Talk About It!: Adherence for Hypertension Patients

Monitoring and encouraging hypertension patients can be life-saving.

For most patients, a hypertension (HTN) diagnosis means taking medication every day for the rest of their lives. This is a simple fact that many prescribers forget to tell newly diagnosed patients. It is an important point to stress at diagnosis and to reinforce often. Antihypertensives—the cornerstone of treatment—don’t help if patients don’t take them correctly and consistently.

Although more than 70% of Americans are now aware that high blood pressure is problematic, we need to underscore these important points¹:

• Uncontrolled HTN is a major risk factor for cardiovascular disease (CVD), which is still the leading cause of death among Americans.²
• One in 3 American adults has HTN (systolic blood pressure [SBP] ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg).²
• People who have HTN are 2 to 3 times more likely to have a heart attack or stroke or develop heart failure. These serious health events alter life permanently or end it prematurely.²
• Treating HTN decreases fatal stroke by 40% and prolongs life expectancy.^2,3

Most important, patients need to know that committing to treatment and lifestyle changes and monitoring their own blood pressure can be life-saving.

The FDA has approved an almost countless number of HTN drugs and drug combinations in 10 different classes (Table 1). Some patients with mild HTN will be able to control their blood pressure with a single agent or with serious dietary salt restriction.4 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7—available for free here) reports, however, that patients who have stage 2 HTN (160/100 mm Hg) or who exceed their blood pressure goals by 20/10 mm Hg will need 2 or more drugs to attain control. Most patients need more than 1 medication with different or complementary mechanisms of action to lower their blood pressure.¹

Nonadherence: A Ubiquitous Issue

Clinical trials have shown that across disease states, adherence to chronic and necessary drug therapy is on average 78%. Patients with HTN appear to experience more adherence challenges since HTN is asymptomatic and the drugs tend to induce more prominent side effect profiles than drugs used to treat other chronic conditions.⁸ Approximately 70% of hypertensive patients are nonadherent.⁹

Addressing nonadherence has developed into its own field of study. Experts in this field have made several suggestions to improve patients’ adherence (Online Table 2). As a first step, health care providers should partner with patients so they know HTN’s specific risks and share decision making.

Table 2: Interventions: Increasing Adherence

• Keep medication regimens as simple as possible.
• When possible, use once-daily dosage forms.
• Educate patients about their medications and potential side effects and tell them if the side effects are likely to be transient.
• Label precisely and concisely using patient-friendly language; including specific dosing times can help patients adhere.
• Try to tie doses to convenient reminders; schedule them when the patient first rises, with breakfast/lunch/dinner, at bedtime, etc.
• Communicate information verbally and reinforce it with written information in lay language.
• If possible, provide information in the patient’s native language.
• If tablets or capsules are large, address whether they can be crushed or broken before the patient leaves the pharmacy.
• Help patients select and load a medication reminder system.

Adapted from references 1, 3, 8, 10-12.

HTN Adherence: The Specifics

A 2004 meta-analysis reviewed 38 trials, half of which reported improved adherence, that targeted antihypertensive adherence.¹³ The researchers found that simplifying the medication regimen was most likely to improve adherence. Using once-daily instead of twice-daily doses improved adherence by up to 20%.¹³ A more recent meta-analysis found that thoroughly educating patients about their medications improved adherence.¹²

Since most HTN patients need more than 1 drug, the regimen’s complexity is a concern and might be addressed using fixed-dose combination drug therapy.

Fixed-Dose Combination Therapy: Easier?

Combination therapy can improve blood pressure and tolerability.³ A meta-analysis that included 42 trials found that combining 2 antihypertensives from different classes lowered blood pressure 5 times more than doubling a single agent’s dose. Overall, the patients needed less medication and tended to have fewer side effects and better adherence.¹⁴ A 2010 meta-analysis found that fixed-dose antihypertensive combinations improved adherence and persistence.¹⁵ Fixed-dose combination therapy also simplifies the patient’s medication regimen, a technique proved to improve adherence in tuberculosis, hypertension, and HIV infection.¹⁰

Combination HTN therapy, particularly with a calcium channel blocker, diuretic, or angiotensin-converting enzyme inhibitor, also improves blood pressure consistency. Fluctuating SBP increases risk of myocardial infarction and stroke.⁵

Fixed-dose combination products’ limitations include lack of flexibility (the dose can only be adjusted in fixed increments) and difficulty using them as first-line therapy. Additionally, some insurance plans do not pay for combination products.¹⁶

Conclusion

Pharmacists need to monitor and encourage their HTN patients. With better medication adherence, perhaps in the foreseeable future CVD won’t be the number-1 preventable cause of death among Americans.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance clinical writer.

References

• Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572.
• Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2-e220.
• Sood N, Reinhart KM, Baker WL. Combination therapy for the management of hypertension: a review of the evidence. Am J Health-Syst Pharm. 2010;67:885-894.
• Harrington JM, Fitzgerald AP, Kearney PM, et al. DASH Diet score and distribution of blood pressure in middle-aged men and women [published online August 6, 2013]. Am J Hypertens.
• Sever PS, Messerli FH. Hypertension management 2011: optimal combination therapy. Eur Heart J. 2011;32:2499-2506.
• Brown MJ, McInnes GT, Papst CC, et al. Aliskiren and the calcium channel blocker amlodipine combination as an initial treatment strategy for hypertension control (ACCELERATE): a randomized, parallel-group trial. Lancet. 2011;377:312-320.
• Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age and older. N Engl J Med. 2008;358:1887-1898.
• Osterberg L, Blaschke T. Adherence to medications. N Engl J Med. 2005;353:487-497.
• Messerli FH, Williams B, Eberhard R. Essential hypertension. Lancet. 2007;370:591-603.
• Bangalore S, Kamalakkannan G, Parkar S, Messerli F. Fixed-dose combinations improve medication compliance: a meta-analysis. Am J Med. 2007;120:713-719.
• De Simoni A, Hardeman W, Mant J, Farmer AJ, Kinmonth AL. Trials to improve blood pressure through adherence to antihypertensives in stroke/TIA: systematic review and meta-analysis. J Am Heart Assoc. 2013;2:e000251.
• Gwadry-Sridhar FH, Manias E, Lal L, et al. Impact of interventions on medication adherence and blood pressure control in patients with essential hypertension: A systematic review by the ISPOR Medication Adherence and Persistence Special Interest Group. Value Health. 2013;16:863-871.
• Schroeder K, Fahey T, Ebrahim S. How can we improve adherence to blood pressure-lowering medication in ambulatory care? Arch Intern Med. 2004;164:722-732.
• Wald DS, Law M, Morris JK, et al. Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials. Am J Med. 2009;122:290-300.
• Gupta AK, Arshad S, Poulter NR. Compliance, safety and effectiveness of fixed dose combinations of antihypertensive agents, a meta-analysis. Hypertension. 2010;55:399-407.
• Epstein BJ. Improving blood pressure control rates by optimizing combination antihypertensive therapy. Expert Opin Pharmacother. 2010;11:2011-2026.