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Agarwal A, Mehta PM, Jacobson T, Shah NS, Ye J, Zhu J, Wafford QE, Bahiru E, de Cates AN, Ebrahim S, Prabhakaran D, Rodgers A, Huffman MD. Fixed-dose combination therapy for the prevention of atherosclerotic cardiovascular disease. Nat Med 2024; 30:1199-1209. [PMID: 38532223 PMCID: PMC11031293 DOI: 10.1038/s41591-024-02896-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 03/01/2024] [Indexed: 03/28/2024]
Abstract
Fixed-dose combination (FDC) therapy, also known as polypill therapy, targets risk factors for atherosclerotic cardiovascular disease (ASCVD) and has been proposed as a strategy to reduce global ASCVD burden. Here we conducted a systematic search for relevant studies from 2016-2022 to assess the effects of FDC therapy for prevention of ASCVD. The studies selected include randomized trials evaluating FDC therapy with at least one blood pressure-lowering drug and one lipid-lowering drug. The study data were independently extracted, the quality of evidence was appraised by multiple reviewers and effect estimates were pooled using a fixed-effect meta-analysis when statistical heterogeneity was low to moderate. The main outcomes of the analysis were all-cause mortality, fatal and nonfatal ASCVD events, adverse events, systolic blood pressure, low-density lipoprotein cholesterol and adherence. Among 26 trials (n = 27,317 participants, 43.2% female and mean age range 52.9-76.0), FDC therapy was associated with lower low-density lipoprotein cholesterol and systolic blood pressure, with higher rates of adherence and adverse events in both primary and mixed secondary prevention populations. For studies with a mostly primary prevention population, FDC therapy was associated with lower risk of all-cause mortality by 11% (5.6% versus 6.3%; relative risk (risk ratio) of 0.89; 95% confidence interval 0.78 to 1.00; I2 = 0%; four trials and 16,278 participants) and risk of fatal and nonfatal ASCVD events by 29% (6.1% versus 8.4%; relative risk (risk ratio) of 0.71; 95% confidence interval 0.63 to 0.79; I2 = 0%; five trials and 15,503 participants). One adequately powered trial in an exclusively secondary prevention population showed that FDC therapy reduced the risk of major adverse cardiovascular events by 24%. These findings support adoption and implementation of polypills to lower risk for all-cause mortality and ASCVD.
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Affiliation(s)
- Anubha Agarwal
- Department of Medicine and Global Health Center, Washington University in St. Louis, St. Louis, MO, USA.
| | - Priya M Mehta
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Tyler Jacobson
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nilay S Shah
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - JingJing Zhu
- Department of Medicine and Global Health Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Q Eileen Wafford
- Galter Health Sciences Library and Learning Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ehete Bahiru
- Desert Cardiology Consultants, Eisenhower Medical Center, Rancho Mirage, CA, USA
| | | | - Shah Ebrahim
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark D Huffman
- Department of Medicine and Global Health Center, Washington University in St. Louis, St. Louis, MO, USA
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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Paoli CJ, Linder J, Gurjar K, Thakur D, Wyckmans J, Grieve S. Effectiveness of Single-Tablet Combination Therapy in Improving Adherence and Persistence and the Relation to Clinical and Economic Outcomes. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2024; 11:8-22. [PMID: 38500521 PMCID: PMC10948140 DOI: 10.36469/001c.91396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/19/2023] [Indexed: 03/20/2024]
Abstract
Background: Single-tablet combination therapies (STCTs) combine multiple drugs into one formulation, making drug administration more convenient for patients. STCTs were developed to address concerns with treatment adherence and persistence, but the impact of STCT use is not fully understood across indications. Objectives: We conducted a systematic literature review (SLR) to examine STCT-associated outcomes across 4 evidence domains: clinical trials, real-world evidence (RWE), health-related quality of life (HRQoL) studies, and economic evaluations. Methods: Four SLRs were conducted across the aforementioned domains. Included studies compared STCTs as well as fixed-dose combinations ([FDCs] of non-tablet formulations) with the equivalent active compounds and doses in loose-dose combinations (LDCs). Original research articles were included; case reports, case series, and non-English-language sources were excluded. Databases searched included EconLit, Embase, and Ovid MEDLINE® ALL. Two independent reviewers assessed relevant studies and extracted data. Conflicts were resolved with a third reviewer or consensus-based discussion. Results: In all, 109 studies were identified; 27 studies were identified in more than one SLR. Treatment adherence was significantly higher in patients receiving FDCs vs LDCs in 12 of 13 RWE studies and 3 of 13 clinical trials. All 18 RWE studies reported higher persistence with FDCs. In RWE studies examining clinical outcomes (n = 17), 14 reported positive findings with FDCs, including a reduced need for add-on medication, blood pressure control, and improved hemoglobin A1C. HRQoL studies generally reported numerical improvements with STCTs or similarities between STCTs and LDCs. Economic outcomes favored STCT use. All 6 cost-effectiveness or cost-utility analyses found FDCs were less expensive and more efficacious than LDCs. Four budget impact models found that STCTs were associated with cost savings. Medical costs and healthcare resource use were generally lower with FDCs than with LDCs. Discussion: Evidence from RWE and economic studies strongly favored STCT use, while clinical trials and HRQoL studies primarily reported similarity between STCTs and LDCs. This may be due to clinical trial procedures aimed at maximizing adherence and HRQoL measures that are not designed to evaluate drug administration. Conclusions: Our findings highlight the value of STCTs for improving patient adherence, persistence, and clinical outcomes while also offering economic advantages.
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Affiliation(s)
- Carly J Paoli
- Janssen Pharmaceutical Companies of Johnson & Johnson, Titusville, New Jersey, USA
| | - Jörg Linder
- Janssen-Cliag of Johnson & Johnson, Neuss, Germany
| | | | | | - Julie Wyckmans
- Janssen Pharmaceutical Companies of Johnson & Johnson, Basel, Switzerland
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Salim H, Musmar B, Saifi M, Ayyad M, Ruzieh M, Azar J, Nazzal Z. The Impact of Polypill on Adherence and Cardiovascular Outcomes: A Comprehensive Systematic Review with Meta-Analysis. Curr Cardiol Rev 2024; 20:61-71. [PMID: 38265377 PMCID: PMC11107474 DOI: 10.2174/011573403x283174240110025442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/11/2023] [Accepted: 12/26/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide. Polypills, containing various combinations of medications for primary and secondary CVD prevention, have been developed to enhance medication adherence and reduce the healthcare burden of CVD. However, their effectiveness compared to usual care remains uncertain. OBJECTIVE This meta-analysis aimed to evaluate the effects of polypills on cardiovascular risk factors, major adverse cardiovascular events (MACE), and medication adherence. METHODS We conducted a comprehensive search for large-scale randomized controlled trials and observational studies comparing the effects of polypills versus usual care on CVD risk factors and events. Outcomes included changes in systolic and diastolic blood pressure (SBP, DBP), lipid profiles, occurrence of MACE, and medication adherence. RESULTS The use of polypills led to a statistically significant yet clinically modest reduction in SBP (mean difference -1.47 mmHg, 95% CI: -2.50 to -0.44, p<0.01) and DBP (mean difference- 1.10 mmHg, 95% CI: -1.68 to -0.51, p< 0.01) compared to usual care. Polypills also showed a significant reduction in the risk of MACE (RR: 0.86, 95% CI: 0.77 -0.95, p<0.01). There was a non-significant reduction in LDL and HDL levels. Adherence to medication improved by up to 17% in polypill users compared to those on usual care (p < 0.01). A multivariable metaregression analysis suggested that adherence may be the underlying factor responsible for the observed effect of the polypills on blood pressure. CONCLUSION Polypills were found to significantly reduce SBP, DBP and MACE. An improvement in medication adherence was also observed among polypill users, which might be responsible for the significant reduction in SBP observed users. Future research might benefit from exploring a more personalized approach to the composition of polypills, which could reveal a more clinically significant impact of increased adherence on CVD outcomes.
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Affiliation(s)
- Hamza Salim
- Department of Medicine, An-Najah National University, Nablus, Palestine
| | - Basel Musmar
- Department of Medicine, An-Najah National University, Nablus, Palestine
| | - Motaz Saifi
- Department of Medicine, An-Najah National University, Nablus, Palestine
| | - Mohammed Ayyad
- Department of Medicine, An-Najah National University, Nablus, Palestine
| | - Mohammed Ruzieh
- Department of Cardiology, University of Florida, Gainesville, Florida, USA
| | - Jehad Azar
- Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Zaher Nazzal
- Department of Medicine, An-Najah National University, Nablus, Palestine
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Rivera A, Campos B, Ceolin S, Godoi A, Castanha E, Campello Jorge CA, Cardoso R. Polypill-based strategy vs. usual care for secondary prevention of cardiovascular disease: a meta-analysis of randomized controlled trials. Eur J Prev Cardiol 2023; 30:1828-1837. [PMID: 37490769 DOI: 10.1093/eurjpc/zwad245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/27/2023] [Accepted: 07/17/2023] [Indexed: 07/27/2023]
Abstract
AIMS We aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of a polypill-based strategy (PBS) on therapeutic adherence and cardiovascular outcomes compared with usual care for secondary prevention of cardiovascular diseases (CVDs). METHODS AND RESULTS We systematically searched PubMed, Cochrane, and Scopus databases from inception to January 2023, including RCTs comparing PBS with usual care in patients with prior CVD. We assessed efficacy outcomes of therapeutic adherence, systolic blood pressure (SBP), and LDL-cholesterol (LDL-C) and safety outcomes of all-cause and cardiovascular mortality. Statistical analysis was performed with Review Manager 5.4.1 and R Version 4.2.1. A total of 8 RCTs with a population of 6541 individuals were included, of whom 3318 (50.7%) were treated with the PBS. Follow-up ranged from 6 to 60 months. The polypill-based strategy was associated with a significantly increased therapeutic adherence [risk ratio (RR) 1.22; 95% confidence interval (CI) 1.10-1.34; P < 0.001]. Cardiovascular mortality (RR 0.61; 95% CI 0.44-0.85; P = 0.004), SBP [mean difference (MD) -1.47 mmHg; 95% CI -2.86 to -0.09; P = 0.04], and LDL-C (MD -3.83 mg/dL; 95% CI -6.99 to -0.67; P = 0.02) were significantly lower in the PBS group. The incidence of all-cause mortality was similar between groups (RR 0.83; 95% CI 0.54-1.29; P = 0.41). CONCLUSION In patients with pre-existing CVD, a PBS is associated with lower cardiovascular mortality and improved therapeutic adherence, along with a modest decrease in SBP and LDL-C compared with usual care. Thus, a PBS may be considered a preferred option for this patient population.
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Affiliation(s)
- André Rivera
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | - Bruno Campos
- Department of Medicine, Maurício de Nassau University, Cacoal, Brazil
| | - Stephanie Ceolin
- Department of Medicine, Vila Velha University, Vila Velha, Brazil
| | - Amanda Godoi
- School of Medicine, Cardiff University, Cardiff, UK
| | - Everton Castanha
- Department of Medicine, Federal University of Pelotas, Pelotas, Brazil
| | | | - Rhanderson Cardoso
- Division of Cardiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Marselin A, Amalia L, Dinarti LK. The interventions to improve medication adherence in coronary heart disease patient: A systematic review. J Saudi Heart Assoc 2023; 35:259-278. [PMID: 38116401 PMCID: PMC10727132 DOI: 10.37616/2212-5043.1356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/05/2023] [Accepted: 10/13/2023] [Indexed: 12/21/2023] Open
Abstract
Objective The clinical outcome and quality of life of CHD patients are greatly influenced by medication adherence. Non-adherence of CHD patients to treatment results in sub-optimal clinical outcomes and increasing costs. This study aims to describe effectiveness of the intervention to improve the medication adherence in CHD patients. Methods Systematic review methodology was used in this study. Scopus and PubMed were used to search the relevant article systematically. The outcome measured was medication adherence in coronary heart disease patients. Results Final screening was 31 articles that met the inclusion criteria in this study of 788 articles. Selection processes the article used the PRISMA guideline. Most of the articles (15 articles) use interventions that utilize information technology (IT) as known with m-health in the form of text messages, website, and smartphone-based applications in increasing medication adherence in CHD patients. The non m-health interventions developed are in the form of self-efficacy programs, monitoring and education by health workers or care workers, pharmacy care by clinical pharmacists, and the use of drugs in the form of multi-capsules. The results of most intervention with m-health can improve the medication adherence in CHD patient effectively. Education and motivation program by professional health care and multi-capsules also increasing the medication adherence in the intervention control. There was a decrease of medication adherence in some articles with long time follow-up that can be attention for the professional health care to manage the patient adherent. Conclusion The medication adherence in CHD patient can be improve by various program. Modification of m-health and non m-health intervention can be resolved to increase the communication, motivation, and knowledge about medication adherence in CHD patients.
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Affiliation(s)
- Amanda Marselin
- School of Pharmacy, Institut Teknologi Bandung,
Indonesia
- Pharmacy Program, STIKES Notokusumo, Yogyakarta,
Indonesia
| | - Lia Amalia
- School of Pharmacy, Institut Teknologi Bandung,
Indonesia
| | - Lucia K. Dinarti
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta,
Indonesia
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Engelbertz C, Feld J, Makowski L, Lange SA, Günster C, Dröge P, Ruhnke T, Gerß J, Reinecke H, Köppe J. Contemporary secondary prevention in survivors of ST-elevation myocardial infarction with and without chronic kidney disease: a retrospective analysis. Clin Kidney J 2023; 16:1947-1956. [PMID: 37915929 PMCID: PMC10616503 DOI: 10.1093/ckj/sfad219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Indexed: 11/03/2023] Open
Abstract
Background Survivors of myocardial infarction have an elevated risk of long-term mortality. We sought to evaluate guideline-directed medical treatment and its impact on long-term mortality in survivors of ST-elevation myocardial infarction (STEMI) according to their chronic kidney disease (CKD) stage. Methods Using German health insurance claims data, 157 663 hospitalized survivors of STEMI were identified. Regarding different CKD stages, we retrospectively analysed the filled prescriptions of platelet inhibitors (PAI)/oral anticoagulation, statins, beta-blocker and angiotensin-converting enzyme inhibitors/angiotensin II type 1 receptor antagonists (ACE-I/AT1-A) and their association with long-term mortality. Results Prescription rates for all four guideline-directed drugs were highest in patients without or with mild CKD and lowest in patients on dialysis. They dropped from 73.4% to 39.2% in patients without CKD and from 47.1% to 29% in patients on dialysis within the 5-year follow-up period. Mortality rates were dramatically increased in patients with CKD compared with patients without CKD (5-year mortality: no CKD, 16.7%; CKD stage 3, 47.1%; CKD stage 5d, 69.7%). Filled prescriptions of at least one drug class [one drug: hazard ratio (HR) 0.70, 95% confidence interval (95% CI) 0.66-0.74; four drugs: HR 0.28, 95% CI 0.27-0.30; P < .001 for both] as well as the distinct drug classes (statins: HR 0.55, 95% CI 0.54-0.56; ACE-I/AT1-A: HR 0.68, 95% CI 0.67-0.70; beta-blocker: HR 0.87, 95% CI 0.85-0.90; PAI/oral anticoagulation: HR 0.97, 95% CI 0.95-1.00; all P < .05) improved long-term mortality. Conclusions An improved long-term guideline-recommended drug therapy after STEMI regardless of renal impairment might lead to beneficial effects on long-term mortality.
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Affiliation(s)
- Christiane Engelbertz
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Muenster, Germany
| | - Jannik Feld
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Lena Makowski
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Muenster, Germany
| | - Stefan A Lange
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Muenster, Germany
| | | | | | | | - Joachim Gerß
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Holger Reinecke
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Muenster, Germany
| | - Jeanette Köppe
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
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Lopez-Lopez JP, Gonzalez AM, Lanza P, Lopez-Jaramillo P. Benefits of the Polypill on Medication Adherence in the Primary and Secondary Prevention of Cardiovascular Disease: A Systematic Review. Vasc Health Risk Manag 2023; 19:605-615. [PMID: 37719697 PMCID: PMC10504901 DOI: 10.2147/vhrm.s421024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/22/2023] [Indexed: 09/19/2023] Open
Abstract
Background Higher medication adherence reduces the risk of new cardiovascular events. However, there are individual and health system barriers that lead to lower adherence. The polypill has demonstrated benefits in cardiovascular morbidity and mortality mainly driven by an increase in adherence. We aim to evaluate the impact of the polypill on adherence to cardiovascular medication, its efficacy and safety in cardiovascular disease (CVD) prevention. Methods A systematic review following PRISMA guidelines was conducted. Databases were searched from January 2003 to December 2022. We included randomized, pragmatic, or real-world clinical trials and observational studies. The primary outcome was medication adherence, secondary outcomes were efficacy in cardiovascular disease in primary and secondary prevention and safety. Results From the 490 publications screened, 13 met the inclusion criteria and were incorporated into a comparative table Of those included, 70% were randomized controlled trials (RCTs) and 53.8% focused on secondary prevention. Most of the studies received a high and moderate quality rating. Self-report, pill counting and, the Morisky scale were the most frequent methods to evaluate adherence (84.6%). Compared with standard medication, the polypill improved overall medication adherence by 13%, with percentages ranging from 7.6% to 34.9%. Moreover, a potential benefit was also observed in reducing Major Adverse Cardiovascular Events (MACE), particularly in secondary prevention studies, with hazard ratios ranged between 0.43 to 0.76. Compared to standard care, the profile of side effects was similar. Conclusion The polypill is an effective, safe, and practical strategy to improve adherence in people at risk of CVD. Although there is a demonstrated benefit in reducing MACE, predominantly in secondary prevention, there are still gaps in its efficacy in primary prevention and reducing total mortality. Therefore, the importance of obtaining long-term results of the polypill effect and how this strategy can be implemented in real practice.
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Affiliation(s)
- Jose P Lopez-Lopez
- MASIRA Research Institute, Universidad de Santander (UDES), Bucaramanga, Santander, Colombia
- Department of Internal Medicine. Cardiology Unit, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Ana Maria Gonzalez
- MASIRA Research Institute, Universidad de Santander (UDES), Bucaramanga, Santander, Colombia
| | - Paola Lanza
- MASIRA Research Institute, Universidad de Santander (UDES), Bucaramanga, Santander, Colombia
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Ogungbe O, Byiringiro S, Adedokun-Afolayan A, Seal SM, Dennison Himmelfarb CR, Davidson PM, Commodore-Mensah Y. Medication Adherence Interventions for Cardiovascular Disease in Low- and Middle-Income Countries: A Systematic Review. Patient Prefer Adherence 2021; 15:885-897. [PMID: 33953548 PMCID: PMC8092634 DOI: 10.2147/ppa.s296280] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/02/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The burden of cardiovascular diseases (CVD) is high in low- and middle-income countries (LMICs). Medications are integral to the management and control of CVD; however, suboptimal adherence impacts health outcomes. This systematic review aims to critically examine interventions targeted at improving medication adherence among persons with CVD in LMICs. METHODS In this systematic review, we searched online databases PubMed, Embase, and CINAHL for studies that evaluated a medication adherence intervention for CVD, reported adherence as an outcome measure, were conducted in LMICs and reported the strategy or tool used to measure adherence. We included articles published in English, available in full text, peer-reviewed, and published between 2010 and 2020. RESULTS We included 45 articles in this review. The majority of the studies implemented counseling and educational interventions led by nurses, pharmacists, or community health workers. Many of the studies delivered medication-taking reminders in the form of phone calls, text messages, short message services (SMS), and in-phone calendars. Multi-component interventions were more effective than unifocal interventions. Interventions involving technology, such as mobile phone calls, electronic pillboxes, and interactive phone SMS reminders, were more effective than generic reminders. The outcomes reported in the studies varied based on the complexity and combination of strategies. When interventions were implemented at both the patient level, such as reminders, and at the provider level, such as team-based care, the effect on medication adherence was larger. CONCLUSION In LMICs, medication adherence interventions among persons with CVD included a combination of patient education, reminders, fixed-dose combination therapy and team-based care approach were generally more effective than singular interventions. Among patients who had CVD, the medication adherence interventions were found to be moderately effective. Future studies focusing on improving medication adherence in LMICs should consider non-physician-led interventions and appropriately adapt the interventions to the local context.
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Affiliation(s)
| | | | | | - Stella M Seal
- William H. Welch Medical Library, Johns Hopkins University and Medicine, Baltimore, MD, USA
| | - Cheryl R Dennison Himmelfarb
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Yvonne Commodore-Mensah
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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