Patient compliance in the treatment of arterial hypertension

How May Coexisting Frailty Influence Adherence to Treatment in Elderly Hypertensive Patients?

Background

Hypertension is considered to be the most common condition in the general population. It is the most important risk factor for premature deaths in the world. Treatment compliance at every stage is a condition for successful antihypertensive therapy, and improving the effectiveness of treatment is a major goal in preventing cardiovascular incidents. Treatment noncompliance and lack of cooperation stem from numerous problems of older age, including frailty syndrome.

Objective

To evaluate the effect of frailty syndrome on treatment compliance in older patients with hypertension.

Methods

The study sample consisted of 160 patients (91 women, 69 men) with hypertension aged 65 to 78 (mean = 72.09, SD = 7.98 years), hospitalized at the University Clinical Hospital due to exacerbation of disease symptoms. Standardised research tools were used: the Tilburg Frailty Indicator questionnaire and the questionnaire for the assessment of treatment compliance in patients with hypertension, the Hill-Bone Compliance to High Blood Pressure Therapy Scale.

Results

Frailty syndrome was diagnosed in 65.62% of patients: 35.62% with mild, 29.38% with moderate, and 0.62% with severe frailty. The treatment compliance was 36.14%. The prevalence of the FS and its three components (physical, psychological, social) significantly affected (p <0.05) the global score of the Hill-Bone Compliance to High Blood Pressure Therapy Scale and all subscales: “reduced sodium intake”, “appointment keeping”, and “antihypertensive medication taking”.

Conclusions

The coexistence of frailty syndrome has a negative impact on the compliance of older patients with hypertension. Diagnosis of frailty and of the associated difficulties in adhering to treatment may allow for targeting the older patients with a poorer prognosis and at risk of complications from untreated or undertreated hypertension and for planning interventions to improve hypertension control.

Antihypertensive efficacy of olmesartan medoxomil and candesartan cilexetil assessed by 24-hour ambulatory blood pressure monitoring in patients with essential hypertension

OBJECTIVE

To compare the antihypertensive efficacy of olmesartan medoxomil with that of candesartan cilexetil after 1, 2 and 8 weeks of treatment.

DESIGN AND SETTING

Randomised, double-blind, parallel-group study conducted at 44 centres in Germany, Poland and the Czech Republic.

PATIENTS

643 patients (aged 19-86 years) with mainly mild-to-moderate essential hypertension received active double-blind treatment.

INTERVENTIONS

Following a 2-week placebo run-in, eligible patients were randomly assigned to receive olmesartan medoxomil 20mg (n = 319) or candesartan cilexetil 8mg (n = 324) once daily for 8 weeks.

MAIN OUTCOME MEASURES

Changes from baseline in daytime, 24-hour and night-time diastolic (DBP) and systolic (SBP) blood pressures assessed by ambulatory blood pressure monitoring (ABPM), and changes from baseline in sitting cuff DBP and SBP.

RESULTS

Mean decreases from baseline in daytime DBP by ABPM at weeks 1, 2 and 8 were 6.7, 8.4 and 9.3mm Hg, respectively, in the olmesartan medoxomil group compared with 5.3, 6.0 and 7.8mm Hg, respectively, in the candesartan cilexetil group. The between-group differences were significantly in favour of olmesartan medoxomil at all three timepoints (p </= 0.0126). Significant differences in favour of olmesartan medoxomil were also observed for mean 24-hour DBP and for mean daytime and 24-hour SBP by ABPM. Decreases from baseline in sitting cuff BP at trough were similar in the two groups (15-16mm Hg for DBP and 21mm Hg for SBP). Both treatments were well tolerated.

CONCLUSIONS

Olmesartan medoxomil reduced daytime and 24-hour DBP and SBP, assessed by ABPM, more effectively than candesartan cilexetil at the doses tested. The majority of the treatment effect in both groups was seen after only 1 or 2 weeks of dosing, when the between-group differences were already statistically significant.

A clinician's guide to the assessment and management of nonadherence in glaucoma

PURPOSE

To apply lessons learned in the treatment of systemic hypertension to the problem of nonadherence in glaucoma medical therapy.

CLINICAL RELEVANCE

Although physicians recognize that nonadherence with glaucoma medication is a problem, most lack the skill set to identify nonadherent patients, to identify the causes of nonadherence, and to provide solutions to address nonadherence.

METHODS

A PubMed search was conducted using the terms "adherence" OR "compliance" AND "hypertension," with the following limitations: title, English language, humans, from 2000 through 2009. Other studies identified outside of the PubMed search were included if relevant.

RESULTS

Studies from the systemic hypertension literature suggest that simplifying medication regimens, lowering costs, and patient education about the disease and the importance of taking medications are successful strategies for improving adherence. In addition, good family or social support, frequent physician visits, and pairing medication administration with specific activities (such as meals or brushing one's teeth) can help improve adherence.

CONCLUSIONS

The body of literature on adherence interventions in chronic diseases such as systemic hypertension shows that although many interventions have been tested and evaluated, only some are successful. Paradigms derived from behavioral medicine and nursing offer valuable lessons on how to motivate patients to change behavior, but these activities require skill sets not traditionally taught in medical school. Just as there are myriad causes of nonadherence, the interventions most likely will need to be multifaceted and tailored to the individual patient.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Identification of psychosocial factors of noncompliance in hypertensive patients

This cross-sectional study was aimed to identify the predictors of medication noncompliance in hypertensive patients. The study was conducted at the Family Medicine Clinic, Hospital Universiti Sains Malaysia, Kelantan, Malaysia, which is a university-based teaching hospital. All hypertensive patients aged 40 or over-registered from January to June 2004, who had been on treatment for at least 3 months, were screened. Previously validated self-administered questionnaires were used to assess the compliance and psychosocial factors. A total of 240 hypertensive patients were recruited in the study. Of these, 55.8% were noncompliant to medication. Logistic regression showed that age (adjusted odds ratio (OR): 0.96; 95% confidence interval (CI): 0.92-0.997; P: 0.035), patient satisfaction (adjusted OR: 0.97; 95% CI: 0.93-0.998; P: 0.036) and medication barrier (adjusted OR: 0.95; 95% CI: 0.91-0.987; P: 0.009) were significant predictors of medication noncompliance. Therefore, younger age, poor patient satisfaction and medication barrier were identified as independent psychosocial predictors of medication noncompliant in hypertensive patients.

Medication adherence among adolescents in a school-based health center

School-based health centers are an integral part of the health care delivery system for low-income children. Medication adherence for these patients may be challenging because the student is often responsible for bringing home the prescription and receiving the instructions. This study assesses medication fill, initiation, and adherence rates among adolescents in a school-based health center to identify major barriers to medication compliance. Students enrolled in a school-based health center, >or=10 years old, able to read and write English, and whose parent had provided consent for participation, were eligible for the study. Eligible students who received a prescription from the health center were invited to return to the clinic a week later to complete a questionnaire (with verbal assent). Primary outcome measures included medication fill rates, medication initiation rates, medication adherence rates, and reasons for nonadherence. Eighty-one students completed the questionnaire: 45 students (55.6%) filled their prescription. Of the students who filled their prescriptions, 75.6% reported always taking their medication at the appropriate time, 22.2% reported sometimes forgetting to take their medication, and 2.2% reported never taking the medication. However, many discrepancies were found between reported medication-taking behavior and the instructions provided to the student. Medication fill, initiation, and adherence rates among students receiving prescriptions for medications in school-based health centers are suboptimal. Interventions that address key identified barriers need to be developed and evaluated in order to achieve optimal fill and adherence rates.

Better renoprotective effect of angiotensin II antagonist compared to dihydropyridine calcium channel blocker in childhood

BACKGROUND

The dihydropyridine calcium channel blocker amlodipine and the angiotensin II antagonist irbesartan effectively reduce blood pressure in hypertensive children.

METHODS

Eligible for the open-label, randomized study were nephropathic children between 6.0 and 18 years of age with plasma creatinine <177 micromol/L, overt proteinuria, untreated arterial hypertension (systolic, 5 to 30 mm Hg; and diastolic, 1 to 15 mm Hg;>95th centile) and stable immunosuppressive treatment. The initial dose of amlodipine was 5 mg (body weight, 20 to 40 kg) and 10 mg (body weight,>40 kg), respectively, that of irbesartan, which was 75 mg (body weight, 20 to 40 kg) and 150 mg (body weight,>40 kg), respectively. The dosage was doubled if necessary.

RESULTS

A total of 26 children aged 6.1 to 17 years were allocated to receive either amlodipine (N = 13) or irbesartan (N = 13) for 16 weeks. Severe edema and headache occurred in two patients on amlodipine who withdrew from the study. No adverse experiences were noted in patients given irbesartan. Amlodipine [by 12 (10 to 14)/7 (5 to 10) mm Hg; median and interquartile range, respectively] and irbesartan [by 13 (9 to 16)/9 (7 to 11) mm Hg, respectively] reduced blood pressure (P < 0.01) in a similar fashion. Heart rate, plasma sodium, and creatinine did not change. Irbesartan slightly increased plasma potassium [by 0.1 (0.0 to 0.2) mmol/L; P < 0.05]. Plasma albumin and the urinary albumin/creatinine ratio were similar before and with amlodipine. On the contrary, irbesartan increased plasma albumin [by 4 (3 to 5) g/L; P < 0.03] and decreased the urinary albumin/creatinine ratio [by 242 (68 to 312) mg/mmol; P < 0.03].

CONCLUSION

The study demonstrates that in children the effect of angiotensin II antagonists on proteinuria is better than that of dihydropyridine calcium channel blockers.

How good is blood pressure control among treated hypertensive children and adolescents?

BACKGROUND

Since good control of arterial hypertension is of paramount importance, the present study was carried out to evaluate blood pressure control in pediatric patients with hypertension receiving regular medical care.

STUDY DESIGN

The charts of 80 hypertensive children receiving medical care were reviewed. Their antihypertensive medication had been stable during three or more separate clinic visits and during 3 or more months. Patients with office hypertension were excluded.

RESULTS

Blood pressure values higher than the corresponding 95th centiles were noted in 20 of the 80 patients. Hypertension was systolic in seven, diastolic in four and both systolic and diastolic in nine patients. The number of prescribed antihypertensive drugs and the number of doses/day of prescribed antihypertensive drugs was similar in patients with good and in those with poor blood pressure control. Plasma creatinine was higher in patients with poor than in those with good blood pressure control.

CONCLUSIONS

The present survey indicates that the goal of antihypertensive medication is not achieved in a noticeable number of pediatric patients with treated hypertension.

[Cost reduction with project based prescription of generic ACE inhibitors]

BACKGROUND

Increasing drug costs are an economic burden for the health insurance system.

AIM

The regional drug prescription pattern for ACE inhibitors in the Austrian county Burgenland was compared for patients discharged from hospital and those in primary care. Furthermore, the potential cost reduction by voluntary prescription of cheaper generic drugs was estimated in the project "Bessere Therapie zum besseren Preis".

METHODS

Following consensual analysis of the regional cross-sectional study, a cheaper generic of the most cost-intensive class of ACE-inhibitor drugs should be prescribed at internal medicine wards and in primary care. The number of prescriptions for patients from the largest health insurance company BGKK was studied and the costs were calculated.

RESULTS

Of the 1347 patients discharged during October 1999 from internal medicine departments of four different hospitals 879 patients received a total of 1440 cardiovascular drugs. The regional prescription pattern at hospitals matched that of physicians in primary care. Between the second quarter of 2000 and 2001, the prescription of ACE inhibitor drugs increased by project advertising from 23,627 packages by 13.1%, and drug costs in this group were reduced by [symbol: see text] 29,778 in this quarter (7.3% of costs). The number of Enalapril prescriptions increased by 33.4% with a percentual portion of generic Enalapril of 57.3%, and in the rest of Austria by 16.9% with 45.0% generics.

CONCLUSION

Consensus based projects are appropriate pharmacoeconomic interventions to change prescription patterns, increase the use of drugs and reduce the increasing cost requirements.