Detecting non-adherence by urine analysis in patients with uncontrolled hypertension: rates, reasons and reactions

Controversies in Hypertension V: Resistant and Refractory Hypertension

Apparent resistant hypertension, defined as uncontrolled office blood pressure despite ≥ 3 antihypertensive medications including a diuretic or use of ≥ 4 medications regardless of blood pressure, occurs in ≤ 15% of treated hypertensives. Apparent refractory hypertension, defined as uncontrolled office pressure despite use of 5 or more medications including a diuretic, occurs in ≤ 10% of resistant cases. Both are associated with increased comorbidity and enhanced cardiovascular risk. To rule out pseudo-resistant or pseudo-refractory hypertension, employ guideline-based methodology for obtaining pressure, maximize the regimen, rule out white-coat effect, and assess adherence. True resistant hypertension is characterized by volume overload and aldosterone excess, refractory by enhanced sympathetic tone. Spironolactone is the preferred agent for resistance, with lower doses. Spironolactone, potassium binders, or both, are preferred if the estimated glomerular filtration rate is below 45. If significant albuminuria, finerenone is indicated. The optimal treatment of refractory hypertension is unclear, but sympathetic inhibition (α-β blockade, centrally acting sympathoinhibitors, or both) seems reasonable. Renal denervation has shown minimal benefit for resistance, but its role in refractory hypertension remains to be defined.

Measurement Tools and Utility of Hair Analysis for Screening Adherence to Antihypertensive Medication

Poor adherence to the prescribed antihypertensive therapy is an understated public health problem and is one of the main causes of the high prevalence of uncontrolled hypertension in sub-Saharan Africa. Medication adherence is vital for the effectiveness of antihypertensive treatment and is key to ameliorating the clinical outcomes in hypertensive patients. However, it has often been ignored because the current methods used to assess medication adherence are not reliable, limiting their utilization in clinical practice. Therefore, the identification of the most accurate and clinically feasible method for measuring medication adherence is critical for tailoring effective strategies to improve medication adherence and consequently achieve blood pressure goals. This review not only explores various available methods for estimating medication adherence but also proposes therapeutic drug monitoring in hair for the measurement of medication adherence to the antihypertensive medication period.

The effect of combining therapeutic drug monitoring of antihypertensive drugs with personalised feedback on adherence and resistant hypertension: the (RHYME-RCT) trial protocol of a multi-centre randomised controlled trial

BACKGROUND

Adherence to antihypertensive drugs (AHDs) is important for adequate blood pressure control. Not taking these drugs as prescribed is one of the main underlying causes for resistant hypertension (RH), which in turn leads to an increased risk of cardiovascular events, stroke and kidney damage. Therefore, correct identification of patients that are non-adherent to AHDs is crucial to improve clinical outcome. For this goal, therapeutic drug monitoring is the most reliable method. The primary objective of this trial is to investigate whether monitoring of drug concentrations with a dried blood spot (DBS) sampling method combined with personalised feedback leads to a decrease in prevalence of RH after 12 months due to an increase in adherence. Secondary objectives include the difference over time in the number of required AHDs as well as the defined daily dose (DDD). Lastly, the cost-utility of SoC versus the intervention in RH is determined.

METHODS

This is a multi-centre single-blinded randomised controlled trial (RHYME-RCT). First, at an eligibility visit, DBS sampling, to monitor drug concentrations in blood, and a 24-h ambulatory blood pressure measurement (24-h ABPM) are performed simultaneously. Patients with a daytime systolic blood pressure (SBP) > 135 and/or diastolic blood pressure (DBP) > 85 mmHg are randomised to SoC or intervention + SoC. The intervention is performed by the treating physician and includes information on drug concentrations and a comprehensive personalised feedback conversation with the use of a communication tool. The follow-up period is one year with visits at 3, 6 and 12 months randomisation and includes 24-h ABPM and DBS sampling.

DISCUSSION

This will be the first trial that focusses specifically on patients with RH without taking into account suspicion of non-adherence and it combines monitoring of AHD concentrations to identify non-adherence to AHDs with a comprehensive feedback to improve non-adherence. Furthermore, if this trial shows positive outcomes for the intervention it can be directly implemented in clinical practice, which would be a great improvement in the treatment of RH.

TRIAL REGISTRATION

RHYME-RCT is registered in the Dutch Trial Register on 27/12/2017 (NTR6914) and can be found in the International Clinical Trials Registry Platform.

Nonadherence in Hypertension: How to Develop and Implement Chemical Adherence Testing

Nonadherence to antihypertensive medication is common, especially in those with apparent treatment-resistant hypertension (true treatment-resistant hypertension requires exclusion of nonadherence), and its routine detection is supported by clinical guidelines. Chemical adherence testing is a reliable and valid method to detect adherence, yet methods are unstandardized and are not ubiquitous. This article describes the principles of chemical adherence testing for hypertensive patients and provides a set of recommendations for centers wishing to develop the test. We recommend testing should be done in either of two instances: (1) in those who have resistant hypertension or (2) in those on 2 antihypertensives who have a less than 10 mm Hg drop in systolic blood pressure on addition of the second antihypertensive medication. Furthermore, we recommend that verbal consent is secured before undertaking the test, and the results should be discussed with the patient. Based on medications prescribed in United Kingdom, European Union, and United States, we list top 20 to 24 drugs that cover >95% of hypertension prescriptions which may be included in the testing panel. Information required to identify these medications on mass spectrometry platforms is likewise provided. We discuss issues related to ethics, sample collection, transport, stability, urine versus blood samples, qualitative versus quantitative testing, pharmacokinetics, instrumentation, validation, quality assurance, and gaps in knowledge. We consider how to best present, interpret, and discuss chemical adherence test results with the patient. In summary, this guidance should help clinicians and their laboratories in the development of chemical adherence testing of prescribed antihypertensive drugs.

Adherence to antihypertensive drug treatment in kidney transplant recipients

PURPOSE

Hypertension is a common cardiovascular co-morbidity after kidney transplantation and contributes to shortened graft and patient survival outcomes. However, by contrast with adherence to immunosuppressive drugs, adherence to antihypertensive treatment in kidney transplant recipients has been seldom explored. The aim of the current study was to assess adherence to antihypertensive drugs in kidney transplant recipients from the Cliniques Universitaires Saint-Luc and to look for demographic and clinical characteristics associated with drug adherence.

METHODS

Demographic and clinical data were collected from medical files in a standardised case report form. Blood pressure was measured in the sitting position after 5 min rest, using validated oscillometric devices. Drug adherence was assessed by drug dosage in urine using liquid chromatography coupled with tandem mass spectrometry.

RESULTS

Our analysis included 53 kidney transplants recipients (75% of men, mean age: 57.2 ± 12.6 years, time since kidney transplantation: 9.5 ± 7.3 years, blood pressure: 130 ± 16/78 ± 11 mmHg on 2.1 ± 1.1 antihypertensive drugs). The proportion of patients showing full drug adherence, partial drug adherence, and total non-adherence to antihypertensive drugs was 79% (N = 42), 15% (N = 8), and 6% (N = 3), respectively. Adherent patients did not differ from less or non- adherers in any of the analysed characteristics.

CONCLUSION

The proportion of patients adhering to antihypertensive drug treatment among kidney transplant recipients appears similar to that reported for immunosuppressive drugs in renal transplanted patients (∼70%), but much higher than that observed in patients with drug-resistant hypertension (30-40%). Our results need further confirmation in a large, multicenter, prospective cohort.

Self-Reported Medication Use and Urinary Drug Metabolites in the German Chronic Kidney Disease (GCKD) Study

BACKGROUND

Polypharmacy is common among patients with CKD, but little is known about the urinary excretion of many drugs and their metabolites among patients with CKD.

METHODS

To evaluate self-reported medication use in relation to urine drug metabolite levels in a large cohort of patients with CKD, the German Chronic Kidney Disease study, we ascertained self-reported use of 158 substances and 41 medication groups, and coded active ingredients according to the Anatomical Therapeutic Chemical Classification System. We used a nontargeted mass spectrometry-based approach to quantify metabolites in urine; calculated specificity, sensitivity, and accuracy of medication use and corresponding metabolite measurements; and used multivariable regression models to evaluate associations and prescription patterns.

RESULTS

Among 4885 participants, there were 108 medication-drug metabolite pairs on the basis of reported medication use and 78 drug metabolites. Accuracy was excellent for measurements of 36 individual substances in which the unchanged drug was measured in urine (median, 98.5%; range, 61.1%-100%). For 66 pairs of substances and their related drug metabolites, median measurement-based specificity and sensitivity were 99.2% (range, 84.0%-100%) and 71.7% (range, 1.2%-100%), respectively. Commonly prescribed medications for hypertension and cardiovascular risk reduction-including angiotensin II receptor blockers, calcium channel blockers, and metoprolol-showed high sensitivity and specificity. Although self-reported use of prescribed analgesics (acetaminophen, ibuprofen) was <3% each, drug metabolite levels indicated higher usage (acetaminophen, 10%-26%; ibuprofen, 10%-18%).

CONCLUSIONS

This comprehensive screen of associations between urine drug metabolite levels and self-reported medication use supports the use of pharmacometabolomics to assess medication adherence and prescription patterns in persons with CKD, and indicates under-reported use of medications available over the counter, such as analgesics.

Monitoring Antihypertensive Medication Adherence by LC-MS/MS: Method Establishment and Clinical Application

ABSTRACT

Proper medication compliance is critical for the integrity of clinical practice, directly related to the success of clinical trials to evaluate both pharmacological and device-based therapies. Here, we established a liquid chromatography tandem mass spectrometry (LC-MS/MS) method to accurately detect 55 chemical entities in human urine sample, which accounting for the most commonly used 172 antihypertensive drugs in China. The established method had good accuracy, intra-day and inter-day precision for all analyses in both bench tests and validated in 21 hospitalized patients. We utilized this method to monitor and ensure drug compliance, and exclude the inferring impacts of medication compliance as a key confounder for our pivotal trial of a catheter-based, renal mapping and selective renal denervation to treat hypertension. It is found that in the urine samples from 92 consecutive subjects, 85 subjects (92.4%) were consistent with their prescriptions after 28 days run-in periods, 90 (97.8%) and 85 (95.5%) patients completely complied with their medications during the 3-month and 6-month follow-up period, respectively. Thus, using LC-MS/MS method with specificity, accuracy and precision, we ensured drug compliance of patients, excluded the key confounder of drug interferences and ensured the quality of our device-based clinical trial for treatment of hypertension.

A systematic review of interventions using health behavioral theories to improve medication adherence among patients with hypertension

Medication adherence is a major problem in the treatment of hypertension. Approximately half of the patients who use antihypertensive medications are not adherent. Several interventions have endeavored to improve medication adherence among patients with hypertension, and some have used health behavioral models/theories. However, the quality and effectiveness of using health behavioral models/theories in improving medication adherence among patients with hypertension remain unknown. The main aim of this systematic review was to describe study characteristics and types of health behavioral models/theories used in interventions for improving medication adherence among adults with hypertension. PubMed, Scopus, Ovid MEDLINE, CINAHL, and PsycINFO databases were searched for randomized clinical trial interventions using any health behavioral models/theories published in English from 1979 to 2019. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two independent reviewers searched, screened abstracts and articles, extracted data, and assessed the risk of bias and the use of the model/theory using the Theory Coding Scheme. A total of 11 articles were included in this systematic review. Two studies reported significant improvement in medication adherence. The Self-Regulation Model and Social Cognitive Theory were the most common types of models/theories. Nine studies used a single model/theory, and four studies measured the constructs of a model/theory. Risk of bias was good (n = 4) and fair (n = 5) in interventions. Using health behavioral models/theories may be an efficient way for health care professionals to improve adherence to medications among patients with hypertension. More interventions with rigorous designs are needed that appropriately utilize health behavioral models/theories for improving medication adherence among adults with hypertension.

Drug nonadherence is a common but often overlooked cause of hypertensive urgency and emergency at the emergency department

OBJECTIVES

Over 70% of patients who visit the emergency department with a hypertensive emergency or a hypertensive urgency have previously been diagnosed with hypertension. Drug nonadherence is assumed to play an important role in development of hypertensive urgency and hypertensive emergency, but exact numbers are lacking. We aimed to retrospectively compare characteristics of patients with hypertensive urgency and hypertensive emergency and to prospectively quantify the attribution of drug nonadherence.

METHODS

We retrospectively analysed clinical data including information on nonadherence obtained by treating physicians of patients with SBP at least 180 mmHg and DBP at least 110 mmHg visiting the emergency department between 2012 and 2015. We prospectively studied drug adherence among patients admitted to the emergency department with severely elevated BP by measuring plasma drug levels using liquid chromatography tandem mass spectrometry from September 2016 to March 2017.

RESULTS

Of the 1163 patients retrospectively analysed, 257 (22.0%) met the criteria for hypertensive urgency and 356 (30.6%) for hypertensive emergency. Mean SBP (SD) was 203 (19) mmHg and mean DBP 121 (12) mmHg. Mean age was 60.1 (14.6) years; 55.1% were men. In 6.3% of patients with hypertensive urgency or hypertensive emergency, nonadherence was recorded as an attributing factor. Of the 59 patients prospectively analysed, 18 (30.5%) were nonadherent for at least one of the prescribed antihypertensive drugs.

CONCLUSION

Hypertensive urgency and hypertensive emergency are common health problems resulting in frequent emergency department admissions. Workup of patients with a hypertensive urgency or hypertensive emergency should include an assessment of drug adherence to optimize treatment strategy.

Perioperative use of renin-angiotensin system inhibitors and outcomes in patients undergoing cardiac surgery

It remains disputable about perioperative use of renin-angiotensin system inhibitors (RASi) and their outcome effects. This multicenter retrospective cohort study examines association between use of perioperative RASi and outcomes in patients undergoing coronary artery bypass graft and/or valve surgery. After the exclusion, the patients are divided into 2 groups with or without preoperative RASi (PreRASi, n = 8581), or 2 groups with or without postoperative RASi (PostRASi, n = 8130). With using of propensity scores matching to reduce treatment selection bias, the study shows that PreRASi is associated with a significant reduction in postoperative 30-day mortality compared with without one (3.41% vs. 5.02%); PostRASi is associated with reduced long-term mortality rate compared with without one (6.62% vs. 7.70% at 2-year; 17.09% vs. 19.95% at 6-year). The results suggest that perioperative use of RASi has a significant benefit for the postoperative and long-term survival among patients undergoing cardiac surgery.

Renin-angiotensin system inhibitors (RASi) are beneficial in several classes of cardiovascular patients. However, whether their perioperative use is beneficial and/or safe in cardiac surgery is unclear. Here the authors perform a multicenter retrospective cohort study showing that preoperative and postoperative use of RASi is associated with reduction of mortality in patients undergoing cardiac surgery.

Antihypertensive Treatment Patterns and Blood Pressure Control in Older Adults: Results from the Berlin Aging Study II

BACKGROUND

Hypertension is highly prevalent in older adults and represents a major public health issue since recognition, awareness, treatment and control are insufficient. Analyses of prescription patterns in conjunction with clinical parameters can provide novel insights into the current practice of hypertension management and help to identify barriers to sufficient hypertension control.

METHODS

A cross-sectional analysis was conducted. Prevalence of hypertension, patterns of antihypertensive therapy, and determinants of blood pressure (BP) control were examined in the Berlin Aging Study II cohort, including 1654 community-dwelling older adults (60-85 years of age).

RESULTS

Of the participants, 75.9% had hypertension; 40.6% of these were not prescribed BP medications. Lack of hypertension awareness, younger age, absence of comorbidities, not being on a statin, and not having visited a physician in the past 3 months were associated with lack of treatment. Forty-two percent of treated hypertensive individuals received monotherapy and 58.0% received combination therapy. Renin-angiotensin-aldosterone system (RAAS) inhibitors, and β-blockers were most commonly prescribed, while calcium channel blockers were least prescribed. Only 38.5% of treated hypertensive individuals had their BP controlled to < 140/90 mmHg. Number and choice of BP medications were not predictive of BP control; neither were age, glycated hemoglobin (HbA_1c), kidney function, or number of healthcare visits. However, female sex, lower low-density lipoprotein cholesterol (LDL-C) levels and current smoking, amongst others, were positively associated with BP control. There was evidence of significant effect modification by statins in the association of LDL-C and BP.

CONCLUSION

The majority of older adults do not reach BP goals. Antihypertensive prescription patterns do not conform to current guidelines. Using more BP medications was not associated with higher odds of BP control. Lowering LDL-C might be favorable in terms of BP control.

The impact of financial strain on medication non-adherence: Influence of psychiatric medication use

Non-adherence to prescribed medications is a systemic public health concern. Financial strain, the extent to which an individual is unable to afford necessary items, may represent an important factor related to adherence. This study evaluated the association between financial strain and medication adherence as a function of medication type. Participants reporting a daily prescription for psychiatric or other chronic health conditions (N = 231) were sampled from the crowdsourcing website Amazon Mechanical Turk (mTurk). All participants completed measures of financial strain and other individual-difference factors related to adherence. Medication adherence was evaluated using a subjective scale (i.e., ARMS) and past month non-adherence rates. General financial strain showed a modest relationship with subjective scales of adherence, but not past month non-adherence rates. Medication-specific financial strain was associated with greater non-adherence, even after controlling for relevant demographic, socio-economic, and personality factors. Medication-specific financial strain also disproportionately affected individuals taking psychiatric medications relative to those not taking psychiatric medications. These findings emphasize the role that financial strain plays in medication adherence, and in particular, in psychiatric conditions. Future studies could design interventions targeting financial strain to improve clinical adherence, broadly, and psychiatric medication adherence, specifically.

Biochemical Screening for Nonadherence Is Associated With Blood Pressure Reduction and Improvement in Adherence

We hypothesized that screening for nonadherence to antihypertensive treatment using liquid chromatography-tandem mass spectrometry-based biochemical analysis of urine/serum has therapeutic applications in nonadherent hypertensive patients. A retrospective analysis of hypertensive patients attending specialist tertiary care centers was conducted in 2 European countries (United Kingdom and Czech Republic). Nonadherence to antihypertensive treatment was diagnosed using biochemical analysis of urine (United Kingdom) or serum (Czech Republic). These results were subsequently discussed with each patient, and data on follow-up clinic blood pressure (BP) measurements were collected from clinical files. Of 238 UK patients who underwent biochemical urine analysis, 73 were nonadherent to antihypertensive treatment. Their initial urinary adherence ratio (the ratio of detected to prescribed antihypertensive medications) increased from 0.33 (0-0.67) to 1 (0.67-1) between the first and the last clinic appointments. The observed increase in the urinary adherence ratio in initially nonadherent UK patients was associated with the improved BP control; by the last clinic appointment, systolic and diastolic BPs were ≈19.5 and 7.5 mm Hg lower than at baseline (P=0.001 and 0.009, respectively). These findings were further corroborated in 93 nonadherent hypertensive patients from Czech Republic-their average systolic and diastolic BPs dropped by ≈32.6 and 17.4 mm Hg, respectively (P<0.001), on appointments after the biochemical analysis. Our data show that nonadherent hypertensive patients respond to liquid chromatography-tandem mass spectrometry-based biochemical analysis with improved adherence and significant BP drop. Such repeated biochemical analyses should be considered as a therapeutic approach in nonadherent hypertensive patients.