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10/11/2015
1
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
10/11/2015
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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
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