Improving adherence in hypertensive patients
Getting patients to take their meds for high BP is one of every clinician's big challenges. Two hypertension experts suggest commonsense solutions.
Patients are notoriously lax in adhering to instructions to take their hypertensive medications. In one study, 31%-44% of patients skipped treatment for at least two months during the first year medication was prescribed.1
How do hypertension specialists deal with this problem? To find out, The Clinical Advisor spoke with two of the nation's leading experts in the field, George Bakris, MD, director of the hypertensive diseases unit at the University of Chicago Medical Center and board member of the American Society for Hypertension, and Thomas Pickering, MD, director of the Center for Behavioral Cardiovascular Health at New York Presbyterian Hospital, in New York City.
Q: What makes adherence to hypertension treatment a challenge?
Dr. Bakris: The notion of taking a pill for a disease that does not hurt and does not cause you obvious problems—with the theoretical promise that if you don't do something about it, you'll eventually have a stroke or heart attack—is a bit ethereal. The threshold for tolerability of drug regimens appears to be lower with an asymptomatic condition. Data suggest that if a patient has the flu or a fever, he'll be more willing to take medication and put up with side effects if the drug makes him feel better.
Q: So tolerability is an important factor?
Dr. Bakris: A patient may start taking a medication that he doesn't want to because his clinician says he needs it. But then he develops a rash and automatically assumes the drug is to blame. If the clinician does not have time to explore cause and effect, that's the way it is recorded in the patient's records—even though maybe 50% of the time, the rash was caused by something else. It becomes an excuse not to take the drug.
I can't tell you how many people come to see me with a four-page, single-spaced list of medications they have been tried on and failed. They say, “I can't take drugs. I'm allergic to everything.” Anytime this has happened to me, I have always been able to go back, retry a drug, and have success with it.
Q: It sounds like clinicians bear some of the responsibility for nonadherence.
Dr. Bakris: The patient is always criticized for poor adherence, and ultimately it is his responsibility, but the clinician can influence behavior in a major way. If the patient is getting signals from the clinician, “I'm recommending this, but if you don't want to take it, I don't really care,” his response will be “If you don't care, why should I?”
If the clinician isn't sensitive to his influence, things won't change. The problem is that being sensitive takes time. And while the government and the insurance companies are willing to fund surgical procedures and prescription writing, they won't fund communication, which is the cornerstone of effective hypertension management.
I can't overemphasize the importance of this. Make sure the patient understands that you're there as a teacher and facilitator and not as a mechanic. Educate the patient about hypertension and its many effects, what his options are, what he can do about it, and how you can help him.
Q: Given the constraints of time, what would you emphasize in educating the patient?
Dr. Bakris: First and foremost, patients need to appreciate the true nature of hypertension. Many don't understand what hypertension really is. They think it's all related to stress and believe if they just control stress, everything will be fine. Next, you have to inform patients about the risks of uncontrolled high BP. More often than not, one of their parents had a heart attack or died of a stroke. I tell them, “It's your problem now.” I'm also very specific about what their BP needs to be.
Dr. Pickering: I emphasize that it's nearly always possible to find a drug or combination of drugs that lowers BP and doesn't cause many side effects. And I stress the major benefits of keeping BP controlled, in terms of both quality and length of life.
Q: How do you motivate patients to take their medications year after year?
Dr. Bakris: If given a choice between a stroke and a heart attack, most people will take a heart attack. So I emphasize their personal risk factors for stroke. I say, “I can tell you about the risks for people in your demographic group, or I can tell you about the risks specifically for you.” And that's what I proceed to do. For example, I'll say, “Right now, your risk is one in nine for a stroke, but if you get your BP down, it will be only one in 50.” Or I say they can reduce their risk of stroke by 30%.
The statistics are persuasive, and patients don't have to take my word for it. They can find the evidence on the Internet.
Dr. Pickering: I encourage my patients to monitor their own BP at home. They can see if the medication is actually working, rather than relying on infrequent measurements in the clinician's office. Initially, we recommend taking the reading first thing in the morning and just before going to bed. It's convenient for most and can become part of a daily routine.
Since not all medications work equally well over the full 24-hour period, home monitoring enables the clinician to see if patients are adequately controlled throughout the day. If patients measure BP just before their medication, we can get a good idea of whether the previous day's dose is still working. I usually have patients come in after three to four weeks of treatment to allow enough time for the drug to have its full effect. It also allows time for side effects to become evident.
Dr. Bakris: Monitoring BP at home forces patients to be involved in their own care. They know what numbers they need to have and whether they're getting there.
Q: Do you tell patients about side effects in advance?
Dr. Pickering: One formidable problem is that hypertension therapy is generally for life, and some patients believe that long-term medications always have negative effects. Many think that a diuretic, which is recommended as first-line treatment for most hypertensive patients, will be bad for the kidneys over a period of years (it is not). This must be clarified up front.
Dr. Bakris: I tell patients that all medications have side effects but that they're tolerable for the most part. I tell them not to bother reading the package insert, or they'll talk themselves into side effects they may or may not actually experience. I make sure they know that if a problem is reported, I'm going to ask questions about it. I won't passively accept it as true.
I inform patients at the outset about the most common side effects for a given drug. If it can cause leg edema, I ask them to let me know if it feels like their shoes fit a little tighter. It shows you care and acknowledges a problem to be alert for. If you haven't told the patient beforehand, he may wonder if you really know what you're doing.
Dr. Pickering: While we can usually find the right pills to lower BP without undue side effects, the same drugs don't work for every patient. We may have to do a bit of switching. There is likely to be some trial and error involved in finding the right drug or combination for each individual. Patients who are told this up front won't be discouraged when they have to come back because they're having side effects or the pills don't seem to be working.
Q: Do you emphasize anything when working with particular racial or ethnic groups?
Dr. Bakris: Not only is hypertension more prevalent in the black population, but the risk for kidney failure is 32 times what it is for the general population. The black community knows this, but cultural biases remain (e.g., if you have high BP and take medication, you will become impotent). Be sensitive to this and explain that while many drugs can cause transient impotence, it will probably go away within six months.
I only discuss this with my black and Hispanic male patients. I say, “If you have sexual problems, have your wife come in. I'll be happy to explain.” If you don't let patients know about the possibility of impotence in advance, they may be too embarrassed to tell you if it occurs. Instead, they'll just stop taking the medication.
Q: How do you design a treatment regimen to optimize adherence?
Dr. Bakris: It is important to streamline. Patients are often taking a number of BP medications, and I try to arrange the dosage so it's at most twice a day. I work around the patient's schedule. Everyone tends to brush his teeth when he first wakes up and just before bed. I tell the patient to put the pills in the bathroom or on the kitchen table so the medicine is right there when he sits down to breakfast or dinner. This allows the patient to be in control and decide what works.
Dr. Pickering: Simplicity is a good reason for prescribing products that combine two medications in one pill. Another advantage of combination regimens is that most side effects depend on dosage. Pushing one drug to the maximum to achieve target BP results in a higher likelihood of adverse effects. It may be possible to put two drugs together that will be more effective in lowering BP and keep each below the threshold that causes side effects.
Dr. Bakris: Some drugs used in combination may counteract one another's side effects. For example, a calcium channel blocker can cause leg edema and an angiotensin receptor blocker will alleviate it by altering blood flow in the leg. Meanwhile, each is lowering BP by a different mechanism.
Q: How do you monitor adherence?
Dr. Pickering: You have to go by what the patient tells you. In theory, you can count the pills in the bottles the patient brings in, but this isn't practical. There are objective signs for some drugs. Most beta blockers slow the pulse even if they don't lower BP. If you put a patient on a beta blocker and his pulse doesn't slow, that's a giveaway. Do not be accusatory. Tell the patient, “It's quite common for people not to remember to take their pills every day. Does this ever happen to you? Have you ever run out of pills and delayed refilling the prescription?”
Dr. Bakris: If I added a drug and BP is still the same as it was the last time the patient came in, I think about nonadherence. But there may be other explanations. Perhaps the dose was too low. If so, I raise it and have the patient call back in one week. If I add a third drug and still nothing is happening, I know he's not taking the medication and I'll ask about it up front.
Q: How do you deal with poor adherence?
Dr. Bakris: Re-education is the key. Make sure the patient truly understands what the risks are. I don't get mad or give lectures. Say, “These are the numbers you need. You can try other things (e.g, diet, exercise), and this is what you can expect.” When the patient gets the results I predict, he might get mad because he wanted me to be wrong. Then he'll start taking the medication but immediately begin to look for excuses not to. I'll say, “If you have a stroke, don't say I didn't warn you.” Eventually, he'll come to his senses. It's a process, and it takes time. It doesn't happen in a few minutes.
Mr. Sherman is a medical writer in New York City.
1. Elliott WJ, Plauschinat CA, Skrepnek GH, Gause D. Persistence, adherence, and risk of discontinuation associated with commonly prescribed antihypertensive drug monotherapies. J Am Board Fam Med. 2007;20:72-80.