Hypertension: Promoting Adherence When a Condition Is "Silent"

Dr. Nguyen is a freelance clinical writer based in San Jose, California. Dr. Muzyk is a freelance clinical writer based in Tampa, Florida.

Hypertension is often a silent condition that can lead to end organ damage such as renal failure if inadequately treated.^1,2 Management of hypertension includes maintaining blood pressure (BP) at goal, preventing complications, and promoting health. According to the hypertension guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the goal BP should be below 140/90 mm Hg (130/80 mm Hg for patients with diabetes or chronic kidney disease).³ It is crucial that health care providers and patients work together closely to achieve and maintain treatment goals for hypertension.

The pharmacist has many opportunities during personal interactions with a patient to establish a professional and caring relationship and become a valuable information resource for hypertension management. One of the best ways to gain respect and trust from a patient is through effective communication during patient counseling sessions. Patient counseling for managing hypertension should focus not only on improving understanding of the disease state and antihypertensive medications, but also on enhancing patients’ awareness of nonpharmacologic treatment options.

When communicating with patients, it is important to simplify medical terminologies. If the patient is receiving an antihypertensive medication for the first time, the pharmacist should assess the patient’s knowledge about hypertension and provide a quick overview when necessary. The overview can begin with an explanation of hypertension as a condition in which BP is elevated. The pharmacist also should point out that untreated hypertension can lead to dire consequences, such as renal failure, stroke, or heart failure.^4-7 According to a review of randomized clinical trials, antihypertensive therapy can reduce incidence of stroke by 35% to 40%, heart attack by 20% to 25%, and heart failure by >50%.⁸

Lifestyle Modification

Lifestyle modification (LSM) alone can sometimes suffice in the management of hypertension. It has been shown that a healthy lifestyle can reduce BP significantly, enhance the efficacy of antihypertensive agents, and decrease cardiovascular risks.^9-12 LSM includes increasing physical activity, smoking cessation, limiting alcohol consumption, reducing sodium intake, and adopting the Dietary Approaches to Stop Hypertension (DASH) plan.¹³ Pharmacists also should inform their patients that every 10 kg in weight reduction can equal a reduction of up to 20 mm Hg in systolic BP, and the continued on page 71 66 n 12.09 | Pharmacy Times www.PharmacyTimes.com All patients on antihypertensive medications should be counseled to monitor for signs and symptoms of hypotension. DASH diet can also equal a reduction of up to 14 mm Hg in systolic BP, according to multiple long-term studies. ^9-12

Antihypertensive Medications

In addition to LSM, some patients with hypertension also require medication( s) to achieve their BP goal. The pharmacist can help to ensure patients know how and when to administer medications correctly and what to expect from them. When taking antihypertensive medications, all patients with hypertension need to be informed about signs and symptoms of hypotension, which include dizziness, blurred vision, weakness, and confusion. Patients should be told to rise slowly from a lying or sitting position to reduce dizziness and avoid falls.

The pharmacist and patient also need to discuss the common side effects of his or her medication and the signs and symptoms of a true allergic reaction, such as hives, wheezing, and swelling of the lips, tongue, or face. The table summarizes the general counseling points for each antihypertensive class.

Patient adherence is paramount for the treatment of hypertension. Hypertension usually does not exhibit any major symptoms, and many antihypertensive medications can have serious side effects; thus, nonadherence is very common.¹⁴ The pharmacist has a vital role in stressing the importance of adherence in managing hypertension and slowing future complications.

Blood Pressure Self-Monitoring

As well as improved understanding of drug therapy and awareness of the importance of LSM, regular self-monitoring of BP can significantly increase adherence. Self-monitoring of BP gives patients a chance to see their response to antihypertensive medications and also helps rule out white-coat syndrome. Pharmacists can provide assistance in the selection of a BP monitoring device to ensure the appropriate cuff size and proper use before purchasing.

Pharmacists should advise patients to measure their BP at home daily and have them demonstrate the proper method to take their BP.¹⁵ All patients should be informed about their BP goal and be advised to keep a record of their BP readings, including the date and time taken. Pharmacists also should encourage patients to bring their BP record to their appointments with their primary health care provider for followup.

Building Trust

In order to build a trusting relationship with patients, pharmacists must express care and sympathy, be responsive to patients’ questions, and be able to recognize their needs and concerns. As the most accessible health care professional, pharmacists can have a great impact on the outcomes of hypertension management.

References

1. Remuzzi, G, Ruggenenti, P, Perico, N. Chronic renal diseases: Renoprotective benefits of renin-angiotensin system inhibition. Ann Intern Med. 2002;136(8):604-615.

2. Weir, MR. Progressive renal and cardiovascular disease: Optimal treatment strategies. Kidney Int. 2002; 62(4):1482-1492.

3. Chobanian, AV, Bakris, GL, Black, HR, Cushman, WC. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA. 2003;289(19):2560-2572.

4. Levy, D, Larson, MG, Vasan, RS, et al. The progression from hypertension to congestive heart failure. JAMA.1996;275(20):1557-1562.

5. Staessen, JA, Fagard, R, Thijs, L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet.1997;350(9080):757-764.

6. Coresh, J, Wei, L, McQuillan, G, et al. Prevalence of high blood pressure and elevated serum creatinine level in the United States. Findings from the Third National Health and Nutrition Examination Survey (1988-1994). Arch Intern Med. 2001;161(9):1207-16

7. Hsu, CY, McCulloch, CE, Darbinian, J, et al. Elevated blood pressure and risk of end-stage renal disease in subjects without baseline kidney disease. Arch Intern Med. 2005;165(8):923-928.

8. Neal B, MacMahon S, Chapman N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: Results of prospectively designed overviews of randomized trials. Blood Pressure Lowering Treatment Trialists' Collaboration. Lancet. 2000;356(9246):1955-1964.

9. The Trials of Hypertension Prevention Collaborative Research Group. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. The Trials of Hypertension Prevention, phase II. Arch Intern Med.1997;157(6):657-667.

10. He J, Whelton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Hypertension. 2000;35(2):544-549.

11. Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2001;344(1):3-10.

12. Vollmer WM, Sacks FM, Ard J, et al. Effects of diet and sodium intake on blood pressure: Subgroup analysis of the DASH-sodium trial. Ann Intern Med. 2001;135(12):1019-1028.

13. Appel, LJ, Moore, TJ, Obarzanek, E, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997;336(16):1117-1124.

14. Wetzels, GE, Nelemans, P, Schouten, JS, Prins, MH. Facts and fiction of poor compliance as a cause of inadequate blood pressure control: A systematic review. J Hypertens. 2004;22(10):1849-1855.

15. Pickering, TG, Hall, JE, Appel, LJ, et al. AHA Scientific Statement: Recommendations for blood pressure measurement in humans and experimental animals. Part 1: Blood pressure measurement in humans. Circulation. 2005;111(5):697-719.

16. Carter BL, Saseen JJ. Hypertension. In: Dipiro JT, Talbert RL, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. New York: The McGraw Hill Company; 2005;157-184.