Comparison between a bid and a tid regimen: improved compliance with no improved antihypertensive effect. The EOL Research Group

Improving medication adherence in hypertensive patients: A scoping review

In recent years, interest in medication adherence has greatly increased. Adherence has been particularly well studied in the context of arterial hypertension treatment. Numerous interventions have addressed this issue, however, the effort to improve adherence has been often frustrating and frequently disorganized. The aim of present study was to perform a scoping review of medication adherence interventions in hypertensive patients, so that a clear overview was achieved. Moreover, an evidence-based categorization of interventions was developed. The review was performed according to the PRISMA-ScR statement. MEDLINE and Web of Science were searched, and studies published from database inception until August 17, 2020 were included. A total of 2994 non-duplicate studies were retrieved. After screening and eligibility phases, a total of 45 articles were included. Studies were analyzed regarding their design, participant characteristics and management of adherence strategies employed. Furthermore, medication adherence and blood pressure outcomes, as well as adherence measuring tools were evaluated. Each study's intervention was then categorized using a novel evidence-based system of categorization, derived from the conceptual clustering framework used in machine learning. This work is an important step in pushing for better informed and more efficient future research efforts, both by providing an overview of the research field and by creating a new, evidence-based intervention categorization tool. It also provides valuable information to clinicians about medication adherence to antihypertensive therapy.

Influence of Adherence to Inhaled Corticosteroids and Inhaler Handling Errors on Asthma Control in a Japanese Population

Objective High adherence to medications and accurate handling of inhaler devices are important for asthma management. However, few reports to date have simultaneously evaluated adherence and handling errors. We therefore investigated the adherence to inhaled corticosteroid (ICS) and inhaler handling errors in the same patients in cooperation with pharmacists. Methods Data were derived from a survey of physicians and pharmacists treating asthma patients who visited participating hospitals and pharmacies from July 2012 to January 2013. The patients were evaluated for asthma control using the Asthma Control Test (ACT) and for inhaler handling errors using checklists. ICS adherence was evaluated based on pharmaceutical records. Results Adherence among participants (n=290) was 33.3% (mean), and the percentage of inhaler handling errors was 20.0% (mean). Total inhalation times in the high-adherence group were fewer than those in the low-adherence group. In a comparison by device, adherence to pressurized metered dose inhalers was significantly lower than that to Diskus® inhalers, presumably attributable to the total number of inhalations per day. Adherence, handling errors, and total number of inhalations per day were significantly different between the asthma-controlled group and the uncontrolled group. A multivariate analysis showed that adherence and handling errors were independent factors contributing to asthma control. Conclusion Our data indicated that both adherence to ICS and device handling errors contributed to asthma control in this population.

Rethinking the laryngopharyngeal reflux treatment algorithm: Evaluating an alternate empiric dosing regimen and considering up-front, pH-impedance, and manometry testing to minimize cost in treating suspect laryngopharyngeal reflux disease

OBJECTIVES/HYPOTHESIS

Empiric proton pump inhibitor (PPI) trials for laryngopharyngeal reflux (LPR) are common. A majority of the patients respond to acid suppression. This work intends to evaluate once-daily, 40 mg omeprazole and once-nightly, 300 mg ranitidine (QD/QHS) dosing as an alternative regimen, and use this study's cohort to evaluate empiric regimens prescribed for LPR as compared to up-front testing with pH impedance multichannel intraluminal impedance (MII) with dual pH probes and high-resolution manometry (HRM) for potential cost minimization.

STUDY DESIGN

Retrospective cohort review and cost minimization study.

METHODS

A chart review identified patients diagnosed with LPR. All subjects were treated sequentially and outcomes recorded. Initial QD/QHS dosing increased after 3 months to BID if no improvement and ultimately prescribed MII and HRM if they failed BID dosing. Decision tree diagrams were constructed to determine costs of two empiric regimens and up-front MII and HRM.

RESULTS

Ninety-seven subjects met the criteria. Responders and nonresponders to empiric therapy were identified. Seventy-two subjects (74%) responded. Forty-eight (67% of responders and 49% of all) improved with QD/QHS dosing. Forty-nine (51%) subjects escalated to BID dosing. Twenty-four subjects (33% of responders and 25% of all) improved on BID therapy. Twenty-five subjects (26%) did not respond to acid suppression. Average weighted cost was $1,897.00 per patient for up-front testing, $3,033.00 for initial BID, and $3,366.00 for initial QD/QHS.

CONCLUSIONS

An alternate QD/QHS regimen improved the majority who presented with presumed LPR. Cost estimates demonstrate that the QD/QHS regimen was more expensive than the initial BID high-dose PPI for 6 months. Overall per-patient cost appears less with up-front MII and HRM.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:S1-S13, 2017.

Interventions to Improve Medication Adherence in Hypertensive Patients: Systematic Review and Meta-analysis

This systematic review applied meta-analytic procedures to synthesize medication adherence interventions that focus on adults with hypertension. Comprehensive searching located trials with medication adherence behavior outcomes. Study sample, design, intervention characteristics, and outcomes were coded. Random-effects models were used in calculating standardized mean difference effect sizes. Moderator analyses were conducted using meta-analytic analogues of ANOVA and regression to explore associations between effect sizes and sample, design, and intervention characteristics. Effect sizes were calculated for 112 eligible treatment-vs.-control group outcome comparisons of 34,272 subjects. The overall standardized mean difference effect size between treatment and control subjects was 0.300. Exploratory moderator analyses revealed interventions were most effective among female, older, and moderate- or high-income participants. The most promising intervention components were those linking adherence behavior with habits, giving adherence feedback to patients, self-monitoring of blood pressure, using pill boxes and other special packaging, and motivational interviewing. The most effective interventions employed multiple components and were delivered over many days. Future research should strive for minimizing risks of bias common in this literature, especially avoiding self-report adherence measures.

Impact of reducing dosing frequency on adherence to oral therapies: a literature review and meta-analysis

OBJECTIVES

To assess the impact of reduced frequency of oral therapies from multiple-dosing schedules to a once-daily (OD) dosing schedule on adherence, compliance, persistence, and associated economic impact.

METHODS

A meta-analysis was performed based on relevant articles identified from a comprehensive literature review using MEDLINE® and Embase®. The review included studies assessing adherence with OD, twice-daily (BID), thrice-daily (TID), and four-times daily (QID) dosing schedules and costs associated with optimal/suboptimal adherence among patients with acute and chronic diseases. Effect estimates across studies were pooled and analyzed using the DerSimonian and Laird random-effect model.

RESULTS

Forty-three studies met inclusion criteria, and meta-analyzable data were available from 13 studies. The overall results indicated that OD schedules were associated with higher adherence rates (odds ratio [OR] 3.07, 95% confidence interval [CI] 1.80-5.23; P < 0.001 for OD versus > OD dosing) and compliance rates (OR 3.50, 95% CI 1.73-7.08; P < 0.001 for OD versus > OD dosing); persistence rates showed the same direction but were not statistically significant (OR 1.43, 95% CI 0.62-3.29; P = 0.405 for OD versus BID dosing). Results for each of the conditions were consistent with those observed overall with respect to showing the benefits of less frequent dosing. From a health economic perspective, higher adherence rates with OD relative to multiple dosing in a number of conditions were consistently associated with corresponding lower costs of health care resources utilization.

CONCLUSION

Current meta-analyses suggested that across acute and chronic disease states, reducing dosage frequency from multiple dosing to OD dosing may improve adherence to therapies among patients. Improving adherence may result in subsequent decreases in health care costs.

Impact of dose frequency on compliance and health outcomes: a literature review (1966-2006)

In order for treatments to be effective, patients must be compliant with their medication regimens. Currently, patient compliance is seen as one of the most challenging issues in treating patients with chronic diseases. Studies in which dose frequency has been changed have been reviewed across several different diseases to examine the impact of a change in dose frequency on compliance and health outcomes, as well as efficacy and tolerability. In general, reducing dose frequency may improve medication compliance and effectiveness, and reduce adverse events, while possibly reducing healthcare costs. Suggestions for future research have been presented, including a need to measure compliance with injectable formulations and a standardized definition of compliance.

Intentional and unintentional medication non-adherence: a comprehensive framework for clinical research and practice? A discussion paper

Non-adherence to medications is a prevalent and persistent healthcare problem, particularly for patients with a chronic disorder. Researchers have endeavoured to address poor adherence for the past five decades resulting in the accumulation of a vast body of literature. Despite the enormity of research conducted, interventions to date have neither been cost-effective nor predictably clinically effective in enhancing medication adherence. Though concerning, such contemporary information serves to refocus attention on the adequacy of knowledge regarding the factors influencing medication non-adherence. Although little consensus exists regarding the optimal categorisation of these influencing factors, increasingly, the broad and 'all encompassing' categorisation of intentional and unintentional factors is being used to account for patient medication-taking behaviours and actions. An extensive review of the related literature provides the basis for a critical discussion on the value and comprehensiveness of this current classification in guiding future adherence research and consequent clinical interventions. An appraisal of this categorisation is important if decisions regarding interventions are not to be made in a vacuum of insufficient understanding, which would result in the continued ineffective use and distribution of valuable resources to combat non-adherence.

Patient perspectives on multiple medications versus combined pills: a qualitative study

BACKGROUND

A growing number of patients are taking multiple medications. Unfortunately, adherence may fall as drug numbers and procedural complexity increase. While there are plausible theoretical reasons why combining pills might improve non-adherence, patients' attitudes are unknown.

AIM

To explore attitudes and practices to medication regimens among patients already in receipt of multiple medications, and to assess whether a combined tablet would be perceived as advantageous.

DESIGN

Qualitative study.

METHODS

Ninety-two men and women aged >40 years currently receiving both antihypertensive and cholesterol-lowering medications took part in 14 focus groups.

RESULTS

Drugs were seen as unwelcome but necessary. Some took drugs flexibly by changing dose timing, thereby increasing the complexity of their regimen. A routine was seen as the key to coping with multiple medications, although it was sometimes threatened by changes in prescriptions and life circumstances. While some participants welcomed a combined pill, there was uncertainty about whether a combination that mirrored their current doses would be available. There were also concerns about tablet size, allergies, the attribution of side-effects, timing of tablets throughout the day, and the ability to alter dose levels.

CONCLUSION

While some patients would be willing to try a combined pill and would appreciate the associated convenience, they are likely to have a number of concerns that prescribers should address. Willingness to move to combined therapy may be hindered if drug combinations that mirror personalized and trusted regimens are not available.

Medication adherence before an increase in antihypertensive therapy: A cohort study using pharmacy claims data

BACKGROUND

Less than one third of patients with hypertension achieve optimal blood pressure control. Poor medication adherence has been identified as one contributor to uncontrolled blood pressure.

OBJECTIVE

This study was conducted to test the hypothesis that patients who require an increase in their antihypertensive regimen have poorer adherence with medication compared with patients who remain on a stable regimen.

METHODS

Health plan enrollment and pharmacy claims data were used to perform a prospective cohort study and a nested case-control study in patients newly starting antihypertensive therapy. In the prospective cohort study, cumulative medication adherence (CMA, the percentage of days the patient had pills available, calculated as the total number of days of medication dispensed, excluding the final prescription, divided by the total number of days between the first and last antihypertensive prescriptions in the observation period) was compared between patients who required an increase in therapy and patients who remained on a stable antihypertensive regimen. In the nested case-control analysis, interval medication adherence (IMA, the ratio of the number of days of medication dispensed in a single prescription divided by the number of days until the next prescription is filled) during the prescription interval immediately before an increase in the antihypertensive regimen was compared with a similar interval in control patients without an increase matched by age, medication, number of days of medication dispensed, and months since initiation of therapy.

RESULTS

The study included data from 5089 patients (mean [SD] age, 47.8 [13.0] years; 50.0% women). Over a median (interquartile range) of 23 (9-49) months of initial antihypertensive treatment, 935 patients (18.4%) had an increase in regimen. After adjusting for age, duration of treatment, number of prescribing physicians, and specific medication, patients with a regimen increase had a 12.0% higher CMA compared with patients remaining on a stable regimen (P < 0.001). IMA for the period immediately before the increase was not significantly different in patients with an increase compared with matched controls (98.3% vs 101.0%, respectively).

CONCLUSIONS

Among these insured patients newly starting antihypertensive therapy, patients who required an increase in therapy had similar or slightly better medication adherence compared with patients remaining on a stable regimen. Poor adherence was not predictive of intensification of the antihypertensive regimen.

Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings

BACKGROUND

Lack of adherence to blood pressure lowering medication is a major reason for poor control of hypertension worldwide. Interventions to improve adherence to antihypertensive medication have been evaluated in randomised trials but it is unclear which interventions are effective.

OBJECTIVES

To determine the effectiveness of interventions aiming to increase adherence to blood pressure lowering medication in adults with high blood pressure

SEARCH STRATEGY

All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, and CINAHL in April 2002.

SELECTION CRITERIA

RCTs of interventions to increase adherence to blood pressure lowering medication in adults with essential hypertension in primary care, with adherence to medication and blood pressure control as outcomes

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Collaboration Handbook.

MAIN RESULTS

We included 38 studies testing 58 different interventions and containing data on 15519 patients. The studies were conducted in nine countries between 1975 and 2000. The duration of follow-up ranged from two to 60 months. Due to heterogeneity between studies in terms of interventions and the methods used to measure adherence, we did not pool the results. Simplifying dosing regimens increased adherence in seven out of nine studies, with a relative increase in adherence of 8 per cent to 19.6 per cent. Motivational strategies were successful in 10 out of 24 studies with generally small increases in adherence up to a maximum of 23 per cent. Complex interventions involving more than one technique increased adherence in eight out of 18 studies, ranging from 5 per cent to a maximum of 41 per cent. Patient education alone seemed largely unsuccessful.

REVIEWERS' CONCLUSIONS

Reducing the number of daily doses appears to be effective in increasing adherence to blood pressure lowering medication and should be tried as a first line strategy, although there is less evidence of an effect on blood pressure reduction. Some motivational strategies and complex interventions appear promising, but we need more evidence on their effect through carefully designed RCTs.

Relationship between daily dose frequency and adherence to antihypertensive pharmacotherapy: evidence from a meta-analysis

BACKGROUND

Rates of patient adherence (compliance) to pharmacotherapy range from <5% to >90%. Negative determinants include multiple daily dosing (MDD), chronic duration, and asymptomatic disease. Reports suggest that once-daily (QD) dosing may improve adherence, but their findings are inconclusive.

OBJECTIVE

The purpose of this study was to compare the rates of adherence with QD, twice-daily (BID), and MDD antihypertensive drug regimens.

METHODS

MEDLINE, Embase, and International Pharmaceutical Abstracts databases were searched to identify comparative trials of patient adherence to antihypertensive medication in solid, oral formulations. Data were combined using a random-effects meta-analytic model.

RESULTS

Eight studies involving a total of 11,485 observations were included (1,830 for QD dosing, 4405 for BID dosing, 4147 for dosing >2 times daily [>BID], and 9655 for MDD), in which the primary objective was to assess adherence. The average adherence rate for QD dosing (91.4%, SD = 2.2%) was significantly higher (Z = 4.46, P < 0.001) than for MDD (83.2%, SD = 3.5%). This rate was also significantly higher (Z = 2.22, P = 0.026) than for BID dosing (92.7% [SD = 2.3%] vs 87.1% [SD = 2.9%]). The difference in adherence rates between BID dosing (90.8%, SD = 4.7%) and >BID dosing (86.3%, SD = 6.7%) was not significant (Z = 1.82, P = 0.069).

CONCLUSIONS

The results of this meta-analysis demonstrate that with antihypertensive medications, QD dosing regimens are associated with higher rates of adherence than either BID or MDD regimens.

Relation between insufficient response to antihypertensive treatment and poor compliance with treatment: a prospective case-control study

OBJECTIVES

To prospectively compare compliance with treatment in patients with hypertension responsive to treatment versus patients with treatment resistant hypertension.

DESIGN

Prospective case-control study.

SETTING

Outpatient department in a large city hospital in Switzerland, providing primary, secondary, and tertiary care.

PARTICIPANTS

110 consecutive medical outpatients with hypertension and taking stable treatment with at least two antihypertensive drugs for at least four weeks.

MAIN OUTCOME MEASURES

Treatment compliance assessed with MEMS devices; blood pressure determined by 12 hour daytime ambulatory monitoring (pressure <135/85 mm Hg in patients aged 60 indicated hypertension responsive to treatment).

RESULTS

Complete data were available for 103 patients, of whom 86 took >/=80% of their prescribed doses ("compliant") and 17 took <80% ("non-compliant"). Of the 49 patients with treatment resistant hypertension, 40 (82%) were compliant, while 46 (85%) of the 54 patients responsive to treatment were compliant.

CONCLUSION

Non-compliance with treatment was not more prevalent in patients with treatment resistant hypertension than in treatment responsive patients.

Dose-finding study of once-daily indinavir/ritonavir plus zidovudine and lamivudine in HIV-infected patients

BACKGROUND

Strategies for treatment of HIV need to be considered in terms of combining potency, safety, and convenience of dosage. However, regimens including once-daily protease inhibitors are not yet available. We have performed a pilot study to determine an indinavir/ritonavir (IND/RTV) regimen for once-daily dosing, by monitoring plasma levels.

METHODS

Antiretroviral-naive HIV-infected adults were eligible. Therapy was zidovudine/lamivudine 1 pill twice daily plus IND/RIT (liquid formulation) 800/100 mg twice daily with food. At 4-week intervals, plasma levels were measured and dosage of IND/RIT switched to 1000/100 mg daily and then 800/200 mg daily. If 12-hour minimum concentrations (Cmin12h) of IND were too low (<0.1 microg/ml) with IND/RIT 1000/100 mg once daily in the first half of the patients, it was planned to switch directly to 800/200 mg once daily in the other half.

RESULTS

In all, 27 patients were recruited. Mean baseline CD4+ lymphocyte count was 107 x 106/L (range, 4-623 x 106/L). Eleven patients (40%) discontinued the study medication within the first 4 weeks due to clinical progression (n = 3) or grade 1-2 RTV related side effects (n = 8). Nine patients (group A) switched from 800/100 mg twice daily to 1000/100 mg once daily and then to 800/200 mg once daily. Seven patients (group B) switched directly to 800/200 mg once daily. At week 32, viral load was <5 copies/ml in 15 of 16 patients (94%). RTV levels were always <2.1 microg/ml. The mean and 95% confidence interval for IND Cmin and Cmax in microg/ml was: using IND/RTV 800/100 mg twice daily (n = 16) 1.4 (0.5-2.3) and 6.7 (4.4-9.1), respectively; using IND/RTV 1000/100 mg once daily (n = 9) 0.18 (0-0.41) and 8.6 (3.3-14), respectively; and using 800/200 mg once daily (n = 16) 0.38 (0-0.9), and 7.5 (0.8-14.8). For all 16 patients who received IND/RTV 800/100 mg twice daily, the Cmin value for IND was >/=0.1 microg/ml. Conversely, IND Cmin was <0.1 microg/ml in 4 of 9 receiving 1000/100 mg once daily but in only 1 of 16 receiving 800/200 mg once daily.

CONCLUSION

Once-daily regimen of IND/RIT is feasible and deserves further evaluation in larger randomized trials. Liquid formulation of RIT was not well tolerated by our antiretroviral-naive patients despite lower than suggested doses.

The steady-state plasma pharmacokinetics of indinavir alone and in combination with a low dose of ritonavir in twice daily dosing regimens in HIV-1-infected individuals

OBJECTIVE

To explore the steady-state plasma pharmacokinetics of indinavir in twice daily dosing regimens with and without the co-administration of 100 mg ritonavir.

DESIGN

Observational pharmacokinetic study.

PATIENTS

HIV-1-infected individuals who use indinavir alone (1200 mg twice daily, n = 6), or the combination of 100 mg ritonavir twice daily plus either 800 mg (n = 6), or 1200 mg indinavir twice daily (n = 2).

METHODS

Steady-state pharmacokinetics of indinavir and ritonavir were assessed by drawing 12 blood samples during an 8-h period after ingestion of the medication.

RESULTS

Significant differences were observed for indinavir pharmacokinetics between the dosing regimens indinavir 1200 mg twice daily alone and indinavir/ ritonavir 800/100 mg twice daily with respect to the mean trough concentration (0.21 and 0.99 microg/ml, respectively, P = 0.002), the mean maximum concentration (13.79 and 8.74 microg/ml, respectively, P = 0.028), and for the mean plasma elimination half-life (1.6 and 3.2 h, respectively, P = 0.001). The combination indinavir/ritonavir 1200/100 mg twice daily led to very high exposure to indinavir and was not well tolerated. However, the combination indinavir/ritonavir 800/100 mg twice daily was well tolerated and resulted in therapeutic concentrations of indinavir with improved trough concentrations and similar maximum concentrations as observed with the licensed dosage of 800 mg three times daily.

CONCLUSION

Combination of indinavir and 100 mg ritonavir in twice daily dosing regimens significantly affects the pharmacokinetic profile of indinavir. The results of this observational study provide a pharmacologic basis for the combination of indinavir (800 mg) and ritonavir (100 mg) in twice daily dosing regimens.

Formulation of controlled release microspheres containing nicardipine: the role of pharmacokinetic modeling and computer simulation

Nicardipine is an antihypertensive drug of the dihydropyridine series. It has high solubility in an acidic and low solubility in an alkaline medium. It is rapidly absorbed, extensively presystemically metabolized and excreted in the urine and faeces, mainly as inactive metabolites. Since the duration of its action can be extended by prolonging the absorption interval, the design of controlled release formulation is reasonable. The aim of the present study was to prepare microspheres which would release nicardipine at a decreased rate in gastric and increased rate in intestinal juice during a 12 h interval. Pharmacokinetic modeling based on compartment analysis and supported by analog computer and digital simulation technique showed that the target steady state peak plasma concentrations of 32 microg/l and trough plasma concentration of 7 microg/l would be maintained if nicardipine were incorporated in a formulation releasing the drug as follows: 25% after 1 h, 40% after 2 h, 65% after 4 h, 80% after 6 h, 90% after 8 h and 100% by 12 h. Microspheres have been prepared from hydroxypropylmethylcellulose phthalate polymer using the solvent evaporation method. Drug content, scanning electron micrographs, particle size distribution and dissolution profile were determined. In vitro nicardipine release was described by a biphasic square root of time kinetics and was in accordance with the above values relating to the dissolution. Furthermore, a composed first-pass pharmacokinetic model with derived release function as an input was developed to predict nicardipine plasma concentrations after single- and 12 h multiple-dosage-regimen scheme administration of controlled release microspheres.