XIII. Adherence Strategies for Patients

Prevention and Treatment

Subgroup Members: Tavis S. Campbell, PhD; Ross D. Feldman, MD; Alain Milot, MD, MSc; Denis Drouin, MD; Kim L. Lavoie, PhD; Ross T. Tsuyuki, BSc(Pharm), PharmD, MSc
Central Review Committee: Stella S. Daskalopoulou, MD, PhD; Kaberi Dasgupta, MD, MSc; Kelly B. Zarnke, MD, MSc; Kara Nerenberg, MD, MSc; Alexander A. Leung, MD, MPH; Kevin C. Harris, MD, MHSc; Kerry McBrien, MD, MPH; Sonia Butalia, BSc, MD; Meranda Nakhla, MD, MSc
Chair: Doreen M. Rabi, MD, MSc
This information is based on the Hypertension Canada guidelines published in Leung, Alexander A. et al. Hypertension Canada’s 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults. Can J Cardiol 2017; 33(5): 557-576.

Guidelines

  1. Adherence to an antihypertensive prescription can be improved by a multipronged approach (Supplemental Table S12).

Assist your patient to adhere by:

  • Tailoring pill-taking to fit patients’ daily habits (Grade D)
  • Simplifying medication regimens to once-daily dosing (Grade D)
  • Replacing multiple pill antihypertensive combinations with single pill combinations (Grade C)
  • Utilizing unit-of-use packaging (of several medications to be taken together) (Grade D)
  • Using a multidisciplinary team approach to improve adherence to an antihypertensive prescription (Grade B)

Assist your patient in getting more involved in their treatment by:

  • Encouraging greater patient responsibility/autonomy in monitoring their blood pressure and adjusting their prescriptions (Grade C)
  • Educating patients and patients’ families about their disease and treatment regimens (Grade C)

Improve your management in the office and beyond by:

  • Assessing adherence to pharmacological and non-pharmacological therapy at every visit (Grade D)
  • Encouraging adherence with therapy by out-of-office contact (either by phone or mail), particularly during the first three months of therapy (Grade D)
  • Coordinating with pharmacists and work-site health care givers to improve monitoring of adherence with pharmacological and lifestyle modification prescriptions (Grade D)
  • Utilizing electronic medication compliance aids (Grade D)

Background

1. Adherence to an antihypertensive prescription can be improved by a multipronged approach (Supplemental Table S12).

Assist your patient to adhere by:

  • Tailoring pill-taking to fit patients’ daily habits (Grade D)

Non-adherence to pharmacological therapy for chronic asymptomatic conditions (such as hypertension) is common, and is an important factor in both poor BP control and the occurrence of hypertension-related complications. Numerous factors can affect adherence with prescribed therapy, including the following: patient factors (such as knowledge, motivation, financial and social supports); drug factors (such as frequency of dosing, cost and side-effect profiles); and health care provider factors (such as lack of interest or time to provide information on prescribed therapies) (1,2). However, numerous strategies can improve adherence with pharmacological therapy (1). The effectiveness of these strategies has been most clearly shown in the setting of multifaceted approaches to improving adherence; the effectiveness of individual components has been much more difficult to show.

  • Simplifying medication regimens to once-daily dosing (Grade D)

A systematic review of randomized trials evaluating various therapies to improve adherence confirms the importance of dose simplification (3). Additionally, several studies have shown once-daily administration of a drug leads to higher adherence rates than more frequent regimens (4–7).

  • Replacing multiple pill antihypertensive combinations with single pill combinations (Grade C)

To limit pill burden, patients taking several pills should ideally be treated with single-pill combinations. Clinicians can achieve this strategy by converting short-acting drugs to once-daily agents and by adopting combination therapy whenever possible. In the recent Simplified Treatment Intervention to Control Hypertension (STITCH) trial (8), 2104 patients with uncontrolled hypertension in 45 family practices in southwestern Ontario were randomly assigned, at the practice level, to receive either simplified treatment consisting of fixed-dose combination therapy with a low-dose ACE inhibitor or ARB, and diuretic combination, or to be managed according to prevailing hypertension guidelines.

The proportion of patients achieving target BP was significantly higher in the simplified treatment group (64.7% versus 52.7%; absolute difference 12.1% [95%CI, 1.5% to 22.4%]). These data should be viewed in concert with supportive results from a meta-analysis of 42 randomized trials showing incremental BP reduction achieved by combining drugs from two different classes (i.e., combination therapy) is approximately five times greater than doubling the dose of one drug (i.e., step therapy) (9).

  • Utilizing unit-of-use packaging (of several medications to be taken together) (Grade D)

This is primarily based upon expert consensus.

  • Using a multidisciplinary team approach to improve adherence to an antihypertensive prescription (Grade B)

This is primarily based upon expert consensus.

Assist your patient in getting more involved in their treatment by:

  • Encouraging greater patient responsibility/autonomy in monitoring their blood pressure and adjusting their prescriptions (Grade C)

The effectiveness of self-directed management of pharmacological therapy (including home BP monitoring) has previously been reviewed (8).

  • Educating patients and patients’ families about their disease and treatment regimens (Grade C)

While disease-specific education of patients and their families appears to improve adherence substantially, it is unclear whether education is independently correlated with adherence or whether the improvements are due to the increased supervision attendant with such educational programs (10).

Improve your management in the office and beyond by:

  • Assessing adherence to pharmacological and non-pharmacological therapy at every visit (Grade D)

This is primarily based upon expert consensus.

  • Encouraging adherence with therapy by out-of-office contact (either by phone or mail), particularly during the first three months of therapy (Grade D)

This Grade D recommendation is based on extrapolation from a small (n=30), randomized, controlled trial (11) evaluating impact of personalized follow-up on compliance with lipid-lowering therapy. Patients randomly assigned to weekly telephone contact for 12 weeks had significantly greater compliance at the end of 2 years compared with those who did not receive telephone contact. The remaining recommendations for this section are unchanged.

  • Coordinating with pharmacists and work-site health care givers to improve monitoring of adherence with pharmacological and lifestyle modification prescriptions (Grade D)

A prospective cluster, randomized trial of clinical pharmacists working with physicians was found to improve physician guideline adherence and also led to greater reductions in patients’ BP (12,13). Findings from this trial support involvement of pharmacists in assisting physicians with BP management and are consistent with a growing literature supporting effectiveness of pharmacists in improving BP control.

  • Utilizing electronic medication compliance aids (Grade D)

This is primarily based upon expert consensus.

References

  1. Chockalingam A, Bacher M, Campbell N, et al. Adherence to management of high blood pressure: recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control. Can J Public Health 1998;89(Suppl 2):15-6.
  2. Fodor JG, Cutler H, Irvine J, et al. Adherence to non-pharmacological therapy for hypertension: problems and solutions. Can J Public Health 1998;89(Suppl 2):112-5.
  3. Schroeder K, Fahey T, Ebrahim S. How can we improve adherence to blood pressure- lowering medication in ambulatory care? Systematic review of randomized controlled trials. Arch Intern Med 2004;164:722-32.
  4. Feldman RD, Bacher M, Campbell NRC, et al. Adherence to pharmacologic management of hypertension. Can J Public Health 1998;89(Suppl 2):116-8.
  5. Mounier-Yehier C, Bernaud C, Carre A, et al. Compliance and antihypertensive efficacy of amlodipine compared with nifedipine slow-release. Am J Hypertens 1998;11:478-86.
  6. Leenen FHH, Wilson TW, Bolli P, et al. Patterns of compliance with once versus twice daily antihypertensive drug therapy in primary care: a randomized clinical trial using electronic monitoring. Can J Cardiol 1997;13:914-20.
  7. Girvin B, McDermott BJ, Johnston GO. A comparison of enalapril 20 mg once daily versus 10 mg twice daily in terms of blood pressure lowering and patient compliance. J Hypertens 1999;17:1627-31.
  8. Feldman RD, Zou GY, Vandervoort MK, Wong CJ, Nelson SA, Feagan BG. A simplified approach to the treatment of uncomplicated hypertension: A cluster randomized, controlled trial. Hypertension 2009;53:646-53.
  9. Wald DS, Law M, Morris JK, Bestwick JP, Wald NJ. Combination therapy versus monotherapy in reducing blood pressure: Meta-analysis on 11,000 participants from 42 trials. Am J Med 2009;122:290-300.
  10. Feldman RD, Campbell N, Larochelle P, et al. 1999 Canadian recommendations for the management of hypertension. CMAJ 1999;161(12 Suppl):S1-17.
  11. Lang T, Nicaud V, Dame B, Rueff B. Improving hypertension control among excessive alcohol drinkers: a randomised controlled trial in France. J Epidemiol Comm Health 1995;49:610-6.
  12. Faulkner MA, Wadibia EC, Lucas BD, Hilleman DE. Impact of pharmacy counseling on compliance and effectiveness of combination lipid-lowering therapy in patients undergoing coronary artery revascularization: A randomized, controlled trial. Pharmacotherapy 2000;20:410-6.
  13. Carter BL, Ardery G, Dawson JD, et al. Physician and pharmacist collaboration to improve blood pressure control. Arch Intern Med 2009;169:1996-2002.