Guidance on managing hypertension in patients receiving bevacizumab

Pre-existing hypertension should not be a barrier to starting bevacizumab. That is the conclusion of a new set of UK-specific recommendations on the management of hypertension in patients with ovarian and cervical cancer receiving bevacizumab.

The recommendations have been developed by a group with representation from oncology, cardiology, general practice, and nursing, and include the following:

Considerations before bevacizumab treatment

• Bevacizumab can be started in patients with a clinic blood pressure (BP) <160/100 mm Hg.
• If average ambulatory or home BP monitoring (ABPM/HBPM) BP over ≥4 days is ≥150/95 mm Hg, delay bevacizumab.
• Initiate bevacizumab when ABPM/HBPM BP is <150/95 mm Hg.
• If BP remains ≥150/95 mm Hg, step up antihypertensive treatment.
• Initiated 5 mg amlodipine daily in antihypertensive-naive patients and reassess after ≥2 weeks.
• Management of hypertension should be initiated in the oncology unit and then transferred to primary care.

Consideration during treatment

• Bevacizumab can be initiated when pre-infusion BP is <160/100 mm Hg.
• No antihypertensive treatment is required in antihypertensive-naive patients.
• Patients already on antihypertensive drugs should continue treatment.
• If clinic BP is ≥160/100 mm Hg or there has been a marked increase of ≥20 mm Hg systolic or ≥10 mm Hg diastolic, bevacizumab dose should be omitted.
• If average ABPM/HBPM BP is <150/95 mm Hg, bevacizumab can be continued at the next visit.
• If BP remains ≥150/95 mm Hg, initiated amlodipine 5 mg daily in antihypertensive-naive patients and reassess after ≥2 weeks.
• If clinic BP remains ≥160/100 mm Hg and/or ABPM/HBPM is ≥150/95 mm Hg, antihypertensive treatment should be stepped up.
• If BP fails to drop below these thresholds despite treatment with ≥3 antihypertensive drugs, or if there are multiple drug intolerances, consider referral to a clinician with a special interest in hypertension.
• Antihypertensive-naive patients with BP ≥220 mm Hg systolic should be checked for functional deterioration of vital organs.
• Bevacizumab should be permanently withheld in cases of malignant-phase hypertension, hypertensive crisis, or hypertensive encephalopathy.

Considerations after bevacizumab

• Bevacizumab-associated hypertension typically resolves after treatment is complete.