Persistence with antihypertensive treatments: results of a 3-year follow-up cohort study

Laboratory testing and antihypertensive medication adherence following initial treatment of incident, uncomplicated hypertension: A real-world data analysis

In this study on medication adherence among newly diagnosed patients with uncomplicated, incident hypertension, we conducted a retrospective cohort study using available administrative and laboratory data from April 1, 2012 to March 31, 2017 in Alberta, Canada to understand the extent to which baseline laboratory assessment and/or subsequent follow-up was associated with persistence with antihypertensive therapy. We determined the frequency of baseline and follow-up testing and compared the rates of medication persistence by patient-, neighbourhood-, and treatment-related factors. Of 103 232 patients with newly diagnosed, uncomplicated hypertension who filled their first prescription within our study timeframe, 52.5% were non-persistent within 6 months. Persistent patients were more often female and residing in neighbourhoods with higher social status (with exception to rurality). Aside from older age, the strongest predictor of persistence was performance of laboratory testing related to hypertension with an apparent effect in which higher levels of medication persistence were seen with more frequent laboratory testing. We concluded that medication persistence was far from optimal, dropping off considerably after 6 months for more than half of patients. Medication persistence is a substantial barrier to realizing the full societal benefits of antihypertensive treatment. Ongoing follow up with patients, including laboratory testing, may be a critical component of better long term treatment persistence.

Starting Antihypertensive Drug Treatment With Combination Therapy: Controversies in Hypertension - Con Side of the Argument

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Impact of Therapeutic Inertia on Long-Term Blood Pressure Control: A Monte Carlo Simulation Study

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Effect of patient and treatment factors on persistence with antihypertensive treatment: A population-based study

Purpose

To analyze patterns of antihypertensive drug use among new users in a Southern European population, and identify patient- and treatment-related factors that influence persistence.

Methods

This is a retrospective observational study of new antihypertensive drug users aged ≥40 years in Aragón, Spain. Information on antihypertensive drugs (2014–2016) prescribed and dispensed at pharmacies via the public health system were collected from a regional electronic population-based pharmacy database. Persistence was assessed using the gap method. Kaplan-Meier and Cox regression analyses were conducted to analyze patterns of use and factors that influence persistence.

Results

The 25,582 new antihypertensive drug users in Aragón during the study period were prescribed antihypertensive drugs in monotherapy (73.3%), fixed combination (13.9%), free combination (9.1%), or other (3.7%). One in five received antihypertensive drugs within 15 days of the prescription date, but not after. During the first year of follow-up, 38.6% of the study population remained persistent. The likelihood of treatment discontinuation was higher for participants who were male, aged ≥80 years, and received an antihypertensive drug in monotherapy compared with fixed combination.

Conclusion

Overall persistence with antihypertensive therapy was poor, and was influenced by the sex, age and type of therapy. Fixed combinations appear to be a good choice for initial therapy, especially in patients with a higher risk of discontinuation. Nonetheless, adverse drug effects and the patient’s preferences and clinical profile should be taken into account.

Factors associated with medication persistence among ischemic stroke patients: a systematic review

OBJECTIVE

An investigation of the prevalence of medication persistence and associated factors in order to inform effective strategies for improving medication persistence.

METHODS

A systematic review of the literature from 2010 to the present was performed, using the PRISMA protocol. Primary and empirical observational studies of adult ischemic stroke or transient ischemic attack patients were included. PubMed, CINAHL, Web of Science, Cochrane Library, and PsycInfo databases were searched using the key terms stroke, ischemic stroke, medication persistence, medication adherence, and patient compliance.

RESULTS

Of four hundred twenty-eight journal articles retrieved, a final 18 articles were included. Short-term medication persistence was 46.2-96.7%, and long-term medication persistence was 41.7-93.0%. Identified hospital-related factors for medication persistence were stroke unit care, in-hospital medical complications, and early follow-up visit. Demographic factors for medication persistence were older age, and high/adequate financial status; disease-related factors were disease history, stroke subtype, and symptom severity. Age less than 75, female sex, comorbidity, antiplatelet medication switch, and polypharmacy were identified as factors of medication nonpersistence.

CONCLUSIONS

Stroke patients' medication persistence decreases over time, and persistence on antiplatelets, anticoagulants, and statin was poor. Several factors were associated with medication persistence, and these factors should be considered in future secondary preventative strategies.

Hypertension and Drug Adherence in the Elderly

Hypertension is highly prevalent after the age of 65 years affecting more than 60% of individuals in developed countries. Today, there is sufficient evidence from clinical trials that treating elderly subjects with hypertension with antihypertensive medications has a positive benefit/risk ratio even in very elderly patients (>80 years). In recent years, partial or total non-adherence has been recognized as major issues in the long-term management of hypertension in all age categories. However, whether non-adherence is more frequent in hypertensive patients older than 65 years or not is still a matter of debate and the common belief is that adherence is lower in older than in younger patients. Are clinical data supporting this belief? In this brief review, we discuss the topic of drug adherence in elderly in the context of the medical treatment of hypertension. Studies show that drug adherence is actually better in patients aged 65 to 80 years when compared to younger hypertensive patients (<50 years). However, in very old patients (>80 years) the prevalence of non-adherence does increase. In this patients' group, there are specific risk factors for non-adherence such as cognitive ability, depression, and health believes, in addition to classical risk factors for non-adherence. One important aspect in the elderly is the prescription of potentially inappropriate medications that will interfere with the adherence to necessary treatments. In this context, an interesting new concept was developed few years ago, i.e., the process of deprescribing. Thus, today, in addition to conventional guidelines recommendations (use of single pill combinations, individualization of treatments), the evaluation of cognitive abilities, the regular assessment of potentially inappropriate medications, and the process of deprescribing appear to be three new additional steps to improve drug adherence in the elderly and thereby ameliorate the global management of hypertension.

Adherence in Hypertension

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Pharmacy-based predictors of non-adherence, non-persistence and reinitiation of antihypertensive drugs among patients on oral diabetes drugs in the Netherlands

Background

Adherence to antihypertensive drugs in patients with diabetes is important. To support adherence, attention should be paid to the dynamic process of implementation, persistence and reinitiation of these drugs. We assessed non-adherence, non-persistence and reinitiation patterns for antihypertensive drugs in patients on oral diabetes drugs and identified pharmacy-based predictors of these processes.

Methods

We conducted a cohort study in patients on oral diabetes drugs who initiated antihypertensive drugs between 1995–2015, as registered in the IADB.nl pharmacy database. Non-adherence was defined as a medication possession ratio < 80% and non-persistence as a gap > 180 days. We defined reinitiation as the dispensing of an antihypertensive drug within one year following discontinuation. We provide descriptive statistics for different time periods and applied logistic and Cox regressions to assess associations with sociodemographic and drug-related factors.

Results

Of 6,669 initiators, non-adherence rates in persistent patients decreased from 11.0% in the first year to 8.5% and 7.7% in the second and third years, respectively. Non-persistence rates decreased from 18.0% in the first year to 3.7% and 2.9% in the second and third years, respectively. Of the 1,201 patients who discontinued in the first year, 22.0% reinitiated treatment within one year. Non-adherence and non-persistence rates were lower in the more recent time period. Predictors of non-adherence were secondary prevention (OR: 1.45; 95% CI: 1.10–1.93) and diuretics as initial drug class (OR: 1.37; 95% CI: 1.08–1.74). Predictors of non-persistence were female gender (HR: 1.18; 95% CI: 1.05–1.32), older age (HR: 1.33; 95% CI: 1.08–1.63) and diuretics, beta-blocking agents or calcium channel blockers as initial drug class. Longer duration of persistence was a predictor of reinitiation.

Conclusions

Adherence to antihypertensive drugs in patients on oral diabetes drugs has improved over time. The first year after initiation is the most crucial with regard to non-adherence and non-persistence, and the risk groups are different for both processes. Early non-persistence is a risk factor for not reinitiating treatment.

Methods for Measuring Multiple Medication Adherence: A Systematic Review-Report of the ISPOR Medication Adherence and Persistence Special Interest Group

BACKGROUND

A broad literature base exists for measuring medication adherence to monotherapeutic regimens, but publications are less extensive for measuring adherence to multiple medications.

OBJECTIVES

To identify and characterize the multiple medication adherence (MMA) methods used in the literature.

METHODS

A literature search was conducted using PubMed, PsycINFO, the International Pharmaceutical Abstracts, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library databases on methods used to measure MMA published between January 1973 and May 2015. A two-step screening process was used; all abstracts were screened by pairs of researchers independently, followed by a full-text review identifying the method for calculating MMA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to conduct this systematic review. For studies that met the eligibility criteria, general study and adherence-specific characteristics and the number and type of MMA measurement methods were summarized.

RESULTS

The 147 studies that were included originated from 32 countries, in 13 disease states. Of these studies, 26 used proportion of days covered, 23 used medication possession ratio, and 72 used self-reported questionnaires (e.g., the Morisky Scale) to assess MMA. About 50% of the studies included more than one method for measuring MMA, and different variations of medication possession ratio and proportion of days covered were used for measuring MMA.

CONCLUSIONS

There appears to be no standardized method to measure MMA. With an increasing prevalence of polypharmacy, more efforts should be directed toward constructing robust measures suitable to evaluate adherence to complex regimens. Future research to understand the validity and reliability of MMA measures and their effects on objective clinical outcomes is also needed.

Suboptimal Adherence to Antihypertensive Treatment: Causes and Management

Suboptimal adherence to antihypertensive treatment is very common and is associated with poor control of blood pressure and increased risk for cardiovascular events. Therefore, frequent evaluation of compliance is essential in all hypertensive patients. Simplifying treatment regimens, using fixed-dose combinations and long-acting agents improves adherence, facilitates achievement of treatment targets and reduces cardiovascular morbidity and healthcare expenditures. Accordingly, physicians should be educated to implement these changes in hypertensive patients, particularly in those who require multiple antihypertensive agents to achieve blood pressure controls and in those who receive additional medications for comorbidities.

Effectiveness of fixed-dose combination therapy in hypertension: systematic review and meta-analysis

INTRODUCTION

Clinical studies have revealed that fixed-dose combinations (FDCs) of drugs can have a better effect on blood pressure than free-equivalent combinations (FECs). Our objectives were to perform an up-to-date assessment of the effectiveness of FDCs and FECs in antihypertensive therapy, to provide more accurate results by using a stratified meta-analysis.

MATERIAL AND METHODS

A systematic review was performed in PubMed, Web of Science, and Cochrane databases according to PRISMA guidelines. The outcomes were adherence (compliance), persistence to medication, reduction of blood pressure and the safety profile. We used the Newcastle Ottawa scale or the Delphi list for the assessment of the quality of cohort studies or clinical trials, respectively. Heterogeneity was assessed using the Cochrane Q test and I² statistic.

RESULTS

Of 301 abstracts screened, 26 primary studies and 2 other meta-analyses were identified, of which 12 studies were included in the meta-analyses and 3 studies were included in the narrative review. The FDC treatment is associated with a significant improvement in adherence and persistence in comparison with FEC treatment, e.g., the average medicine possession ratio increased with FDC by 13.1% (p < 0.001). For endpoints correlated with higher adherence (e.g., a reduction in blood pressure), a nonsignificant benefit was observed for FDCs. Moreover, it was demonstrated that higher adherence can lead to a lower risk of cardiovascular events.

CONCLUSIONS

In comparison with FECs, the FDC treatment is associated with a significant improvement in the cooperation between a doctor and a patient and with increased patients' adherence to the treatment schedule.

Frequency of blood pressure and estimated glomerular filtration rate monitoring in patients affected by hypertension: a retrospective study with 176 565 patients in Germany

OBJECTIVE

The aim of this study was to analyze the frequency of blood pressure (BP) and estimated glomerular filtration rate (eGFR) monitoring in hypertension patients followed in primary care practices in Germany.

PATIENTS AND METHODS

This study included patients who had received at least two hypertension diagnoses (ICD-10: I10) in 2016. The primary outcome of this study was the frequency of BP and eGFR monitoring in patients with hypertension in the year 2016. The impact of the different demographic and clinical variables on the likelihood of receiving at least two BP and at least one eGFR tests was analyzed using multivariate logistic regression models. These two cutoff values were selected on the basis of the recommendations of the European Society of Hypertension and the European Society of Cardiology.

RESULTS

This study included 176 565 patients, 53.0% of whom were women. The mean age was 68.2 years (SD=13.3 years). The mean number of BP tests was 1.9 (SD=3.1), whereas the mean number of eGFR tests was 0.2 (SD=0.8) in 2016. Only 33.7 and 9.1% of the population received at least two BP tests and one eGFR test, respectively. Older age (>60 years), comorbidities (particularly diabetes, hyperlipidemia, and renal insufficiency), and the number of antihypertensive treatments were associated with higher odds of receiving at least two BP and at least one eGFR tests, whereas the duration of hypertension was associated negatively with these odds.

CONCLUSION

The frequency of BP and eGFR monitoring was low in Germany in 2016. Several demographic and clinical variables had a significant impact on this frequency.

Non-persistence with antiplatelet therapy in elderly patients after a transient ischemic attack

BACKGROUND

Antiplatelet therapy following a transient ischemic attack (TIA) constitutes an important secondary prevention measure.

AIMS

The study was aimed at evaluating the development of non-persistence with antiplatelet therapy in elderly patients after a TIA and identifying patient-related characteristics associated with the probability of non-persistence during the follow-up period.

METHODS

The study cohort (n = 854) was selected from the database of the largest health insurance provider of the Slovak Republic. It included patients aged ≥65 years, in whom antiplatelet medication was initiated following a TIA diagnosis during the period between 1 January 2010 and 31 December 2010. Each patient was followed for a period of 3 years from the date of the first antiplatelet medication prescription associated with TIA diagnosis. Patients in whom there was a treatment gap of at least 6 months without antiplatelet medication prescription were defined as "non-persistent". The factors predicting non-persistence were identified in the Cox proportional hazards model.

RESULTS

At the end of the follow-up period, 345 (40.4%) patients were non-persistent with antiplatelet medication. Protective factors decreasing a patient´s likelihood of becoming non-persistent were age ≥75 years [hazard ratio (HR) = 0.75], polypharmacy (concurrent use of ≥6 drugs) (HR = 0.79), arterial hypertension (HR = 0.68), diabetes mellitus (HR = 0.74), hypercholesterolemia (HR = 0.75), and antiplatelet medication switching during the follow-up period (HR = 0.73).

CONCLUSIONS

It is concluded that following a TIA, elderly patients aged <75 years or those with normal serum cholesterol levels, without certain comorbid conditions and polypharmacy may benefit from special counselling to encourage persistence with secondary preventive medication.

Different approaches to the assessment of adherence and persistence with cardiovascular-disease preventive medications

OBJECTIVE

To assess suitability and comparability of the most common methods of treatment adherence and persistence assessment, as applied to the same pharmacy dataset.

METHODS

Data on drugs prescribed for cardiovascular primary prevention to participants in the Aragon Workers' Health Study (AWHS) were collected from a regional electronic drug prescription database. Several different approaches were used to measure treatment adherence (with the medication possession ratio [MPR]) and proportion of days covered [PDC]) and persistence in new users by therapeutic subgroup. Defined daily dose (DDD) was used as a proxy of the number of days' supply, or substituted with surrogate daily dose values.

RESULTS

Higher mean adherence values and proportions of adherent patients were obtained using MPR versus PDC, with additional differences depending on the approach used. The proportion of adherent patients was lowest for oral antidiabetics (14.4%-30.6%) and highest for antihypertensives (70.2%-82.1%). The use of surrogate daily dose values increased adherence for antidiabetics and statins and decreased adherence for antihypertensives. After a 1 year follow-up, treatment persistence was observed for 21.1%, 58.7%, and 29.5% of antidiabetic, antihypertensive and statin users, respectively.

CONCLUSIONS

Our findings indicate that use of multiple measures of treatment adherence and persistence provides a more complete overview of medication use patterns, and certain limitations associated with DDD for some drug groups can be overcome with replacement by surrogate doses. The PDC indicator seems to provide a more accurate reflection of patient behavior and treatment continuity than the MPR. Any comparison of adherence/persistence should always consider the method used, variables analyzed, and corresponding data collection process.

Patient-related characteristics associated with non-persistence with statin therapy in elderly patients following an ischemic stroke

PURPOSE

This study was aimed at evaluating the extent of non-persistence with statin therapy in elderly patients after an ischemic stroke and identifying patient-related characteristics that are risk factors for non-persistence.

METHODS

The evaluable study cohort (n = 2748) was derived from the database of the largest health insurance provider in the Slovak Republic. Patients aged ≥65 years who were initiated on statin therapy following the diagnosis of an ischemic stroke during one full year (1 January 2010 to 31 December 2010) constituted this cohort. Each patient was followed for a period of 3 years from the date of the first statin prescription. Patients with a continuous treatment gap of 6 months without statin prescription were designated as non-persistent. The Cox proportional hazard model was applied to determine patient-associated characteristics that influenced the likelihood of non-persistence.

RESULTS

During the 3-year follow-up period, 39.7% of patients in the study cohort became non-persistent. Factors associated with decreased probability of a patient becoming non-persistent were age ≥75 years (hazard ratio (HR) 0.75), polypharmacy (concurrent use of ≥6 drugs) (HR 0.79), diabetes mellitus (HR 0.80), dementia (HR 0.81) and hypercholesterolemia (HR 0.50). On the other hand, the presence of anxiety disorders (HR 1.33) predicted an increased likelihood of a patient being non-persistent.

CONCLUSIONS

Our findings suggest that patients aged ≥75 years or those with the presence of diabetes mellitus, dementia, hypercholesterolemia or polypharmacy were likely to be persistent with statin therapy, whereas those with anxiety disorders may need greater assistance with persistence of statin therapy. Copyright © 2016 John Wiley & Sons, Ltd.

Comparison of therapy persistence for fixed versus free combination antihypertensives: a retrospective cohort study

OBJECTIVES

The aim of the study was to compare therapy persistence among patients who started with one of three drug regimens: a monotherapy, or combination therapy either as a fixed combination (ie, 'single pill') or as a free combination (ie, two separate antihypertensive agents).

DESIGN

In a secondary data analysis, we used descriptive statistics and multivariate logistic regression to measure the effect of the three therapy regimens on therapy persistence over 4 years.

SETTING

Prescription data from a large German statutory health insurance provider.

PARTICIPANTS

All patients who started with a new antihypertensive therapy in 2007 or 2008 (n=8032) were included and followed for 4 years.

PRIMARY OUTCOME MEASURE

Therapy persistence, defined as receiving a refill prescription no later than within 180 days.

RESULTS

The persistence rates after 4 years were nearly identical among patients who started with a monotherapy (40.3%) or a fixed combination of two drugs (39.8%). However, significantly more patients who started with free-drug combinations remained therapy persistent (56.4%), resulting in an OR of 2.00 (95% CI 1.6 to 2.5; p<0.0001) for free combinations versus fixed combinations. This trend was observed in all age groups and for men and women. At the end of the study period, the number of different antihypertensive agents was still similar between patients who started with a fixed combination (2.41) and patients who started with a free combination (2.28).

CONCLUSIONS

While single-pill combinations make it easier to take different drugs at once, the risk is high that these several substances are stopped at once. Therapy persistence was significantly better for patients who started with a free-drug combination without taking much fewer different antihypertensive drugs as those with a fixed combination.

Persistence to antihypertensive drug classes: A cohort study using the Swedish Primary Care Cardiovascular Database (SPCCD)

The aim was to study persistence to, and switching between, antihypertensive drug classes and to determine factors associated with poor persistence.This was an observational cohort study. The Swedish Primary Care Cardiovascular Database includes data from medical records, socioeconomic data, filled prescriptions, and hospitalizations from national registries for 75,000 patients with hypertension. Patients included in the study were initiated on antihypertensive drug treatment in primary healthcare in 2006 to 2007. We defined class persistence as the proportion remaining on the initial drug class, including 30 days of gap. Patients with a filled prescription of another antihypertensive drug class after discontinuation of the initial drug, including 30 days of gap, were classified as switchers. Persistence to the various drug classes were compared with that for diuretics.We identified 4997 patients (mean age 60 ± 12 years in men and 63 ± 13 years in women). Out of these, 95 (2%) filled their first prescription for fixed combination therapy and 4902 (98%) for monotherapy, including angiotensin converting enzyme inhibitors (37%), angiotensin receptor blockers (4%), beta blockers (21%), calcium channel blockers (8%), and diuretics (28%). Persistence to the initial drug class was 57% after 1 year and 43% after 2 years. There were no differences in persistence between diuretics and any of the other antihypertensive drug classes, after adjustment for confounders. Discontinuation (all adjusted) was more common in men (P = 0.004), younger patients (P < 0.001), those with mild systolic blood pressure elevation (P < 0.001), and patients born outside the Nordic countries (P < 0.001). Among 1295 patients who switched drug class after their first prescription, only 21% had a blood pressure recorded before the switch occurred; and out them 69% still had high blood pressures.In conclusion, there appears to be no difference in drug class persistence between diuretics and other major antihypertensive drug classes, when factors known to be associated with poor persistence are taken into account.

How does prescribing for antihypertensive products stack up against guideline recommendations? An Australian population-based study (2006-2014)

AIMS

We describe choice of first-line antihypertensive drug therapy and uptake of fixed-dose combinations (FDCs) in Australia, and investigate the impact of initiation on FDCs and other non-recommended first-line therapies on treatment discontinuation.

METHOD

This was a population-based retrospective cohort study using a random 10% sample of persons dispensed an Australian Pharmaceutical Benefits Scheme listed medicine from 1 July 2005 to 30 June 2014. The primary outcomes were adherence to Australian recommendations at initiation of antihypertensive therapy, discontinuation of initial therapy and discontinuation of any therapy in the first year after initiation.

RESULTS

In our sample of 55 937 persons initiating therapy, 42.0% did so outside Australian recommendations, including not initiating on recommended monotherapy (26.3%) and not initiating on the lowest recommended dose (30.6%). Only 1.7% of individuals who were dispensed an FDC established therapy on the free combination regimen (as recommended) prior to switching. After adjusting for covariates, persons initiating on non-recommended monotherapy (OR = 2.64, 95% CI 2.47-2.83) or FDCs of two or more antihypertensives (OR = 1.42, 95% CI 1.30-1.55), were more likely to discontinue all antihypertensive drug treatment in the first year compared to persons initiating on recommended monotherapy.

CONCLUSION

More than half of antihypertensive initiators conformed to Australian guidelines. Initiation on FDCs and other non-recommended treatments was associated with lower persistence on antihypertensive therapy in the first year. Long-term effectiveness and outcomes may be enhanced by initiating with low dose monotherapy.

Medication adherence and persistence according to different antihypertensive drug classes: A retrospective cohort study of 255,500 patients

BACKGROUND

Suboptimal adherence to antihypertensives leads to adverse clinical outcomes. This study aims to determine and compare medication adherence and persistence to different first-line antihypertensive drug classes in a large cohort.

METHODS

A cohort study was performed using claims data for prescriptions in the German statutory health insurance scheme that insures approximately 90% of the population. A total of 255,500 patients with a first prescription of an antihypertensive were included and followed for 24months. Persistence was determined based on gaps in continuous dispensation. Adherence was analyzed by calculating the medication possession ratio (MPR).

RESULTS

Within a 2-year period, 79.3% of all incident users of antihypertensive monotherapy met the classification of non-persistence (gap >0.5 times the number of days supplied with medication) and 56.3% of non-adherence (MPR<0.8). Beta-blockers (42.5%) and angiotensin-converting enzyme inhibitors (31.9%) were the most widely prescribed drug classes. Non-persistence and non-adherence were highest for diuretics (85.4%, n=6149 and 66.3%, n=4774) and lowest for beta-blockers (77.6%, n=76,729 and 55.2%, n=54,559). The first gap of antihypertensive medication occurred in median 160-250days after initiation, and the average medication possession ratio for all drug classes was less than 0.8. Fixed combinations with diuretics showed a 19.8% lower chance for non-adherence (OR=0.802, 99.9% CI=[0.715-0.900], p<0.001) and an 8.4% lower hazard for non-persistence (HR 0.916, 99.9% CI=[0.863-0.973], p<0.001) compared with monotherapies.

CONCLUSIONS

This large cohort study reveals important differences in 2-year adherence and persistence between antihypertensives that were lowest for diuretics. Fixed-dose combinations with diuretics may facilitate adherence compared to single substance products. However, effective strategies to improve adherence to antihypertensives are needed regardless of drug class.

Non-adherence to antihypertensive medication: The role of mental and physical comorbidity

BACKGROUND

Multiple parameters influence adherence to drug treatment, including socio-economic, healthcare, condition, therapy, and patient-related factors. However, studies of the impact of patient-related factors, particularly regarding comorbid conditions, have produced conflicting results.

OBJECTIVES

To analyse the association between mental and physical comorbidity and non-adherence to antihypertensive medication in patients attending primary care, after including a comprehensive range of chronic comorbidities and potential confounders.

METHODS

Cross-sectional study of 113,397 adults with a diagnosis of hypertension in 2010 assigned to the public health service of a region in northeastern Spain. Pharmacy billing records were linked to data from electronic health records at individual level. Non-adherence was defined as an antihypertensive medication possession ratio (MPR) <80%. Multivariable logistic regression models were used to estimate the odds ratio for non-adherence. Potential predictors included mental and physical comorbidity, age, sex, blood pressure level, nationality, rurality, polypharmacy, and number of visits to the GP and to different specialties.

RESULTS

One fifth of the study population showed poor adherence levels. Female sex, younger age, foreign nationality, living in a rural area, low blood pressure levels, polypharmacy, and mental comorbidity were positively and significantly associated with non-adherence. Conversely, non-adherence was negatively and significantly associated with the presence of cardiovascular risk factors and higher annual rates of GP visits.

CONCLUSION

The majority of patient-related determinants identified here (e.g., the presence of mental comorbidity, polypharmacy, foreign nationality) underscores the need for a patient- rather than a disease-centred care approach, as well as adequate physician-patient communication.

Persistence with Antihypertensive Medications in Uncomplicated Treatment-Naïve Patients: Effects of Initial Therapeutic Classes

We aimed to assess one-year persistence with antihypertensive therapy (AHT) among newly treated uncomplicated hypertensive patients in Korea and to evaluate the effect of initial therapeutic classes on persistence. We retrospectively analyzed a random sample of 20% of newly treated uncomplicated hypertensive patients (n = 45,787) in 2012 from the National Health Insurance claims database. This group was classified into six cohorts based on initial AHT class. We then measured treatment persistence, allowing a prescription gap of 60 days. Adherence to AHT was assessed with the medication possession ratio. Calcium channel blockers (CCB, 43.7%) and angiotensin receptor blockers (ARB, 40.3%) were most commonly prescribed as initial monotherapy. Overall, 62.1% and 42.0% were persistent with any AHT and initial class at one year, respectively, and 64.2% were adherent to antihypertensive treatment. Compared with ARBs, the risk of AHT discontinuation was significantly increased with initial use of thiazide diuretics (hazard ratio [HR], 3.16; 95% confidence interval [CI] 2.96-3.74) and beta blockers (HR, 1.86; CI, 1.77-1.95) and was minimally increased with CCBs (HR, 1.12; CI, 1.08-1.15). In conclusion, persistence and adherence to AHT are suboptimal, but the differences are meaningful in persistence and adherence between initial AHT classes.

Adherence to Antihypertensive Therapy and Elevated Blood Pressure: Should We Consider the Use of Multiple Medications?

Background

Although a majority of patients with hypertension require a multidrug therapy, this is rarely considered when measuring adherence from refill data. Moreover, investigating the association between refill non-adherence to antihypertensive therapy (AHT) and elevated blood pressure (BP) has been advocated.

Objective

Identify factors associated with non-adherence to AHT, considering the multidrug therapy, and investigate the association between non-adherence to AHT and elevated BP.

Methods

A retrospective cohort study including patients with hypertension, identified from a random sample of 5025 Swedish adults. Two measures of adherence were estimated by the proportion of days covered method (PDC≥80%): (1) Adherence to any antihypertensive medication and, (2) adherence to the full AHT regimen. Multiple logistic regressions were performed to investigate the association between sociodemographic factors (age, sex, education, income), clinical factors (user profile, number of antihypertensive medications, healthcare use, cardiovascular comorbidities) and non-adherence. Moreover, the association between non-adherence (long-term and a month prior to BP measurement) and elevated BP was investigated.

Results

Non-adherence to any antihypertensive medication was higher among persons < 65 years (Odds Ratio, OR 2.75 [95% CI, 1.18–6.43]) and with the lowest income (OR 2.05 [95% CI, 1.01–4.16]). Non-adherence to the full AHT regimen was higher among new users (OR 2.04 [95% CI, 1.32–3.15]), persons using specialized healthcare (OR 1.63, [95% CI, 1.14–2.32]), and having multiple antihypertensive medications (OR 1.85 [95% CI, 1.25–2.75] and OR 5.22 [95% CI, 3.48–7.83], for 2 and ≥3 antihypertensive medications, respectively). Non-adherence to any antihypertensive medication a month prior to healthcare visit was associated with elevated BP.

Conclusion

Sociodemographic factors were associated with non-adherence to any antihypertensive medication while clinical factors with non-adherence to the full AHT regimen. These differing findings support considering the use of multiple antihypertensive medications when measuring refill adherence. Monitoring patients' refill adherence prior to healthcare visit may facilitate interpreting elevated BP.

Adherence to Disease Modifying Drugs among Patients with Multiple Sclerosis in Germany: A Retrospective Cohort Study

Background

Long-term therapies such as disease modifying therapy for Multiple Sclerosis (MS) demand high levels of medication adherence in order to reach acceptable outcomes. The objective of this study was to describe adherence to four disease modifying drugs (DMDs) among statutorily insured patients within two years following treatment initiation. These drugs were interferon beta-1a i.m. (Avonex), interferon beta-1a s.c. (Rebif), interferon beta-1b s.c. (Betaferon) and glatiramer acetate s.c. (Copaxone).

Methods

This retrospective cohort study used pharmacy claims data from the data warehouse of the German Institute for Drug Use Evaluation (DAPI) from 2001 through 2009. New or renewed DMD prescriptions in the years 2002 to 2006 were identified and adherence was estimated during 730 days of follow-up by analyzing the medication possession ratio (MPR) as proxy for compliance and persistence defined as number of days from initiation of DMD therapy until discontinuation or interruption.

Findings

A total of 52,516 medication profiles or therapy cycles (11,891 Avonex, 14,060 Betaferon, 12,353 Copaxone and 14,212 Rebif) from 50,057 patients were included into the analysis. Among the 4 cohorts, no clinically relevant differences were found in available covariates. The Medication Possession Ratio (MPR) measured overall compliance, which was 39.9% with a threshold MPR≥0.8. There were small differences in the proportion of therapy cycles during which a patient was compliant for the following medications: Avonex (42.8%), Betaferon (40.6%), Rebif (39.2%), and Copaxone (37%). Overall persistence was 32.3% at the end of the 24 months observation period, i.e. during only one third of all included therapy cycles patients did not discontinue or interrupt DMD therapy. There were also small differences in the proportion of therapy cycles during which a patient was persistent as follows: Avonex (34.2%), Betaferon (33.4%), Rebif (31.7%) and Copaxone (29.8%).

Conclusions

Two years after initiating MS-modifying therapy, only 30–40% of patients were adherent to DMDs.

Adherence and medication utilisation patterns of fixed-dose and free combination of angiotensin receptor blocker/thiazide diuretics among newly diagnosed hypertensive patients: a population-based cohort study

OBJECTIVE

The study aimed to compare the adherence and persistence among newly diagnosed hypertensive patients using fixed-dose (FDC) and free combinations (FC) of angiotensin receptor blocker (ARB)/thiazide diuretic using Taiwan's National Health Insurance Research Database.

METHODS

General linear regression and Kaplan-Meier analyses were used to estimate the impact of FDC on adherence [measured by medication possession ratio (MPR)] and persistence (time from day of initiation to treatment discontinuation) of ARB/thiazide diuretic.

RESULTS

The adjusted MPRs were all significantly higher among FDC group compared with FC group (6 months: 66.55% vs. 63.86%; 1 year: 52.58% vs. 46.73%, 1.5 year: 46.30% vs. 38.07%; 2 year: 42.06% vs. 32.45%, all p < 0.001). Patients received FDC therapy were less likely to discontinue their therapy [adjusted hazard ratio (HR) 0.79, 95% CI = 0.74-0.85].

CONCLUSIONS

Our findings suggest that use of FDC is associated with higher adherence and persistence rates than use of FC in newly diagnosed hypertensive patients.

Effect of depression onset on adherence to medication among hypertensive patients: a longitudinal modelling study

OBJECTIVES

Although a link between depression and poor adherence to antihypertensive medication (AHM) has been found, it is not known whether depression actually leads to poorer adherence or whether poor adherence only is a marker of depression. In this study we aimed to determine the time order between hypertension, depression and changes in adherence to AHM.

METHODS

The analyses were based on data gathered from a longitudinal cohort of Finnish employees (The Finnish Public Sector Study). A total of 852 chronically hypertensive men and women at baseline with a recorded onset of depression during the 9-year observation window and 2359 hypertensive control participants matched for age, sex, socio-economic status, time of study entry, employer and geographic area were included in the study. Individuals with any sign of depression during 4 years before the beginning of the study were excluded. To describe long-term trajectories (4 years before and 4 years after the recorded depression) of AHM adherence in relation to the onset of depression, annual data on reimbursed AHM prescriptions were gathered from the national Drug Prescription Register. Annual nonadherence rates (i.e. number of 'days-not-treated') were based on filled prescriptions.

RESULTS

Among male cases, the rate of 'days-not-treated' was 1.52 times higher (95% confidence interval 1.08-2.14) in the years after the onset of depression compared to preonset levels. In women and in male controls, no change in adherence to AHM was observed between these time periods.

CONCLUSION

In hypertensive men, the onset of recorded depression increases the risk of nonadherence to AHM.

The impact of cardiovascular profile on persistence associated with antihypertensive medications

BACKGROUND

Antihypertensive drug treatment (AHT) is effective in reducing the risks of cardiovascular events, but long-term persistence is required to achieve these benefits. The aim of the present study was to evaluate persistence with antihypertensive treatment in France.

METHODS AND RESULTS

A total of 6924 patients, first prescribed for hypertension in 2008, were retrospectively studied from the principal French National Public Health Insurance Scheme database. Persistence was defined as remaining on therapy at the end of the 12 months postindex date. Cox proportional hazards regression models controlled for demographics and cardiovascular profile. Over 1 year, 65% of patients were persistent and 16% maintained the initial therapy. When correcting for significant factors determining persistence, a 13% risk reduction of discontinuation is observed with angiotensin II antagonists (AIIAs) and 11% with angiotensin-converting enzymes inhibitors (ACE) compared with thiazide diuretics. Persistence therapy depended significantly on the cardiovascular profile. In the secondary prevention subgroup (18% of the study population), no statistically significant differences were observed between thiazide diuretics and the four major classes. In contrast, a 19% risk reduction of discontinuation is observed with AIIA and with ACE compared with thiazide diuretics for primary prevention patients without diabetes or hyperlipidaemia.

CONCLUSIONS

When choosing AHT agents for patients with essential hypertension, practitioners are primarily driven by the cardiovascular profile of patients. The study suggests that the therapeutic decision must encompass the individual 'persistence risk', the latter not being independent from the cardiovascular risk.

Persistence of antihypertensive drug use in German primary care: a follow-up study based on pharmacy claims data

PURPOSE

To study drug persistence for antihypertensive treatment considering typical patient behaviour including extended drug holidays or irregular repeat prescriptions.

METHODS

We used prescription data from a German statutory health insurance to follow up patients for 4 years. Medication persistence was defined as the continued use of a specific drug class, therapy persistence as the continued use of any antihypertensive drug. We applied 2 different interval criteria within which a repeat prescription had to be issued: 180 and 360 days.

RESULTS

A total of 9,513 patients started an antihypertensive therapy between 2006 and 2008. Applying the 180-day (360-day) interval criterion, 28 % (66 %) of the patients starting therapy with a beta-blocker were still medication-persistent after 4 years. The rates were similar for angiotensin-II receptor blockers (ARBs; 30 % and 69 % respectively) or angiotensin-converting enzyme (ACE) inhibitors (28 % and 61 % respectively). Looking at therapy persistence, these rates were 44 % (79 %) when an ACE inhibitor was the initial drug, 46 % (82 %) for ARBs. On average, even of those who were defined as therapeutically persistent with the 360 days criterion, half received a repeat prescription within 96 days, three quarters within 131 days-with a median supply of 1.2 units per day and 1.25 defined daily doses.

CONCLUSION

By applying more patient-orientated criteria, we found that many patients were therapy-persistent and received a prescription at the appropriate time. Therapy persistence was nearly independent of the initial agent; thus, drug persistence may not be an argument in favour of choosing a certain drug as a first-line option.

Patient compliance based on genetic medicine: a literature review

For this literature review, medical literature data bases were searched for studies on patient compliance after genetic risk assessment. The review focused on conditions where secondary or tertiary preventive options exist, namely cancer syndromes (BRCA-related cancer, HNPCC/colon cancer), hemochromatosis, thrombophilia, smoking cessation, and obesity. As a counterpart, patient compliance was assessed regarding medication adherence and medical advice in some of the most epidemiologically important conditions (including high blood pressure, metabolic syndrome, and coronary heart disease) after receiving medical advice based on nongenetic risk information or a combination of genetic and nongenetic risk information. In the majority of studies based on genetic risk assessments, patients were confronted with predictive rather than diagnostic genetic profiles. Most of the studies started from a knowledge base around 10 years ago when DNA testing was at an early stage, limited in scope and specificity, and costly. The major result is that overall compliance of patients after receiving a high-risk estimate from genetic testing for a given condition is high. However, significant behavior change does not take place just because the analyte is "genetic." Many more factors play a role in the complex process of behavioral tuning. Without adequate counseling and guidance, patients may interpret risk estimates of predictive genetic testing with an increase in fear and anxiety.

[Drug compliance and its factors in a group of hypertensive Congolese]

L'objectif de ce travail était d’évaluer le niveau d'observance des patients hypertendus et identifier les facteurs prédictifs de mauvaise observance. Il s'est agi d'une étude transversale à recueil de données prospectif sur une période de six mois. Elle s'est déroulée dans les services de consultations externes de cardiologie dans trois hôpitaux: le CHU de Brazzaville, l'hôpital central des armées de Brazzaville, et l'hôpital général de Loandjili (Pointe-Noire). Cette étude a concerné 212 patients dont 122 femmes (57.5%) et 90 hommes (42.5%), âgés de plus de 18ans, hypertendus traités depuis au moins six mois. Le questionnaire à six questions conçu par Girerd a été utilisé pour évaluer l'observance médicamenteuse. Une régression logistique a été utilisée pour rechercher les facteurs de mauvaise observance. L'observance était considérée comme bonne chez 45 patients soit 21.2%, et mauvaise chez 69 patients soit 32.5%. Dans 98 cas soit 46.2% il y avait un minime problème d'observance. Une HTA ancienne de plus de 5 ans, la présence des complications évolutives de l'HTA ainsi que les niveaux élevés de la PAS et de la PAD étaient liés à la mauvaise observance. Par contre aucune relation statistique n'a été retrouvée entre la mauvaise observance et l'existence d'une co-morbidité, la fréquence des prises médicamenteuses, le nombre de comprimés par jour et une pression artérielle non contrôlée. Les patients non observant étaient en moyenne plus âgés que les autres. Une mauvaise connaissance du traitement et des complications de l'HTA, le fait de ne pas acheter soi-même ses médicaments, l'ignorance de la gravité de l'HTA, et le coût élevé du traitement étaient prédictifs d'une mauvaise observance. La possession d'un tensiomètre électronique d'auto mesure tensionnelle ainsi que le rappel des prises médicamenteuses par les parents étaient liés à une bonne observance. Après ajustement par une régression logistique, seule la bonne connaissance du traitement et la perception de la gravité de l'HTA étaient liées à une bonne observance. L'observance médicamenteuse dans notre population d’étude s'est révélée faible. Il faut insister sur l’éducation thérapeutique des patients.

Diuretics for hypertension-reasons for a contradiction in primary care prescribing behavior: a qualitative study

There has been a long international discussion on diuretics as first-line therapy for hypertension. In Germany, thiazide diuretics are very rarely prescribed in monotherapy and concurrently highly prescribed in fixed-combinations. The aim of this study was to approach the reasons for this inconsistency in primary care prescribing behavior. A qualitative study design consisting of single interviews with general practitioners (GPs) was chosen. Most GPs perceived diuretics as too weak to treat arterial hypertension effectively in monotherapy. In combination therapy, GPs expected to spare the dose and to offset certain side effects of other drugs. The convenient availability of diuretics in most fixed-dose combinations on the German drug market was seen as an important reason for their frequent prescription in combination therapy. Thus, the reasons given by the GPs differed from the main arguments of the academic debate. Dissemination strategies for guidelines should take the perceptions and opinions of practicing GPs into account.

Updated report on comparative effectiveness of ACE inhibitors, ARBs, and direct renin inhibitors for patients with essential hypertension: much more data, little new information

OBJECTIVES

A 2007 systematic review compared angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) in patients with hypertension. Direct renin inhibitors (DRIs) have since been introduced, and significant new research has been published. We sought to update and expand the 2007 review.

DATA SOURCES

We searched MEDLINE and EMBASE (through December 2010) and selected other sources for relevant English-language trials.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included studies that directly compared ACE inhibitors, ARBs, and/or DRIs in at least 20 total adults with essential hypertension; had at least 12 weeks of follow-up; and reported at least one outcome of interest. Ninety-seven (97) studies (36 new since 2007) directly comparing ACE inhibitors versus ARBs and three studies directly comparing DRIs to ACE inhibitor inhibitors or ARBs were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

A standard protocol was used to extract data on study design, interventions, population characteristics, and outcomes; evaluate study quality; and summarize the evidence.

RESULTS

In spite of substantial new evidence, none of the conclusions from the 2007 review changed. The level of evidence remains high for equivalence between ACE inhibitors and ARBs for blood pressure lowering and use as single antihypertensive agents, as well as for superiority of ARBs for short-term adverse events (primarily cough). However, the new evidence was insufficient on long-term cardiovascular outcomes, quality of life, progression of renal disease, medication adherence or persistence, rates of angioedema, and differences in key patient subgroups.

LIMITATIONS

Included studies were limited by follow-up duration, protocol heterogeneity, and infrequent reporting on patient subgroups.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Evidence does not support a meaningful difference between ACE inhibitors and ARBs for any outcome except medication side effects. Few, if any, of the questions that were not answered in the 2007 report have been addressed by the 36 new studies. Future research in this area should consider areas of uncertainty and be prioritized accordingly.

Real-life treatment patterns, compliance, persistence, and medication costs in patients with hypertension in Germany

OBJECTIVE

This retrospective patient data analysis was initiated to describe current treatment patterns of patients in Germany with arterial hypertension, with a special focus on compliance, persistence, and medication costs of fixed-dose and unfixed combinations of angiotensin receptor blockers (ARBs), amlodipine (AML) and hydrochlorothiazide (HCT) in Germany.

METHODS

The study analyzed prescription data collected by general practitioners, using the IMS Disease Analyzer database. The database was searched for patients with the diagnosis hypertension (ICD-10 code I10) and treatment data in the period 09/2009 to 08/2010. Compliance was measured indirectly based on the medication possession ratio (MPR), and persistence was defined as the duration of time from initiation to discontinuation of therapy. Medication costs were assessed from the statutory health insurance perspective in Germany.

RESULTS

In the IMS DA 406,888 observable patients in Germany were encoded with the diagnosis I10 essential hypertension. In total, 88,716 patients received prescriptions including ARBs, monotherapy (18.6%) or unfixed combinations with other anti-hypertensives (19.3%). The compliance with fixed-dose combinations of ARB with HCT, either dual or with one other anti-hypertensive drug, was significantly better, compared to unfixed combinations (mean compliance 78.1% for fixed-dose vs 71.5% for unfixed combinations of ARB with HCT, p < 0.0001; mean compliance 79.4% vs 72.0%, p < 0.0001 if an additional anti-hypertensive medication was added). Fixed-dose combinations of ARB with HCT, ARB with AML, dual only or prescribed with another anti-hypertensive medication resulted in a substantial increase of persistence, especially for patients on fixed-dose dual combinations (225.7 vs 163.6 days for ARB with HCT; 232.9 vs 178.4 days for ARB with AML, respectively). Fixed-dose combinations (varying from €1.38 to €2.20 per patient and day) were on average cheaper than unfixed combinations.

LIMITATIONS

Persistence and compliance could be under- or over-estimated because their assessment was based on prescription information. For two thirds of 69,060 patients, data on compliance and persistence was missing.

CONCLUSION

The study shows considerable variations in ARB treatment patterns among patients, with the majority of patients treated with fixed-dose or semi-fixed combination therapy. Fixed-dose combinations of ARBs with HCT and/or AML seem to result in better compliance and persistence compared to unfixed regimes of these drug classes, leading to reduction in all-cause hospitalizations, emphasizing the benefit and potential cost-savings of using fixed-dose regimes in a real-life general practice setting in Germany.

Single-pill vs free-equivalent combination therapies for hypertension: a meta-analysis of health care costs and adherence

This meta-analysis compares health care resource use costs, adherence, and persistence between groups of patients taking antihypertensives as single-pill combinations (SPCs) vs free-equivalent components (FEC) based on a structured review of published studies. The search yielded 12 retrospective database studies included in analyses. The mean difference in combined total annual all-cause and hypertension-related health care costs was $1357 (95% confidence interval [CI], $778-$1935) lower in favor of SPC than FEC groups. Adherence, measured as the mean difference in medication possession ratio, was estimated to be 8% higher for patients naive to prior antihypertensives and 14% higher for nonnaive SPC patients compared with corresponding FEC patients. Persistence in the SPC groups was twice as likely as the FEC groups (pooled risk ratio, 2.1; 95% CI, 1.1-4.1). Improved adherence and persistence may have contributed to the lower costs in the SPC groups via improved clinical outcomes.

Retrospective analysis of real-world efficacy of angiotensin receptor blockers versus other classes of antihypertensive agents in blood pressure management

BACKGROUND

Efficacy of blood pressure (BP) lowering may differ between clinical trials and what is observed in clinical practice. These differences may contribute to poor BP control rates among those at risk.

OBJECTIVE

We conducted an observational study to determine the BP-lowering efficacy of angiotensin receptor blocker (ARB) versus non-ARB-based antihypertensive treatments in a large Canadian primary care database.

METHODS

We analyzed the South Western Ontario database of 170,000 adults (aged >18 years) with hypertension persisting with antihypertensive medication for ≥9 months. Routine standard of care office BP was measured using approved manual aneroid or automated devices. BP <140 mm Hg and/or <90 mm Hg ≤9 months after treatment initiation, persistence (presence of initial antihypertensive prescription at the first, second, third, and fourth year anniversary) with antihypertensive therapy, and the presence of a cardiovascular (CV) event (ie, myocardial infarction) were studied.

RESULTS

After 9 months of monotherapy, 28% (978 of 3490) of patients on ARBs achieved target BP versus 27% (839 of 3110) on angiotensin-converting enzyme inhibitors (ACEIs) (P > 0.05), 26% (265 of 1020) on calcium channel blockers (CCBs) (P > 0.05), 21% (221 of 1050) on β-blockers (P = 0.002), and 19% (276 of 1450) on diuretics (P = 0.001). Attainment rates were significantly higher with irbesartan (38%; 332 of 873) versus losartan (32%; 335 of 1047; P = 0.01), valsartan (19%; 186 of 977; P = 0.001), and candesartan (25%; 148 of 593; P = 0.001). BP goal attainment rates were significantly higher when ARB was compared with non-ARB-based dual therapy (39%; 1007 of 2584 vs 31%; 1109 of 3576; P = 0.004); irbesartan + hydrochlorothiazide (HCTZ) was significantly higher than losartan + HCTZ (36%; 500 of 1390 vs 20%; 252 of 1261; P = 0.001). For patients receiving dual or tri-therapy, 48% (667 of 1390) of patients receiving irbesartan reached target BP versus 41% to 42% for losartan (517 of 1261), valsartan (194 of 462), and candesartan (168 of 401) (P = 0.001 for each). After 4 years, persistence rates were not statistically different among ARB, CCB, and diuretic monotherapies, but appeared somewhat higher with ACEIs and β-blockers (78%, 78%, 79%, 91%, and 84%, respectively). Persistence was not significantly different between irbesartan and losartan monotherapy (76% for both; P > 0.05), but was significantly higher with irbesartan + HCTZ versus losartan + HCTZ (96% vs 73%, respectively; P = 0.001). Patients treated with ARBs reported fewer CV events than those receiving ACEIs or CCBs (4.3% vs 7.0% and 11.0%, respectively; P < 0.001). Within the ARB class, the lowest rate was with irbesartan (3.0% vs 4.6%-5.0% for other ARBs; P < 0.02).

CONCLUSIONS

In this real-world setting, hypertensive adults treated with ARBs versus β-blockers or diuretics were more likely to have evidence-based target BP recorded. In addition, patients using ARBs versus ACEIs or CCBs had fewer reports of CV events.

Diuretics for hypertension--an inconsistency in primary care prescribing behaviour

OBJECTIVE

Internationally there is an ongoing debate on diuretics as first-line therapy for most patients with hypertension. In spite of many arguments against them in antihypertensive monotherapy, the authors of the present study perceived them to be regularly prescribed in combination therapy in Germany. The study objective was to look for this discrepancy in prescribing reality as a contribution from clinical practice to an academic debate.

METHODS

A descriptive cross-sectional study in a yearly contact group (YCG; 1.7.2007-31.06.2008) was conducted based on data from a scientific network of 22 general practitioners in Germany. All patients with hypertension as diagnosed by their general practitioner were included. Antihypertensives were grouped according to the ATC classification. To assess for potential design effects by the given two-level setting, 95% confidence intervals (CI) were adjusted for clustering.

RESULTS

Hypertension had been diagnosed in 9.3% of the 58 852 patients. Of these, 21.6% received no antihypertensives. Of those who were treated, 30.6% (CI [28.6-32.6]) had monotherapy. In monotherapy, 8.6% (CI [7.1-10.2]) were prescribed some diuretic, 1.5% (CI [0.5-3.0]) received hydrochlorothiazide (HCT). Combination therapy was prescribed to 69.4% (CI [67.2-71.6]). These patients received some diuretic in 79.0% (CI [76.9-81.0]) of the cases, of which 80.8% (CI [78.5-83.1]) had a combination with HCT. HCT was prescribed in 76.2% (CI [73.5-78.9]) in fixed-dose formulations.

CONCLUSION

In spite to the many arguments against them, leading to their almost complete disregard in monotherapy, thiazide-diuretics seem to be standard in combination therapy in Germany. This inconsistency can not be explained by the arguments of the current debate. Key limitations of the present study include the lack of ability to tell whether a given monotherapy is the first-line medication, the small sample size and the possible selection bias.

The effect of selected patient's characteristics on the choice of antihypertensive medication in the elderly in Slovakia

PURPOSE

The aim of the present study was to determine which patient-related characteristics influence the selection of the antihypertensive drug class in elderly patients in Slovakia.

METHODS

The sample for our study (n = 401) was selected from 1045 patients admitted to the Department of Internal Medicine of a general hospital during the period of 1 December 2003-31 March 2005. Patients aged 65 or more with documented arterial hypertension and treated with at least one antihypertensive drug were enrolled in our retrospective study. Specific socio-demographic and clinical characteristics as well as cardiovascular comorbid conditions were evaluated as potential factors that could have influenced the choice of antihypertensive drug class.

RESULTS

The most frequently prescribed antihypertensive drugs were angiotensin-converting enzyme (ACE) inhibitors and diuretics (61.8% and 60.1% of patients, respectively). Patients aged >/= 85 years had lower probability of ACE inhibitors prescription (OR = 0.49). Females had higher chance of calcium channel blockers use (OR = 3.84) and lower odds of diuretics administration (OR = 0.50). In patients living alone, ACE inhibitors were preferred (OR = 2.16). The use of diuretics was more frequent in polymorbid patients (OR = 1.95). Immobile patients had lower chance of being prescribed beta-blockers and calcium channel blockers (OR = 0.25 and OR = 0.39, respectively).

CONCLUSION

The present study revealed that the selection of the antihypertensive drug class in elderly patients is influenced not only by comorbid conditions present but also by socio-demographic and clinical characteristics, such as age, sex, living alone, polymorbidity and immobilization. These characteristics reflect the doctor's perception of risk from pharmacotherapy of hypertension in elderly patients.

Improving outcomes in hypertensive patients: focus on adherence and persistence with antihypertensive therapy

Although effective control of blood pressure (BP) reduces the risk of cardiovascular events in patients with hypertension, BP control rates among treated patients in actual clinical practice are less than optimal. Although the costs of medicines and medical care (which are difficult to estimate both in clinical trials and general clinical practice) are important, medication-taking behavior--adherence and persistence with antihypertensive regimens--influences BP control rates. Many factors affect adherence and persistence with medications, including efficacy and tolerability of drugs prescribed, such that rates vary greatly among antihypertensive classes. In general, medications with fewer adverse effects (in registration trials or large outcomes studies) are associated with increased adherence and lower discontinuation rates. More widespread use of such agents, particularly those available in generic formulations or in low-cost formularies, may lead to better long-term BP control and fewer cardiovascular events.

Blood pressure reduction, persistence and costs in the evaluation of antihypertensive drug treatment--a review

Background

Blood pressure lowering drugs are usually evaluated in short term trials determining the absolute blood pressure reduction during trough and the duration of the antihypertensive effect after single or multiple dosing. A lack of persistence with treatment has however been shown to be linked to a worse cardiovascular prognosis. This review explores the blood pressure reduction and persistence with treatment of antihypertensive drugs and the cost consequences of poor persistence with pharmaceutical interventions in arterial hypertension.

Methods

We have searched the literature for data on blood pressure lowering effects of different antihypertensive drug classes and agents, on persistence with treatment, and on related costs. Persistence was measured as patients' medication possession rate. Results are presented in the form of a systematic review.

Results

Angiotensin II receptor blocker (ARBs) have a competitive blood pressure lowering efficacy compared with ACE-inhibitors (ACEi) and calcium channel blockers (CCBs), beta-blockers (BBs) and diuretics. 8 studies describing the persistence with treatment were identified. Patients were more persistent on ARBs than on ACEi and CCBs, BBs and diuretics. Thus the product of blood pressure lowering and persistence was higher on ARBs than on any other drug class. Although the price per tablet of more recently developed drugs (ACEi, ARBs) is higher than that of older ones (diuretics and BBs), the newer drugs result in a more favourable cost to effect ratio when direct drug costs and indirect costs are also considered.

Conclusion

To evaluate drugs for the treatment of hypertension several key variables including the blood pressure lowering effect, side effects, compliance/persistence with treatment, as well as drug costs and direct and indirect costs of medical care have to be considered. ARBs, while nominally more expensive when drug costs are considered only, provide substantial cost savings and may prevent cardiovascular morbidity and mortality based on the more complete antihypertensive coverage. This makes ARBs an attractive choice for long term treatment of hypertension.