 3