(NB if low BP at baseline adjust accordingly – see notes section)

The recommended target BP is <140/90 – ideally should be this before starting therapy. 

Treatment can continue as long as BP<160/100*(see notes section). Above this, VEGF-i treatment should be withheld until hypertension treated. Antihypertensive therapy should be initiated/increased if BP consistently >140/90. 

Refer to specific study protocol for all patients receiving VEGF-i in a clinical trial. 

• Ensure pre-existing hypertension is adequately controlled before starting treatment with VEGF-inhibitors (should be below 140/90 on most recordings at rest).  
• Actively monitor blood pressure throughout VEGF-inhibitor treatment. 
• All blood pressure (BP) recordings should be taken whilst patient is relaxed and after sitting resting for 10 minutes in a quiet place.  
• If elevated, BP should be repeated after 20-30 minutes of rest in a relaxed place.  
• If persistently elevated in the oncology clinic/ward (but not requiring immediate treatment), arrangements should be made for either home BP monitoring (see below) or confirmatory BP measurements at the GP surgery.

Patients taking oral VEGF-inhibitors should be asked to purchase a home BP monitor and check their BP daily as per the home BP monitoring Patient Information Leaflet (PIL) (only accessible when connected to intranet) In the event of persistent elevated BP, the patient should contact their GP for advice on management of their BP.  If grade 3 or 4 hypertension, they should also contact the on call oncology team at WGH as per advice in the PIL(only accessible when connected to intranet) If unable to purchase a home BP monitor, then:  

• Arrange weekly BP measurements by the GP practice nurse  
• Review results at next clinic/SACT visit 
• Use average value of all measurements to confirm a diagnosis of hypertension. Exclude outliers.

Patients treated with VEGF-i should have their blood pressure monitored, whilst resting, before initiating therapy and with each cycle of therapy (every 2-3 weeks). Please see notes in sections above about how to monitor and check BP.

Drug choice 

(more detail about each drug in later section)

NHS Scotland. East region formulary. Hypertension.  

NHS Lothian hypertension guidelines (only available when connected to the intranet)

• BP should be <140/90 prior to initiating treatment with VEGF-i. If above this then optimise management of BP in conjunction with GP before first dose of VEGF-i. 
• *Care if low BP at start. If BP rises to ≥ 40mmHg syst or 20mmHg diast above baseline then start BP drugs. If BP rises ≥ 60mmHg syst or 30mmHg diast above start then withhold VEGF-i and start BP drugs. 
• Sometimes up to three or more drugs may be required to control hypertension.  
• Antihypertensives from different classes generally have an additive effect when prescribed together.  
• Submaximal doses of two drugs may result in larger falls in BP and fewer adverse effects than maximal dosages of a single drug.  
• The best classes of antihypertensive drugs to treat hypertension caused by VEGF-i appear to be ACE inhibitors but calcium blockers are often preferred with SACT.  
• Angiotensin II inhibitors (e.g. candesartan 8mg) can be used as an alternative to ACE-i in black patients, or patients intolerant of ACE-i.  
• As ACE-i are often discontinued during platinum therapy and not given if renal impairment, the risks and benefits of BP therapy must be evaluated, and steps 1-3 modified according to individual circumstances.

Points to consider when selecting and prescribing antihypertensives for an individual patient: