ASSOCIATION MEDICAMENTEUSE ET OBSERVANCE THERAPEUTIQUE: QUOI DE NEUF? Philippe van de Borne Service de cardiologie,hopital Erasme, Bruxelles,Belgique
Adherence, compliance, persistence: definitions Adherence the extent to which a patient actively follows treatment recommendations (e.g. lifestyle, medicine-taking) agreed with his/her healthcare provider Compliance a more passive measure of how much a healthcare provider s instructions are followed by patients Persistence the length of time a patient adheres to the agreed recommendations (e.g. prescribed dosing regimen) Corrao et al. J Hypertens 2011;29:610-8. Adherence to Long Term Therapies: Evidence for action. WHO 2003 Hill MN, et al. J Clin Hypertens 2011;12:757-64.
Persistence and adherence in hypertensive patients WE HAVE A PROBLEM!
Persistence and adherence in hypertensive patients typically falls over time. Evaluated by medication event monitoring system Fall in persistence because of discontinuation of treatment 4783 patients in 21 phase IV clinical studies Fall in adherence because of poor execution of dosing regimen Vrijens et al. BMJ 2008;336:1114-7.
WHY SHOULD WE CARE? Poor adherence is a major global health issue The consequences are poor health outcomes and increased costs Improving adherence might be the best way to effectively tackle chronic conditions Adherence to Long Term Therapies: Evidence for action. WHO 2003
Association between adherence to beneficial drug therapy and mortality Simpson et al. BMJ 2006;333(7557):15.
Adherence to antihypertensive therapy as a factor in BP control Patients with BP control* (%) 50 40 30 20 10 43 Odds ratio = 1.45 p=0.026 (controlling for age, gender and comorbidities) 34 33 0 High ( 80%) Medium (50 79%) Low (<50%) *<140/90 mmhg (or <130/85 mmhg in patients with diabetes) Level of compliance Bramley et al. J Manag Care Pharm 2006;12:239 45.
Persistence on antihypertensive medications: long-term cardiovascular risk 242,594 patients newly treated for hypertension during 2000-2001 without history of cardiovascular (CV) disease Data obtained from administrative databases in Italy (Lombardy Region); mean follow-up 6 years Hospitalization for coronary or cerebrovascular disease was identified as outcome and analyzed in relation to persistence on and adherence with therapy. Change in CV risk (hazard ratio) RR 37% (95% CI 34-40%) Corrao et al. J Hypertens 2011;29:610-8.
Adherence with antihypertensive medications: long-term coronary risk 242,594 patients newly treated for hypertension during 2000-2001 without history of cardiovascular (CV) disease Data obtained from administrative databases in Italy (Lombardy Region); mean follow-up 6 years Hospitalisation for coronary or cerebrovascular disease was identified as outcome and analysed in relation to persistence on and adherence with therapy Risk of coronary outcome (hazard ratio) Adherence calculated using medication possession ratio: total number of days supply of dispensed medication divided by duration of follow up Corrao et al. J Hypertens 2011;29:610-8.
Persistence and adherence in hypertensive patients WHAT ARE THE REASONS?
MEDICATION ADHERENCE: IT S IMPORTANCE IN CARDIOVASCULAR OUTCOME : many apply to hypertension!
Persistence and adherence in hypertensive patients WHAT CAN YOU DO?
Simplify treatment to improve adherence/compliance There are various ways in which adherence can be improved and treatment simplification is one of the most straightforward complicated treatment regimens are a major contributory factor to poor patient compliance 1 Reducing pill burden through the use of fixed-dose combination (FDC) therapy has an important role to play in improving compliance 2 1. Burnier et al. Int J Clin Pract 2009;63:790-8; 2. Redon et al. J Hypertens Suppl 2008;26:S1-14.
Persistence and adherence in hypertensive patients IS THERE A MAGIC TOOL TO IMPROVE COMPLIANCE?
Persistence and adherence in hypertensive patients YES: YOURSELF!
Physician motivation plays a key part Motivated physician More confidence & optimism More empathetic & supportive Higher rates of controlled BP a positive, optimistic, motivated perception of hypertension and its management is associated with higher probability of having controlled BP and lower SBP measures in patients Consoli et al. J Hypertens 2010;28:1330-9.
Motivated physicians get higher rates of control Probability of having controlled BP Consoli et al. J Hypertens 2010;28:1330-9.
Persistence and adherence in hypertensive patients WHAT CAN YOU DO? 1 BE CONVINCED AND YOU WILL CONVINCE 2 EDUCATE YOUR PATIENT 3 USE FIXED-DOSE COMBINATION
et ça marche. Entre 2002 et 2007, 161585 patients initient un traitement hypotenseur Année 2002 2007 Bithérapie 21% 36% p<0.001 Plus fréquent si HTA de stade 2: Bithérapie 22% 45% p<0.001 Augmente les chances d avoir une PA sous contrôle après 12 mois de 1.2, après correction pour facteurs confondants, p<0.001 Traitement combiné initial: 48% thiazide + diurétique d épargne potassique 41% thiazide+ IEC
Fixed dose combination in hypertensive patients WHY DOES IT WORK?
The increase in blood pressure occurs through the activation of a large variety of pathogenetic mechanisms.
Fixed dose combination in hypertensive patients
Fixed dose combination in hypertensive patients In extreme cases, reflex responses can nullify any fall in pressure
Fixed dose combination in hypertensive patients
Combination is better than Uptitration With RAAS inhibitors doubling the dose has minimal incremental effect on BP. With CCBs, additional antihypertensive efficacy can be gained when, forexample, the starting dose of amlodipine is doubled from 5 to 10 mg. However, the incidence of pedal oedema also is dose dependent and increases with a higher dose of amlodipine. The additional blood pressure fall from combining drugs from two different classes is 5 times greater than the one from doubling the dose of a single drug. Chances of getting blood pressure to goal are several times greater with combining drugs than with up titration of monotherapy.
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