Drug Adherence in Hypertension: The Challenge and Opportunity

Shelley Wood

June 16, 2014

ATHENS, GREECE — Physicians have a clearer picture of which patient-related factors can increase the risk of noncompliance with antihypertensive treatments at a population level but still lack information on what will dissuade or motivate individual patients to take their drugs. Experts speaking here at HYPERTENSION 2014 , the joint conference of the European Society of Hypertension (ESH) and the International Society of Hypertension (ISH), also pointed out that physicians themselves need to step up their game before deeming a patient drug-resistant.

Dr Josep Redon (Hospital Clinico, University of Valencia, Spain) presented an overview of factors related to antihypertensive drug compliance. Many of the same issues are well-known to physicians—and came up in other presentations throughout the day—but they are worth emphasizing, Redon said:

  • Women tend to be less compliant than men.

  • Younger patients are less compliant than old.

  • Presence of cancer, dementia, rheumatic disease, and depression appears to increase the risk of noncompliance.

  • A diagnosis of cardiovascular disease or renal disease appears to increase compliance.

  • Number of prescriptions is inversely associated with compliance, regardless of whether the other medications are antihypertensive drugs or drugs for other ailments.

Dr Giuseppe Mancia (University of Milano-Bicocca, Milan, Italy), also presenting on this topic, noted that choice of initial therapy is another factor that appears to influence whether a patient stays on treatment. He cited studies showing that patients started on monotherapy with a diuretic, who then later had other medications added on, were more likely to stop taking their meds, compared with patients started on combination therapy or started on nondiuretic monotherapy.

Both Mancia and Redon showed that patients were significantly more likely to stay on their medications if treated with ACE inhibitors or an angiotensin-receptor blocker (ARB).

The Mystery of Noncompliance

One of the problems with understanding patient noncompliance is the lack of research into patient-level factors. Speaking with heartwire , Dr Michael Weber (State University of New York, Brooklyn) described patients gripped with anxiety about potential heart attacks or strokes who tell him they are worried they won't live to see their daughter married, etc. Yet this anxiety seldom translates into better compliance with the medications that will reduce their risk.

Weber says he keeps "begging the behavioral scientists" to study this issue, because of the profound lack of knowledge as to what makes one patient noncompliant and another not. "It's not education," he noted, pointing out that doctors are no more likely to be compliant with their medications than nondoctors. "It's an extraordinary mystery."

Researchers in France recently tackled this conundrum with a unique trial design. They asked 873 general practitioners to administer the French League Against High Blood Pressure (FLAH) questionnaire to their first two male and first two female patients with controlled hypertension. Over a seven-month period in 2013, 1636 males and 1613 females filled out the six-question quiz.

According to Dr Bernadette Darné (Monitoring Force, Maisons Laffitte, France), who presented the study results at HYPERTENSION 2014, the reasons for noncompliance were not always the same for men and women. While both sexes reported the number of other pills (either number of other drugs or number of antihypertensive medications) as key reasons, both also cited a "lack of motivation" and "financial difficulties." In men, obesity, high SBP, and a history of stroke were all associated with poor drug adherence, whereas with women, the most common factors were past or current smoker or infrequent contact with their family doctor, as measured by irregular cervical exams. For both sexes, the notion of hypertension as a "simple anomaly" and not a disease that is directly related to heart disease and stroke was a commonly cited explanation for not taking blood-pressure meds.

This misconception is a common one, Mancia stressed to heartwire . "What we're fighting is the basic nature of this disease, which is symptomless. Patients don't see any immediate benefit, so this reduces motivation to take their drugs," he said.

A Shared Burden

Both Mancia and Redon emphasized that the burden of noncompliance does not rest solely with the patients but also reflects what Redon characterized as "medical inertia" on the part of both physicians and institutions.

"The [2013] European hypertension guidelines are really trying to take into account this lack of compliance, and one of the recommendations of the guidelines is to use a team approach, involving nurses, pharmacists, and doctors to cooperate with the patients and empower the patients to really take care of themselves," Redon said.

Dr Antonio Coca (BarnaClinic, Barcelona, Spain), who moderated a "topical workshop" dedicated in part to patient noncompliance, emphasized the importance of trust between patient and physician. Too often, he said, patients ignore the advice of their GPs, only to hear the same message—and pay more attention—when they are referred to a specialized hypertension clinic.

"Sometimes healthcare structures don't allow us to approach the patient enough at the primary-care level, so some of the experiences with trying to improve adherence through [strategies like] pay for performance . . . may be part of how this inertia can be reversed. It's complex, but if we are able to improve this, it will [have a] much better [effect] than many of our other treatment strategies."

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