From the Guidelines
Managing hypertension in homeless individuals requires a multifaceted approach that prioritizes lifestyle modifications and accessible medical care. The most recent and highest quality study, 1, emphasizes the importance of lifestyle intervention in hypertension management, including weight loss, a Dietary Approaches to Stop Hypertension (DASH)-style eating pattern, moderation of alcohol intake, and increased physical activity.
Key Considerations
- Lifestyle modifications, such as reducing sodium intake to less than 2,300 mg/day and increasing consumption of fruits, are crucial in managing hypertension, as highlighted in 1 and supported by earlier studies like 1.
- Given the challenges faced by homeless individuals, it is essential to provide a 90-day supply of medication when possible and connect patients with pharmacy assistance programs or federally qualified health centers that offer sliding scale medication costs.
- Blood pressure monitoring can be facilitated through regular visits to free clinics, emergency departments, or community health centers, and patients should be encouraged to limit alcohol consumption and quit smoking, with connections to community resources for cessation support.
- Addressing comorbidities like diabetes and substance use disorders simultaneously is vital, as these conditions can worsen hypertension, and helping patients establish a consistent relationship with a community health center can provide continuity of care despite housing instability.
Practical Recommendations
- First-line treatment should include long-acting medications that require minimal daily dosing, such as amlodipine 5-10mg once daily, chlorthalidone 12.5-25mg once daily, or losartan 50-100mg once daily, as these medications maintain effectiveness even with occasional missed doses and often have lower costs.
- Diet modifications should be realistic, focusing on reduced sodium intake by avoiding canned foods when possible and choosing lower-sodium options at soup kitchens or food pantries.
- Providing written documentation of the diagnosis and medication regimen that patients can carry with them can help maintain treatment consistency across different healthcare settings, as suggested by the principles outlined in 1 for managing resistant hypertension and improving overall hypertension management.
From the FDA Drug Label
Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than one drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)
The management of hypertension in the homeless population is not directly addressed in the provided drug labels. However, the labels suggest that control of high blood pressure should be part of comprehensive cardiovascular risk management. This may involve:
- Lipid control
- Diabetes management
- Antithrombotic therapy
- Smoking cessation
- Exercise
- Limited sodium intake It is also noted that many patients will require more than one drug to achieve blood pressure goals, and that published guidelines such as those from the National High Blood Pressure Education Program should be consulted for specific advice on goals and management 2 3.
From the Research
Managing Hypertension in the Homeless
- Hypertension is a common chronic physical health problem among homeless persons, with material conditions of homelessness complicating its management 4.
- A survey of medical directors in health care clinics for the homeless in large US cities found that therapeutic goals for hypertension management are similar to those in traditional clinical practice, but the means of achieving them often differ 4.
- Factors such as lack of insurance, smoking, and alcohol abuse can contribute to uncontrolled hypertension among homeless adults 5.
- Comprehensive approaches to improve social support, access to medical insurance, and medication adherence may be necessary to improve blood pressure control in this population 5.
Treatment Options
- Combination antihypertensive therapy, including agents that address renin secretion and renin-independent hypertension, may be effective in managing hypertension in homeless individuals 6, 7.
- The use of a single pill containing multiple agents, such as amlodipine, valsartan, and hydrochlorothiazide, may simplify therapy and improve blood pressure control 6.
- Calcium channel blockers and diuretics may be effective add-on therapies to renin-angiotensin system blockers for treating hypertension in patients with renal disease 7, 8.