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FACULTY OF MEDICINE, DENTISTRY AND HEALTH SCIENCES

Winthrop Professor Markus Schlaich

Dobney Chair in Clinical Research

School of Medicine and Pharmacology - Royal Perth Hospital Unit

Faculty of Medicine, Dentistry & Health Sciences

The University of Western Australia

Hypertension

Overcoming Barriers to Compliance

The University of Western Australia

Mr L. , 68 years Old

retired in the Swan Valley

- Last medical consultation : 2007 …

- Cardiovascular Risk Factor

Past history of hypertension for 20 years Current smoker (20 cigarettes / day)Weight/Height: 80 kg/180 cm (BMI : 24.69 )

- Treatment :Candesartan: 8 mg dailyAmlodipine: 5mg dailyThiazide : 12.5 mg daily

“But not very useful…”

The University of Western Australia

- Physical examination:

Regular rate and rhythm HR: 73bpmNormal heart sounds (no clicks, murmurs or gallops)No bruits, chest clear, nil peripheral oedema, no JVD

- Office blood pressure :

SBP/DBP : 173/80 mmHg “Unusual , probably due to consultation“

- No ABPM neither Home BP monitoring

Forced by his Wife…

The University of Western Australia

After ( a long) negotiation

- ABPM:

Mean: 158/ 80 mmHg

Day: 169/82 mmHg

Night: 145/78 mmHg

- Urinary Albumin Excretion : microalbuminuria

- eGFR : 52 ml/min/m2

What else …?

The University of Western Australia

www.cvdcheck.org.auThe University of Western Australia

Hypertension Control Rates:

53.1

41.0

15.5

29.2

33.6

49.5

28.8

Patients

With C

ontr

olled B

P (

%)

Globally, <50% of treated hypertensive patients achieve BP goal

Kearney PM et al. J Hypertens. 2004;22:11-19.

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The University of Western Australia The University of Western Australia

The University of Western Australia

Medications and Foods Known to

Interfere With BP Control

• Nonnarcotic analgesics

• NSAIDs (including aspirin)

• Selective COX-2 inhibitors

• Sympathomimetic agents

• Decongestants

• Diet pills

• Cocaine

• Corticosteroids

• Tricyclic antidepressants

• Stimulants

• Cyclosporine

• Alcohol

• Oral contraceptives

• Erythropoietin

• Herbal compounds

• Ephedra

• Ma huang

• Foods

• Salt

• Natural licorice

The University of Western Australia

Adherence

Persistence

Compliance

Page 11: Baker IDI

“Drugs don’t work in patients who

don’t take them”

C. Everett Koop, MD

US Surgeon General (1982 to 1989)

Page 12: Baker IDI

What is Persistence?

Persistence refers to the percentage of patients still taking their prescribed therapy over time

– Reflects the physician’s willingness to continue prescribing and the patient’s willingness to continue taking the prescribed therapy

– Is a measure of both tolerability and efficacy

Poor persistence is well documented in chronic, asymptomatic conditions, despite the proven clinical benefits of treatment

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Page 13: Baker IDI

Patterns Of Adherence

Perfect adherence

All doses but some timing irregularity

Occasional missed doses and some timing

irregularity

Drug holidays three to four times a year

Drug holidays monthly or more often

No doses but gives impression of good adherence

White coat adherence – dose prior to doctors’ visit

Greenberg RN. Clin Ther. 1984, 6. 592.

Feinstein AR. Arch Intern Med. 1990. 150. 1377.

The University of Western Australia

Diuretics

68 %

61 %

54 %

46 %

21 %

ß-BlockerAT1-Blockers

ACE-Inhibitors

Ca-Antagonists

n = 21.723 (12 Months)

51%46%

41%35%

16%

n = 15.175 (48 Months)

Adherence with antihypertensive therapy

Conlin et al., Clin Ther 2001; 23:1999-2010; *Vrijens B et al. BMJ 2008;336:1114-17;

**Caro JJ et al. CMAJ 1999; 160:31-37

• ~40% of newly diagnosed hypertensive discontinue during the first year*

• Discontinuation rate of antihypertensive drugs in phase IV studies ~50% within 1 year**

Page 15: Baker IDI

Persistence with BP lowering therapy

after 1 year – UK data

Source: UK GRRDS Database 2005Page 16: Baker IDI

Persistence with BP lowering therapy –

Australian data

Simons LA et al. Med J Aust. 2008; 188: 224-227

The University of Western Australia The University of Western Australia

Percentage of prescribed drugs taken by non-adherent patients

Complete Incomplete

non-adherence non-adherence

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The University of Western Australia

Adherence to therapy according to drug classes

Page 20: Baker IDI

Methods to improve adherence to physician’s

recommendations

The University of Western Australia

Optimized

Pharmacotherapy

The University of Western Australia

Multiple Antihypertensive Agents are needed

to reach BP Target

Bakris et al. Am J Med 2004;116(5A):30S–8Dahlöf et al. Lancet 2005;366:895–906; Jamerson et al. Blood Press 2007;16:80–6

*Interim 6-month data

Average no. of antihypertensive medications

1 2 3 4

Trial (SBP achieved)

ASCOT-BPLA (136.9 mmHg)

ALLHAT (138 mmHg)

IDNT (138 mmHg)

RENAAL (141 mmHg)

UKPDS (144 mmHg)

ABCD (132 mmHg)

MDRD (132 mmHg)

HOT (138 mmHg)

AASK (128 mmHg)

ACCOMPLISH* (132 mmHg)

Initial 2-drug combination therapy

The University of Western Australia

Lower Blood Pressure is Associated with

Cardiovascular Event Risk Reduction

- Meta-analysis of 61 prospective, observational studies.

- 1 million adults.

- 12.7 million person-years.

2 mmHg

lower mean

SBP 10% lower risk of

stroke mortality

7% lower risk of

ischaemic heart

disease mortality

Lewington et al. Lancet 2002;360:1903–1913.

The University of Western Australia

Possible combinations of classes of antihypertensive drugs

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The University of Western Australia The University of Western Australia

The University of Western Australia

Managed Care, December 2013; 45-55

The University of Western Australia

Bramlage P et al., Vasc Health Risk Manag 2014 Dec 17;11:1-8

The University of Western Australia

Bramlage P et al., Vasc Health Risk Manag 2014 Dec 17;11:1-8

The University of Western Australia

Frequency of adverse drug reactions

Bramlage P et al., Vasc Health Risk Manag 2014 Dec 17;11:1-8

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The University of Western Australia

Mean change in SBP and DBP

Bramlage P et al., Vasc Health Risk Manag 2014 Dec 17;11:1-8

The University of Western Australia

Change in the severity of hypertension

Bramlage P et al., Vasc Health Risk Manag 2014 Dec 17;11:1-8

The University of Western Australia

Device based approaches

to antihypertensive therapy

The University of Western Australia

Renal denervation

The University of Western Australia

Carotid Baroreceptor Stimulation

The University of Western Australia

Carotid Body Modulation

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Page 40: Baker IDI

Conclusions

The initial choice of antihypertensive agent

has a major impact on persistence

Persistence is a major determinant of effective

long-term blood pressure control

Long term blood pressure control is a major

determinant of effective CV risk reduction

The trajectory of persistence is determined

in the first weeks of blood pressure

treatment

The University of Western Australia

Professor Markus Schlaich

Renal Physician & Hypertension Specialist, MD, FAHA, FESC

Dobney Chair in Clinical Research

School of Medicine and Pharmacology - Royal Perth Hospital Unit

Faculty of Medicine, Dentistry & Health Sciences | The University of Western Australia

Level 3, MRF Building, Rear 50 Murray St, PERTH WA 6000 | MDBP: M570

Phone: +61 8 9224 0382

Fax: +61 8 9224 0374

E-mail: markus.schlaich@uwa.edu.au

RPH Hypertension Service