'Take as directed'—strategies to improve adherence to cardiac medication

Challenges in Improving Adherence to Diet and Drug Treatment in Hypercholesterolemia Patients

Poor adherence to chronic disease treatment may seriously compromise the effectiveness of therapy, characterizing itself as a critical element for the population's health, both from the point of view of quality of life and health economics. The causes of low adherence are many and can depend on the patient, the physician and the healthcare system. Low adherence to dietary recommendations and lipid-lowering drug therapy for hypercholesterolemia is a widespread phenomenon that may strongly limit the great advantages of serum lipid reduction strategies in primary and secondary cardiovascular prevention. Many patients discontinue treatment, and adherence decreases with time. Increasing therapeutic adherence can have a much greater impact on the health of the population than any other therapeutic advance. There are numerous strategies to increase therapy adherence according to behavior change theories. They concern the doctor and the patient. Some must be implemented at the time of prescription, others later during the follow-up. The active role of the patient in the therapeutic decision and the shared definition of LDL cholesterol targets are of paramount importance. The aim of this narrative review is to summarize evidence on current levels of adherence to lipid-lowering strategies, the causes of the lack of adequate adherence and possible physician-applicable strategies to improve it.

Effect of self-administration of medication programme on cardiovascular inpatients' medication adherence and nurses' satisfaction: A randomized clinical trial

AIM

To investigate the effect of self-administration of medication programme on medication adherence in cardiovascular inpatients and nurse's satisfaction.

DESIGN

Randomized clinical trial with parallel-group design guided by the CONSORT checklist.

METHODS

In this study, sixty cardiovascular inpatients were selected through convenience sampling and then randomly assigned to control and intervention groups, in 2018, Iran. The intervention group took responsibility for consuming their prescribed medication according to the self-administration of medication programme and the control group took medications routinely. Medication adherence was measured one and two weeks after the discharge via telephonic follow-up by Morisky Medication Adherence Scale MMAS-8-item and nurses' satisfaction by researcher-made questioner.

RESULT

There was a higher medication adherence level in the intervention group rather than the usual care group at the follow-up. Most nurses in the study environment were very satisfied.

CONCLUSION

The self-administration of medication programme can effectively increase patients' medication adherence and nurses' satisfaction.

Prevention of Progression of Aortic Aneurysm by Peptide Vaccine Against Ang II (Angiotensin II) in a Rat Model

There is no proven medical therapy to inhibit the progression of abdominal aortic aneurysm (AAA) in the clinical setting. To develop a novel therapeutic approach for the treatment of AAA, we focused on vaccination targeting Ang II (angiotensin II) and assessed the effect of an Ang II peptide vaccine on the progression of AAA using a rat model. Ang II peptide was conjugated with KLH (keyhole limpet hemocyanin) carrier protein to induce a sufficient immune response. Male rats were subcutaneously immunized with Ang II-KLH with an adjuvant on days 0, 14, and 28. Aortic dilatation was induced by intraluminal incubation with elastase on day 35. Treatment with Ang II vaccine successfully induced the production of a high titer of anti-Ang II antibodies. Immunization with Ang II vaccine resulted in a significant reduction in expansion of the aortic diameter compared with control rats, without a blood pressure-lowering effect. Four weeks after operation, the increase in Ang II in the aneurysm wall was significantly inhibited by treatment with Ang II vaccine. Inhibition of Ang II action led to suppression of the inflammatory response in the AAA wall through attenuation of the NFκB (nuclear factor kappa B) and c-jun N-terminal kinase signaling cascades. Treatment with Ang II vaccine inhibited accumulation of macrophages in the AAA wall. In addition, expression of TNF-α (tumor necrosis factor alpha) and activation of MMP (matrix metalloproteinase)-2 and MMP-9 were also inhibited by treatment with Ang II vaccine, resulting in protection against the destruction of elastic fibers. This vaccine therapy could become a potent therapeutic option to treat patients with AAA.

Impact of number of medications and age on adherence to antihypertensive medications: A nationwide population-based study

This study tried to investigate the effects of number of medications and age on antihypertensive medication adherence in a real-world setting using a nationwide representative cohort.We obtained data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) of Korea, which is a sample of 2.2% (N = 1,048,061) of total population (N = 46,605,433). Patients aged 20 years or older (N = 150,550) who took antihypertensive medications for at least 1 year were selected. Medication possession ratio (MPR) was used for measuring adherence. The subjects were divided into 5 subgroups according to total number of medications: 1-2, 3-4, 5-6, 7-8, and 9 or more. The mean age and the mean number of medications were 60.3 ± 12.6 years and 4.1 ± 2.2, respectively. The mean MPR was 80.4 ± 23.9%, and 66.9% (N = 100,645) of total subjects were adherent (MPR ≥ 80%). The overall tendency of antihypertensive medication adherence according to the total number of medications displayed an inverted U-shape with a peak at 3-4 drugs. Adherence consistently increased as the age increased until age 69 and started to decrease from age 70. The proportion of adherent patients (MPR ≥ 80%) according to the total number of medications also showed an inverted U-shape with a peak at 3-4 drugs. When the same number of drugs was taken, the proportion of adherent patients according to age featured an inverted U- shape with a peak at 60 to 69 years. Patients taking 9 or more total drugs had the overall odds ratio (95% CI) of non-adherence (MPR < 80%) with 1.17 (1.11-1.24) compared with those taking 1 to 8 total drugs and the odds ratios in the age subgroups of 40 to 49, 50 to 59, 60 to 69 years were 1.57 (1.31-1.87), 1.21 (1.08-1.36), and 1.14 (1.04-1.25), respectively (P < .05).Association between age, total number of medications, and antihypertensive adherence displayed an inverted U-shape with a peak at 3 to 4 total medications and at age 60 to 69 years. When the total number of drugs was 9 or more, adherence decreased prominently, regardless of age.

Effects of combination drugs on antihypertensive medication adherence in a real-world setting: a Korean Nationwide Study

OBJECTIVES

We tried to clarify, by using representative national data in a real-world setting, whether single-pill combinations (SPCs) of antihypertensives actually improve medication adherence.

DESIGN

A nationwide population-based study.

SETTING

We used a 2.2% cohort (n=1 048 061) of the total population (n=46 605 433) that was randomly extracted by National Health Insurance of Korea from 2008 to 2013.

PARTICIPANTS

We included patients (n=116 677) who were prescribed with the same antihypertensive drugs for at least 1 year and divided them into groups of angiotensin II receptor blocker (ARB)-only, calcium channel blocker (CCB)-only, multiple-pill combinations (MPCs) and SPCs of ARB/CCB.

PRIMARY OUTCOME MEASURES

Medication possession ratio (MPR), a frequently used indirect measurement method of medication adherence.

RESULTS

Adjusted MPR was higher in combination therapy (89.7% in SPC, 87.2% in MPC) than monotherapy (81.6% in ARB, 79.7% in CCB), and MPR of SPC (89.7%, 95% CI 89.3 to 90.0) was higher than MPR of MPC (87.2%, 95% CI 86.7 to 87.7) (p<0.05). In subgroup analysis, adherence of SPC and MPC was 92.3% (95% CI 91.5 to 93.0) vs 88.1% (95% CI 87.1 to 89.0) in those aged 65-74 years and 89.3% (95% CI 88.0 to 90.7) vs 84.8% (95% CI 83.3 to 92.0) in those ≥75 years (p<0.05). According to total pill numbers, adherence of SPC and MPC was 90.9% (CI 89.8 to 92.0) vs 85.3% (95% CI 84.1 to 86.5) in seven to eight pills and 91.2% (95% CI 89.3 to 93.1) vs 82.5% (95% CI 80.6 to 84.4) in nine or more (p<0.05). The adherence difference between SPC and MPC started to increase at five to six pills and at age 50-64 years (p<0.05). When analysed according to elderly status, the adherence difference started to increase at three to four pills in the elderly (≥65 years) and at five to six in the non-elderly group (20-64 years) (p<0.05). These differences all widened further with increasing age and the total medications.

CONCLUSION

SPC regimens demonstrated higher adherence than MPC, and this tendency is more pronounced with increasing age and the total number of medications.

Nonadherence to statins: individualized intervention strategies outside the pill box

Poor adherence to statin therapy is linked to significantly increased risk of cardiovascular events and death. Unfortunately, adherence to statins is far from optimal. This is an alarming concern for patients prescribed potentially life-saving cholesterol-lowering medication, especially for those at high risk of cardiovascular events. Research on statin adherence has only recently garnered broader attention; hence, major reasons unique to adherence to statin therapy need to be identified as well as suggestions for countermeasures. An integrated approach to minimizing barriers and enhancing facilitation at the levels of the patient, provider, and health system can help address adherence issues. Health care professionals including physicians, pharmacists, and nurses have an obligation to improve patient adherence, as routine care. In order to achieve sustained results, a multifaceted approach is indispensable.

Attitudes and actions: A survey to assess statin use among Finnish patients with increased risk for cardiovascular events

BACKGROUND

Statins are the first-line treatment for lowering serum cholesterol and preventing coronary artery disease (CAD). Patients who fail to comply with the prescribed statin treatment face a markedly increased risk for cardiovascular events.

OBJECTIVE

The aim of the article was to study the subjective factors, which modulate persistence with and adherence to statin therapy among Finnish patients at high risk for cardiovascular events.

METHODS

A total of 1022 Finnish adults diagnosed with CAD, diabetes, hypertension, or severe hereditary dyslipidemia completed an electronic questionnaire survey during a visit in 1 of the 84 community pharmacies participating in the study.

RESULTS

Thirty-four percent of the survey respondents were diagnosed with CAD or severe hereditary dyslipidemia and 82% were current or former statin users. Prevalence of nonpersistence with statin therapy was 15% among CAD patients and 17% among respondents without the diagnosis. Most of the nonpersistent statin users had discontinued the medication without consultation of a physician. None of the studied sociodemographic background factors were associated with persistence with statin therapy. Instead, experienced adverse effects, fear of adverse effects, perceived lack of need, and difficulties in use of a statin emerged as powerful predictors of nonpersistence. Awareness of treatment goals was low, and strikingly, public discussion about adverse effects of statins had induced nearly every third discontinuation of statin treatment.

CONCLUSION

Several subjective, potentially modifiable reasons for nonpersistence were identified from the patient perspective. Improved utilization of patient-centered approaches in pharmacologic management of cardiovascular risks is necessary to improve adherence, and ultimately, treatment outcomes.

Patient-Centered Tablet Application for Improving Medication Adherence after a Drug-Eluting Stent

BACKGROUND/AIMS

This study's objective was to evaluate a patient-centered educational electronic tablet application, "My Interventional Drug-Eluting Stent Educational App" (MyIDEA) to see if there was an increase in patient knowledge about dual antiplatelet therapy (DAPT) and medication possession ratio (MPR) compared to treatment as usual.

METHODS

In a pilot project, 24 elderly (≥50 years old) research participants were recruited after a drug-eluting stent. Eleven were randomized to the control arm and 13 to the interventional arm. All the participants completed psychological and knowledge questionnaires. Adherence was assessed through MPR, which was calculated at 3 months for all participants who were scheduled for second and third follow-up visits.

RESULTS

Relative to control, the interventional group had a 10% average increase in MPR. As compared to the interventional group, more patients in the control group had poor adherence (<80% MPR). The psychological data revealed a single imbalance in anxiety between the control and interventional groups. On average, interventional participants spent 21 min using MyIDEA.

DISCUSSION

Consumer health informatics has enabled us to engage patients with their health data using novel methods. Consumer health technology needs to focus more on patient knowledge and engagement to improve long-term health. MyIDEA takes a unique approach in targeting DAPT from the onset.

CONCLUSION

MyIDEA leverages patient-centered information with clinical care and the electronic health record highlighting the patients' role as a team member in their own health care. The patients think critically about adverse events and how to solve issues before leaving the hospital.

Evidence of poor adherence to secondary prevention after acute coronary syndromes: possible remedies through the application of new technologies

Adherence to secondary prevention medications following acute coronary syndrome (ACS) is disappointingly low, standing around 40–75% by various estimates. This is an inefficient use of the resources devoted to their development and implementation, and also puts patients at higher risk of poor outcomes post-ACS. Numerous factors contribute to low adherence including poor motivation, forgetfulness, lack of education about medications, complicated polypharmacy of ACS regimens, (fear of) adverse side effects and limited practical support. Using technology to improve adherence in ACS is an emerging strategy and has the potential to address many of the above factors—computer-based education and mobile phone reminders are among the interventions trialled and appear to improve adherence in patients with ACS. As we move into an increasingly technological future, there is potential to use devices such as smartphones and tablets to encourage patient responsibility for medications. These handheld technologies have great scope for allowing patients to view online medical records, education modules and reminder systems, and although research specific to ACS is limited, they have shown initial promise in terms of uptake and improved adherence among similar patient populations. Given the overwhelming enthusiasm for handheld technologies, it would seem timely to further investigate their role in improving ACS medication adherence.