Self-medication among people living with hypertension: a review

Intervention strategies to improve adherence to treatment for selected chronic conditions in sub-Saharan Africa: a systematic review

INTRODUCTION

Evidence-based intervention strategies to improve adherence among individuals living with chronic conditions are critical in ensuring better outcomes. In this systematic review, we assessed the impact of interventions that aimed to promote adherence to treatment for chronic conditions.

METHODS

We systematically searched PubMed, Web of Science, Scopus, Google Scholar and CINAHL databases to identify relevant studies published between the years 2000 and 2023 and used the QUIPS assessment tool to assess the quality and risk of bias of each study. We extracted data from eligible studies for study characteristics and description of interventions for the study populations of interest.

RESULTS

Of the 32,698 total studies/records screened, 2814 were eligible for abstract screening and of those, 497 were eligible for full-text screening. A total of 82 studies were subsequently included, describing a total of 58,043 patients. Of the total included studies, 58 (70.7%) were related to antiretroviral therapy for HIV, 6 (7.3%) were anti-hypertensive medication-related, 12 (14.6%) were anti-diabetic medication-related and 6 (7.3%) focused on medication for more than one condition. A total of 54/82 (65.9%) reported improved adherence based on the described study outcomes, 13/82 (15.9%) did not have clear results or defined outcomes, while 15/82 (18.3%) reported no significant difference between studied groups. The 82 publications described 98 unique interventions (some studies described more than one intervention). Among these intervention strategies, 13 (13.3%) were multifaceted (4/13 [30.8%] multi-component health services- and community-based programmes, 6/13 [46.2%] included individual plus group counselling and 3/13 [23.1%] included SMS or alarm reminders plus individual counselling).

DISCUSSION

The interventions described in this review ranged from adherence counselling to more complex interventions such as mobile health (mhealth) interventions. Combined interventions comprised of different components may be more effective than using a single component in isolation. However, the complexity involved in designing and implementing combined interventions often complicates the practicalities of such interventions.

CONCLUSIONS

There is substantial evidence that community- and home-based interventions, digital health interventions and adherence counselling interventions can improve adherence to medication for chronic conditions. Future research should answer if existing interventions can be used to develop less complicated multifaceted adherence intervention strategies.

Safety classification of herbal medicine use among hypertensive patients: a systematic review and meta-analysis

Background

The use of herbal medicines (HMs) for the treatment of hypertension (HTN) is increasing globally, but research on the potential adverse effects and safety of HMs in HTN patients is limited. Therefore, this systematic review and meta-analysis aim to determine the global prevalence of HM usage among HTN patients and assess the safety of identified herbs based on current scientific evidence.

Methods

The PubMed/MEDLINE, EMBASE (Ovid), and Cumulated Index to Nursing and Allied Health Literature (CINAHL) databases were searched for cross-sectional studies on the use of HM among HTN patients. Our review includes studies published in English up to the year 2023. After extracting and appraising the data from the studies, a meta-analysis was conducted using the Stata version 16.0 to estimate the pooled prevalence of HM use in patients with HTN (PROSPERO: CRD42023405537). The safety classification of the identified HM was done based on the existing scientific literature.

Results

This study analyzed 37 cross-sectional studies from 21 countries and found that 37.8% of HTN patients used HM to manage their health. The prevalence of HM use varied significantly based on publication year and geographical region. Among the 71 identified herbs, Allium sativum L., Hibiscus sabdariffa L., and Olea europaea L. were the most commonly used. However, four herbs were identified as contraindicated, 50 herbs required caution, and only 11 herbs were considered safe for use.

Conclusion

The study highlights the potential risks of toxicities and adverse effects associated with HM use in the treatment of HTN. Ensuring patient safety involves using safe HMs in appropriate doses and avoiding contraindicated HMs. Future research should focus on identifying commonly used herbs, especially in resource-limited countries with poor HTN management, and additional clinical research is required to assess the toxicity and safety of commonly used HMs.

Adult Cannabis Use: An Exploratory Case Study

Cannabis use is on the rise among adults and older adults managing chronic health conditions in the United States. There is limited understanding of this trend and the factors influencing cannabis use in the health care community. The current study explores the perceptions and experiences of adults and older adults with chronic health conditions who use cannabis regularly. Case study data were gathered through interviews guided by the Biopsychosocial Model. Biological, psychological, and social reasons for cannabis use emerged in the interviews. Despite reporting adverse events, cannabis was reported as an effective treatment for participants' chronic health issues, and participants were more comfortable with its use compared to prescription medications. A feeling of autonomy contributed to cannabis use being perceived as positive. Cannabis use is rising in the United States. Primary care providers must regularly screen older adults to identify appropriate and inappropriate use patterns. [Journal of Gerontological Nursing, 49(8), 19-26.].

Self-Care Management for Hypertension in Southeast Asia: A Scoping Review

Background

Self-care practices such as lifestyle modifications in diet, exercise, and stress management are effective in reducing the incidence of and enhancing better management of hypertension. However, little is known about the self-care management practices of people with hypertension in Southeast Asia (SEA) countries where the prevalence of hypertension is sharply increasing.

Methods

A scoping review of research and grey literature (2006-2021) was performed using Scoping Review Frameworks by Arkey and O'Malley. For the research literature, ten databases were searched followed by a manual search of the reference lists of relevant topical papers. Criteria for inclusion included both qualitative and quantitative primary data studies, focused on adult (18 years and over) hypertensive patients, self-care management methods, conducted in SEA. The study protocol has been registered at Open Science Framework (https://osf.io/s4nvk/).

Results

Out of 1667 studies examined, there were 57 studies that met criteria and were included in this review. Results indicate a paucity of relevant literature. Moreover, most studies reviewed showed an incident rate of 50% or more incidence of behavioural risk factors in people diagnosed with hypertension, including overweight/obesity, poor physical exercise, poor/low-quality dietary intake, and not adhering to medication. Few studies indicated adequate traditional self-care practice among SEA hypertension populations. Use of a non-prescription herbal as the medication is identified in some studies. Several reviewed articles indicated that there is individual variation in the facilitators and barriers to implementing self-care practices and we put it into a working framework. The facilitators and barriers are relevant to personal choice (internal factors) or to the environment or context (external factors).

Conclusion

Enhancing self-care management of hypertension in SEA may require a multi-focused approach including targeting personal choice as well as external factors such as cultural relevance, environment, and resources.

'Doing' hypertension: Experiential knowledge and practice in the self-management of 'high blood' in the Philippines

Patients' embodied experiences do not always correspond to the biomedical concepts of particular diseases. Drawing from year-long fieldwork in the Philippines that involved semi-structured interviews, focus group discussions and digital diaries, we examine how individuals 'do' hypertension through their embodied experiences and the knowledge and practice that emerge from them. Drawing inspiration from Annemarie Mol's work on the notion of 'multiplicity' of disease, our analysis was informed by a commitment to privileging patients' embodied experiences and the multiple ontologies of hypertension. We find that for patients diagnosed with hypertension in the Philippines, symptoms enact illness; patients rely on their own embodied knowledge to define their illness' nature (e.g., diagnosis), experience (e.g., frequency of symptoms and non-chronicity) and praxis (e.g., self-care practices). We show how this knowledge gained from having embodied experiences of living with the disease interacts in various ways with biomedical knowledge, other diagnostic labels and clinical practices, to shape how hypertension manifests and is managed by patients. Beyond interrogating the relationship between what counts as a 'disease' and what is considered a 'symptom', our findings underscore the need to pay attention instead to the mutually co-constitutive processes of embodied experiences and disease categories in co-producing patient knowledge.

Music Therapy as an Intervention to Reduce Blood Pressure and Anxiety Levels in Older Adults With Hypertension: A Randomized Controlled Trial

Hypertension is a serious medical condition, the frequency of which increases significantly with age; has a negative impact on certain health complications; and increases the rate of mortality. Music therapy as a nonpharmacological treatment has many positive effects on an individual's body and mind. A randomized controlled trial was used to evaluate the effects of music therapy on blood pressure, heart rate, and anxiety levels in older adults with hypertension living in a nursing home. Sixty older adults were randomly divided into experimental and control groups (n = 30 each). Significant reductions in systolic blood pressure, heart rate, and anxiety levels were found in older adults with hypertension receiving music therapy compared with the control group. The current study confirms music therapy as a safe, noninvasive, nonpharmacological, and cost-effective intervention for reducing blood pressure, heart rate, and anxiety levels in older adults with hypertension. [Research in Gerontological Nursing, 15(2), 85-92.].

Self-Medication in the COVID-19 Pandemic: Survival of the Fittest

OBJECTIVE

After the World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) a pandemic, intense efforts to combat the novel coronavirus were undertaken, with many fatalities in most regions of the world. The high fatality rate and socioeconomic collapse affected the health of uninfected individuals because healthcare measures and scheduled clinical and hospital visits were avoided by people in an attempt to reduce their exposure to the contagion. The general population began self-medication practices as means to safeguard against exposure to the virus.

METHODS

The present study investigated the effectiveness of self-medication compliance among the general population. For this purpose, a questionnaire on the Zenodo scale was developed and adults and teen respondents were asked to complete it, after providing consent. The data gathered were analyzed using IBM SPSS Statistics Version 26.

RESULTS

The study amazingly found high compliance with self-medication among the focused population during the period of COVID-19. Estimated results showed a highly significant correlation of 0.000, P < 0.05, between the adaptation of self-medication and pandemic situation, which was estimated from chi-squared and Fisher test results.

CONCLUSIONS

However, the fear of coronavirus made the practice, or malpractice, a survival of the fittest, innate ability of human nature.

Self-medication among people visiting outpatient clinics of a Tertiary care hospital, Karachi

Background and Aim:

“Self-medication” is the self-use of medicines for treatment of illnesses. Inappropriate use of medicines without prescription leads to unwanted adverse effects, harmful drug interactions, and antibiotic resistance which is an emerging concern in developing countries due to escalating burden of infectious diseases. This study aims at identifying the frequency and contributing factors of self-medication, nature of illness, and types of medicines used without doctor's prescription.

Material and Methods:

This cross sectional study was conducted at Indus Hospital Karachi between March 2017 and December 2018. Two hundred and forty people of any age visiting the outpatient clinics of the Indus hospital consenting to participate were included. Whereas all clinicians including medical officers, specialists and consultants were excluded from the study.

Results:

Three-fifth (n = 147; 61.3%) of the participants reported that they did self-medication either for themselves or for their children in the past one year. The most common symptoms for which self-medication was done were fever (n = 82, 55.8%), cough/cold (n = 38; 25.8%) or diarrhea (n = 22; 15.0%). Out of which, 122 (83%) did self-medication based on their previous experience, 18 (12.2%) used previous doctor's prescriptions, whereas 22 (15%) reported that other people advised them. Education, presence of unused medicines at home, and those who have heard of antibiotic were found to be the significant risk factors associated with self-medication.

Conclusion:

Among Pakistani population, the frequency of self-medication is very high, with most people practicing self-medication on the basis of their previous experiences. It puts them at risk of experiencing adverse reactions and most importantly antibiotic resistance.

Socioeconomic Determinants of Health Contributing to the Consumption of Nonprescribed Medicines in Ethiopia

BACKGROUND

Social determinants of health are understood as the conditions in which people are born, grow, live, work, and age that shapes health and include a domain of factors. Self-medication is influenced by these socioeconomic factors. This study, aims to quantitatively examine the relationship between these factors and the use of nonprescribed medicines and then identify which of the factors have the highest predictable value in Ethiopia.

METHODS

A quantitative, descriptive, cross-sectional, community-based research approach was used to explore the relationship between the dependent and independent variables in Addis Ababa, Ethiopia. Descriptive statistics, cross-tabulations, bivariate and regression analysis were used in the analysis.

RESULTS

A total of 72.2% (n=433) participants were found to have an ever experience of self-medication in their life and 35.7%) (n=214) have the practice in the last two months. Bivariate analysis showed that in the predisposing factors categories: age group (50-59) (p-value=0.034); those who are knowledgeable about all drugs not to be given to nursing mother (p-value=0.006); those who agree on the attitude that they would rather treat themselves than go to the nearest health facility (p-value=0.000) in the enabling factors; those who were satisfied with their financial quality of life (p-value=0.014) and from the need factors; those who perceived their health status as good (p-value=0.000) showed a significant association. Multivariate analysis showed that age, knowledge, attitudes showed statistical significance. Also, quality of life satisfaction of enabling factors and illness in the past two months from need factors had a statistically significant effect as predictors of utilization of nonprescribed medicines.

CONCLUSION

To strategize for appropriate self-medication, interventions should focus on changing the knowledge, attitude, and perception of the specific sociodemographic factors identified in the study.

Simultaneous Use of Herbal Medicines and Antihypertensive Drugs Among Hypertensive Patients in the Community: A Review

In various countries, approximately 80% of patients use herbal medicine, both in single form or in combination with antihypertensive drugs, for the treatment of hypertension. Therefore, this research summarized studies on the simultaneous use of herbal medicines and antihypertensive drugs among hypertensive patients in the community. A literature search was conducted on PubMed in April 2020, and the following keywords were used: “herbal medicines” and “antihypertensive patients.” In total, 15 of 263 articles were found to be eligible in the initial research. Results showed that studies were performed in different countries worldwide including America and those in Europe, Asia, and Africa between 1960 and 2020. The factors associated with the use of herbal medicines and antihypertensive drugs were age, gender, education level, income, and residence. Herbal medicines and antihypertensive drugs are simultaneously utilized primarily due to their safety and high efficacy. Herbal medicine is frequently recommended by friends or colleagues, herbalists, advertisements, and health workers. Garlic is the most common herbal medicine used along with antihypertensive drugs. The side effects of combination therapy with herbal medicines and prescription drugs for the management of antihypertension include shortness of breath and cough, ulcers, diarrhea, knee cramps, and abdominal discomfort. The lack of communication between patients and health care workers could cause an increase in the simultaneous use of herbal medicines and antihypertensive drugs. Therefore, effective communication among health care workers and appropriate care are important in preventing the side effects and other risks of combined therapy.

Herbal or Dietary Supplement Use and Hypertensive Medications: Does the Combination Relate to Medication Adherence and Blood Pressure Control?

Introduction: Medication nonadherence contributes to poor blood pressure control and increases cardiovascular disease risk in patients with hypertension. Identifying modifiable risk factors for low or nonadherence to antihypertensive medication is needed. Studies that have examined the relationship between herbal or dietary supplement (HDS) use and antihypertensive medication nonadherence provide inconsistent findings. Data from the National Health and Nutrition Examination Survey were used to examine the association between HDS use, current use of prescribed antihypertensive medication, and blood pressure status. Methods: The study sample included hypertensive adults (n = 5,478) who have been told by a health professional to take prescribed medication for their health condition. Respondents were classified as either HDS users or HDS nonusers. Depending on the kind of supplement used, HDS users were further divided into three mutually exclusive groups: hypertension HDS users, nonhypertension HDS users, and those who used both kinds of supplements. Supplements groupings were based on reports in the literature. Blood pressure status definition was based on Eighth Joint National Committee (JNC 8) recommendations. Adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) were obtained from logistic models. Results: Overall HDS use prevalence was 62%. Current medication use did not significantly differ between patients reporting no HDS use and those reporting HDS use (aOR: 1.45; 95% CI: 0.78-2.69). No observable differences were found in current medication use between patients reporting no HDS use and those taking nonhypertension HDS or both kinds of supplements. Use of hypertension HDS was associated with improved blood pressure (aOR: 1.90; 95% CI: 1.07-3.36) compared with no HDS use. Conclusion: In a nationally representative U.S. sample, HDS use did not compromise current use of prescribed medication and was associated with improved blood pressure control. More research is needed to better understand why HDS use is associated with better blood pressure control.

Application of Freire's adult education model in modifying the psychological constructs of health belief model in self-medication behaviors of older adults: a randomized controlled trial

Background

Self-medication by older adults has been always a public health concern. The present study aimed to modify the psychological constructs of Health Belief Model (HBM) in relation to self-medication behaviors using Freire’s Adult Education Model (FAEM) among older adults in Khorramabad, Iran, from 2017 to 2018.

Methods

The mean age of the older adults was 66.28 ± 7.18 years. This was a randomized controlled trial study conducted on 132 individuals older than 60 who were referred from different health care centers. The participants were selected using multistage sampling method and randomly divided into two groups of intervention and control. The data collection instruments included a questionnaire which was designed based on both HBM and self-medication behaviors questionnaire. The phase of adult education model (AEM) was used to modify the psychological constructs of HBM and self-medication behaviors. Data were analyzed using SPSS software version 20 with a significant level of 0.05. Descriptive statistical tests, chi-squared test, paired t-test, independent t-test, and univariate modeling were employed for the purpose of analyzing data.

Results

There was no significant difference between groups in terms of self-medication. Unawareness of the effects of medicine were the most important reason for self-medication (p = 0.50). The two groups were not significantly different in terms of knowledge, HBM constructs, and self-medication behaviors (p > 0.05). However, they came up to be considerably different for the above variables after the intervention was implemented (p <  0.05). When the findings were adjusted for the effects of confounding variables, there were significant differences between the two groups in almost all constructs of HBM and their behaviors (p <  0.05). However, the perceived barrier modality of HBM did not reach to a significant level of difference between two groups.

Conclusion

The educational intervention, which was based on Freire’s AEM, had positive effects on the constructs of HBM and consequently on self-medication behaviors. The psychological constructs of HBM were affected at the phases of listening to problems. Self-medication was tempered at the action-reflection phase with shared creation and evaluation of the action plan geared toward the achievement of the behavioral objectives. The results might be of importance to healthcare professionals involved in care of older patients.

Trial registration

Current Controlled Trials IRCT2013091814512N2. Registered on January 2 - prospectively registered, the trial was registered in the Iranian Clinical Trials Registry http://www.irct.ir.

The Development and Psychometric Assessment of Chinese Medication Literacy Scale for Hypertensive Patients (C-MLSHP)

OBJECTIVE

To develop the medication literacy scale for patients with hypertension, and to test the reliability and validity of the scale.

METHODS

The initial draft of the scale was formulated based on the operationalization of medication literacy with four core elements of knowledge, attitude, skill, and practice, and was developed through procedures of literature review, interviews to hypertensive patients, and research group discussion. Expert panel meeting, interviews, and pre-test on the initial draft of the scale to 10 hypertensive patients, as well as a two iterations of expert feedback were used to form a primary medication literacy scale for pilot investigation and item selection. In this study, 260 patients with hypertension in Changsha city of China were purposively selected to conduct a pilot survey using the primary medication literacy scale. After item selection by a series of statistical analysis method and item re-wording according to patients' feedback, the scale was revised to form a formal investigation scale with four domains and 37 items. A formal investigation was carried out on 650 patients with hypertension selected purposively in a tertiary general hospital and two community health service centers in Changsha city of China. The reliability and validity of the scale were analyzed.

RESULTS

Finally, the formal scale consists of four domains on knowledge, attitude, practice and skills, 11 sub-factors and 37 items in total. The scale-level content validity index (S-CVI/Ave) of this scale was 0.968, and the I-CVI for each item ranged from 0.833 to 1.000, indicating a good and acceptable content and face validity. The Cronbach's α coefficient was 0.849 for the overall scale and ranged from 0.744 to 0.783 for domains. The Pearson's correlation coefficients between domains and the total scale were ranging from 0.530 to 0.799. Besides, the Pearson's correlation coefficient among domains of the scale ranged from 0.157 to 0.439. The Spearman-Brown split-half reliability coefficient was 0.893 for the total scale and ranged from 0.793 to 0.872 for domains. The test-retest reliability coefficient of the total scale was 0.968 and ranged from 0.880 to 0.959 for domains. Four domains of knowledge, attitude, skill, and practice were identified through the exploratory factor analysis and confirmatory factor analysis from each domain. The total explained variation of domains for the overall scale was 51.420%. Eleven sub-factors for domains were extracted through respective exploratory factor analysis from each domain, and the total explained variation of sub-factors for its belonging domain were ranging from 56.111 to 64.419%. The confirmatory factor analysis showed the fit indices of the four-domain model were as follows (χ2/df=2.629, GFI=0.804, AGFI=0.777, RMR=0.012, IFI=0.746, RMSEA=0.066, PNFI=0.599, PCFI=0.689), which indicated an acceptable model fit.

CONCLUSIONS

The medication literacy scale for hypertensive patients has good reliability and acceptable validity, which is suitable and acceptable for evaluating the medication literacy level of hypertension patients in China. In the future, further construct and model fit validation and English translation with appropriate adaptation of this whole scale are required, so that this scale can be further validated and applied worldwide.

Exploring medications for hypertension advertised online: A qualitative study in Indonesia

Introduction:

Patients with hypertension often self-medicate and are increasingly purchasing their medications online. This study aimed to identify the medications and products used for hypertension offered by Indonesian online marketplaces and the availability of prescription-only antihypertensive medication on these platforms.

Materials and Methods:

This qualitative document analysis comprehensively assessed three online marketplaces in Indonesia in May 2019. Five top products in each online marketplace were identified and reviewed. An in-depth analysis was performed to obtain detailed information about the products (e.g., ingredients), indications, and customers’ comments. Selected antihypertensive medications (captopril, amlodipine, and valsartan) were searched for. The data were analyzed thematically.

Results:

The search results showed that more than 5000 products were available in each online marketplace and that all of the top products offered in these platforms were traditional medicines. Some products specifically claimed to be effective for lowering blood pressure (e.g., “the solution for hypertension without complications”). Morinda citrifolia (noni) and Allium sativum (garlic) were ingredients found in all three platforms, mainly in combination with other herbal medicines. The prescription-only antihypertensive medications offered and could be purchased through online marketplaces reviewed. However, information about dosage forms, indications, side effects, and contraindications of these medications was rarely provided on these platforms.

Conclusion:

Indonesian online marketplaces provide a wide range of products for the treatment of hypertension, particularly traditional medicines. Given the increasing trends of online shopping, providing objective and adequate information for customers is essential. Regulations for the purchase of prescription-only medicines, such as antihypertensive medications, should be strengthened.

Hypertension prevalence as a function of different guidelines, India

Objective

To determine the effect of different hypertension management guidelines and of basing diagnosis on a single reading of blood pressure on the hypertension prevalence in the Indian population.

Methods

We performed a secondary analysis of data acquired as part of the Fourth national family health survey, 2015 to 2016, over all districts in India. We calculated the proportion of the population within three different age groups (18 to 34, 35 to 49 and 18 to 49 years of age) with raised blood pressure according to six different guidelines, and how prevalence changed if diagnoses were based on a single blood pressure measurement.

Findings

We observed that the Government of India and the American College of Cardiology/American Heart Association guidelines consistently yielded the lowest and highest prevalence of raised blood pressure; in the combined age group, we calculated the proportion of the population categorized as having raised blood pressure as 7.5% (95% confidence interval (CI): 7.4 to 7.7) and 40.1% (95% CI: 39.7 to 40.7), respectively. When basing diagnosis on a single reading of blood pressure only, a total of 56 million individuals would be erroneously categorized as hypertensive following the Government of India guidelines. We also showed that prevalence of hypertension in India varies with guidelines adhered to; in the combined age group, the national hypertension prevalence was three times higher when following the American College of Cardiology/American Heart Association compared with the Government of India guidelines.

Conclusion

To optimize current clinical practice, health-care providers need to follow universally agreed, evidence-based methods of diagnosing hypertension.

Evaluation of Bloodletting Cupping Therapy in the Management of Hypertension

Background

Bloodletting cupping therapy (Hijama) is a traditional alternative medicine practiced in different cultures. Claims about the therapeutic efficacy of Hijama in hypertension are contradictory. The aim of this project was to determine if Hijama therapy is beneficial in the treatment of patients with hypertension.

Materials and Methods

In this retrospective study, 60 files for patients treated for hypertension, aged 40-60 years and whose systolic blood pressure (SBP) is at least 140mm Hg, were used. The data from 30 patient files were obtained from three licensed Hijama centers (study group), whereas data from the rest of 30 patient files were collected from a hospital (control group). The data from Hijama centers included age, date of Hijama therapy, and blood pressure measured before each Hijama session. Both diastolic blood pressure (DBP) and SBP data were obtained over 3-month period.

Results

The results showed a significant reduction in SBP (P value < 0.01) over three sessions of wet cupping (from 149.2 to 130.8mm Hg), but this was not significant for DBP over three sessions (P = 0.074). The study also found that the mean SBP in the study group was 9.6mm Hg less than that in the control group (130.8 vs. 140.4mm Hg, P = 0.019), whereas there was no significant difference in DBP between the study group and the control group (87.0 vs. 86.0mm Hg, P = 0.75).

Conclusions

Our study shows clear relationship between Hijama and the reduction and control of SBP in patients with hypertension. Therefore, Hijama can be used as an adjunct to conventional therapy, which may allow downtitration of given doses of antihypertensive drugs. The possible association of SBP reduction by Hijama and pain reduction needs an investigation.