National Institute for Health and Care Excellence Draft for consultation Hypertension in pregnancy [E] Evidence review for postnatal management of hypertension NICE guideline CG107 (update) Evidence review February 2019 Draft for Consultation This evidence review was developed by the National Guideline Alliance hosted by the Royal College of Obstetricians and Gynaecologists DRAFT FOR CONSULTATION Error! No text of specified style in document. Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties. NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn. Copyright © NICE 2019. All rights reserved. Subject to Notice of Rights ISBN: DRAFT FOR CONSULTATION Contents Review question HiP5. What is the optimal management of hypertension for women during the postnatal period? .................................................................................. 6 Introduction ........................................................................................................... 6 Summary of the protocol ....................................................................................... 6 Methods and process ............................................................................................ 7 Clinical evidence ................................................................................................... 7 Summary of clinical studies included in the evidence review ................................. 7 Quality assessment of clinical studies included in the evidence review ............... 12 Economic evidence ............................................................................................. 12 Evidence statements ........................................................................................... 13 Comparison 1. Beta blockers / mixed alpha-beta blockers versus centrally acting α2-adrenoceptor agonists .............................................................. 13 Comparison 2. Beta blockers versus beta blockers. ............................................ 13 Comparison 2.1 Atenolol versus metoprolol ........................................................ 13 Comparison 2.2 Atenolol versus propranolol ....................................................... 14 Comparison 3. Beta blockers/mixed alpha-beta blockers versus placebo ............ 14 Comparison 4. Centrally acting α2-adrenoceptor agonists versus ACE inhibitors .................................................................................................. 14 Comparison 5. Calcium channel blockers versus placebo/ low sodium diet ......... 15 Comparison 6. Calcium channel blockers versus beta blockers .......................... 15 Comparison 7. Diuretics versus placebo/no intervention ..................................... 16 Comparison 8. Vasodilators versus beta blockers / mixed alpha-beta blockers ... 16 Beta-blockers (non-comparative studies)............................................................. 16 Calcium channel blockers (non-comparative studies) .......................................... 17 Recommendations .............................................................................................. 17 Rationale and impact ........................................................................................... 18 The committee’s discussion of the evidence ........................................................ 19 References ................................................................................................................... 22 Appendices ........................................................................................................................ 24 Appendix A – Review protocol ...................................................................................... 24 Appendix B – Literature search strategies .................................................................... 32 Review question search strategies ...................................................................... 32 Databases: Medline; Medline EPub Ahead of Print; and Medline In-Process & Other Non-Indexed Citations .................................................................... 32 Database: Embase; and Embase Classic ............................................................ 34 Databases: Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects; and Health Technology Assessment ........................................... 36 Health economics search strategies .................................................................... 38 4 DRAFT FOR CONSULTATION Databases: Medline; Medline EPub Ahead of Print; and Medline In-Process & Other Non-Indexed Citations .................................................................... 38 Databases: Embase; and Embase Classic .......................................................... 40 Databases: Cochrane Central Register of Controlled Trials; Health Technology Assessment; and NHS Economic Evaluation Database ........................... 43 Appendix C – Clinical evidence study selection ............................................................ 45 Appendex D – Clinical evidence tables ......................................................................... 46 Appendix E – Forest plots............................................................................................. 83 Appendix F – GRADE tables ........................................................................................ 84 Appendix G – Economic evidence study selection ...................................................... 104 Appendix H – Economic evidence tables .................................................................... 105 Appendix I – Health economic evidence profiles ......................................................... 106 Appendix J – Health economic analysis ...................................................................... 107 Appendix K – Excluded studies .................................................................................. 108 Clinical studies .................................................................................................. 108 Economic studies .............................................................................................. 113 Appendix L – Research recommendations ................................................................. 114 5 DRAFT FOR CONSULTATION Postnatal management 1 Review question HiP5. What is the optimal management of 2 hypertension for women during the postnatal period? 3 Introduction 4 Hypertension in the postnatal period affects several groups of women, including those with 5 chronic hypertension, gestational hypertension and pre-eclampsia. Hypertension may also 6 present for the first time in the postnatal period. Regardless of the different underlying 7 causes and clinical presentations, treatment of hypertension is broadly similar. 8 There is limited information about the use of antihypertensive drugs in the postnatal period, 9 particularly in women who choose to breastfeed, and some antihypertensive drugs are 10 contraindicated or must be used with caution by women who are breastfeeding. The choice 11 of medication should therefore be discussed with women requiring antihypertensive drugs so 12 that women can make informed choices. Encouraging and supporting breastfeeding is a key 13 priority for maternity care providers. 14 The aim of this review is to identify the efficacy and safety of different antihypertensives for 15 the management of hypertension in the postnatal period. 16 Summary of the protocol 17 See Table 1 for a summary of the population, intervention, comparison and outcome (PICO) 18 characteristics of this review. 19 Table 1: Summary of the protocol (PICO table) Population Postnatal women who require antihypertensive treatment up to 6 weeks after delivery Intervention Beta blockers / mixed alpha-beta blockers Centrally acting α2-adrenoceptor agonists Calcium channel blockers Angiotensin receptor blockers Angiotensin converting enzyme (ACE) inhibitors Diuretics Vasodilators Comparison Other antihypertensive agents Placebo No treatment Outcome Critical outcomes: Outcomes for women