in japan , it is estimated that there are 43 million ( 23 million men and 20 million women ) hypertensive patients 1 .
hypertension ( ht ) has been reported to increase the risk of cardiovascular disease ( cvd ) , including heart disease and stroke 2 , 3 , 4 , 5 .
the stroke morbidity and mortality rates have been reported to be higher in east asian countries than in western countries 1 .
of 834,000 deaths from noncommunicable diseases and injuries in japan , high blood pressure ( bp ) accounted for 104,000 deaths 1 .
previous studies found that home bp monitoring ( hbpm ) was readily accepted by and performed by hypertensive patients 6 , 7 , 8 .
moreover , bp control was found to be better with these systems than with traditional methods 9 , 10 , 11 .
margolis et al . reported that bp control was better with home bp telemonitoring systems and pharmacist case management than with usual care 12 .
we believed that these systems could be useful for monitoring side effects of antihypertensive drugs .
pharmacist management programs , which was conducted using bp telemonitoring systems , were recently introduced in our community pharmacy ( haruka community pharmacy ) 13 .
pharmacist comanagement , and a female patient who was under one of these programs was found to have orthostatic dizziness induced by antihypertensive drugs . here , we present the case of a patient who experienced side effects induced by antihypertensive drugs and show the importance of pharmacist bp management programs using telemonitoring systems for monitoring side effects of antihypertensive drugs in a community pharmacy .
a 55yearold woman with ht was advised to measure her bp regularly by her doctor .
she consulted with a pharmacist at haruka community pharmacy , and the pharmacist recommended that she participate in a pharmacist bp management program .
she agreed to participate in the program and started taking antihypertensive drugs ( azilsartan , 20 mg / day ; cilnidipine , 10 mg / day ) on the same day .
the home bp telemonitoring system involved the use of medical link ( omron healthcare , kyoto , japan ) .
this system wirelessly transmits bp data to a central web server via a mobile network .
the pharmacist advised that she measure her bp twice per day ( at the time of awakening and at bedtime ) , and provided her with information on the importance of lifestyle modification via a printed handout before starting bp monitoring 13 .
briefly , the pharmacist collected information regarding her lifestyle from an interview and advised her about lifestyle modification .
her systolic and diastolic bp values and drug history are presented in figures 1 and 2 , respectively .
although she did not measure bp at home before the monitoring period , the frequency of bp measurement was 96.1% after starting the program ( fig .
the mean systolic and diastolic bp values from day 0 to day 13 were 136 mmhg and 83 mmhg , respectively .
therefore , her doctor switched azilsartan ( 20 mg / day ) to olmesartan ( 20 mg / day ) and cilnidipine ( 10 mg / day ) to azelnidipine ( 16 mg / day ) on day 15 .
moreover , indapamide ( 1 mg / day ) was added on the same day .
her body weight ( 50 kg ) did not change from day 0 to day 15 .
furthermore , to improve muscle tone , etizolam ( 0.25 mg / day ) and afloqualone ( 70 mg / day ) were started on the same day .
the mean systolic and diastolic bp values from day 15 to day 21 were 104 and 66 mmhg , respectively .
therefore , the pharmacist believed that the antihypertensive drugs might be responsible for her orthostatic dizziness and consulted with her doctor to check whether the drugs should be changed .
the mean systolic and diastolic bp values from day 22 to day 29 days were 106 and 66 mmhg , respectively .
the pharmacist called her on day 29 to check whether she was still experiencing orthostatic dizziness .
the pharmacist again consulted with her doctor to check whether the drugs should be changed based on her symptom and bp values .
olmesartan ( 20 mg / day ) and azelnidipine ( 16 mg / day ) were discontinued , and indapamide ( 1 mg / day ) was restarted on day 29 .
her orthostatic dizziness improved , and the mean systolic and diastolic bp values from day 30 to day 93 were 122 and 72 mmhg , respectively .
her systolic bp values were over 140 mmhg on days 62 , 79 , and 87 .
therefore , her doctor added amlodipine ( 2.5 mg / day ) on day 93 .
the mean systolic and diastolic bp values from day 94 to day 101 were 116 and 68 mmhg , respectively .
she did not experience orthostatic dizziness induced by antihypertensive drugs from day 94 to day 101 .
in the present case report , the pharmacist advised the patient with ht to perform hbpm , and she successfully performed monitoring at regular intervals . the pharmacist could consult with her doctor based on her symptom of orthostatic dizziness induced by antihypertensive drugs and her bp values , which resulted in the improvement of her orthostatic dizziness .
etizolam and azelnidipine are metabolized by cyp3a4 , and the blood levels of these drugs increase via drug  drug interactions .
etizolam can cause dizziness as a side effect , and dizziness may worsen if drug  drug interactions occur .
orthostatic dizziness induced by antihypertensive drugs can be improved by reducing the dose of the drugs or switching to other antihypertensive drugs . in the present case ,
improvement in orthostatic dizziness after modification of the treatment indicated that the patient 's dizziness was induced by antihypertensive drugs .
hbpm and medical interview are important to prevent symptoms induced by antihypertensive drugs . in japan , pharmacists in a community pharmacy
obtain the home bp values from selfreports or medical reports of patients ; however , selfreports are less reliable than medical reports .
medical reports are based on the records of medical staff ; therefore , the updating frequency is lower for medical reports than for selfreports .
although home bp telemonitoring can solve these problems , bp telemonitoring systems have been introduced in a small number of pharmacies in japan . to our knowledge , this is the first case report of the use of a bp telemonitoring system to monitor side effects of antihypertensive drugs in a community pharmacy .
our findings suggest that an hbpm system can improve pharmaceutical management in a community pharmacy .
however , to operate this system effectively , the frequency of measuring home bp should be high .
although the frequency of measuring home bp was high in present case , further studies are required to assess the introduction of a bp telemonitoring system for patients with poor adherence .
pharmacist bp management programs using telemonitoring systems might be useful for monitoring side effects of antihypertensive drugs in a community pharmacy .
 key clinical messagewe previously started pharmacist blood pressure ( bp ) management programs using telemonitoring systems for monitoring side effects of antihypertensive drugs in a community pharmacy . 
 the present case demonstrates that pharmacist bp management programs using telemonitoring systems are useful for monitoring side effects of antihypertensive drugs in a community pharmacy . 
Introduction
Case History and Examination
Discussion
Conclusion
Consent
Conflicts of Interest