• Simplify the drug regimen with single pill combos, medication calendars/electronic reminders 

Part I of this article was published in The Daily Morning issued 8 July

Since forgetting to take medications is one of the most commonly reported reasons and correctable factors for non-adherence to anti-hypertensive (high blood pressure [HBP]) medications, measures such as simplifying the drug regimen with single pill combinations and once daily formulations and synchronising medications along with the use of blister packs, pill boxes, medication calendars or electronic reminders are important.

These findings were made in a research article on ‘Factors associated with uncontrolled hypertension in patients attending a medical clinic of a tertiary care hospital in Sri Lanka’ which was authored by C.N. Wijekoon (attached to the Sri Jayewardenepura University's Medical Sciences Faculty's Pharmacology Department), M.T. Samarawickrama and G.S.C. Mendis (attached to the same Faculty's Allied Health Sciences Department's Pharmacy Unit), J.K.P. Wanigasuriya and P.W.M.C.S.B. Wijekoon (attached to the same Faculty's Medicine Department) and published in the Journal of the Ceylon College of Physicians' 51st Volume's Second Issue in December, 2020.

In Wijekoon et al.’s study, uncontrolled hypertension was seen in 31.5% on treatment for hypertension. T.H. Jafar, M. Gandhi, I. Jehan, A. Naheed, H.A.d. Silva, H. Shahab, D. Alam, N. Luke and C.W. Lim's ‘Determinants of uncontrolled hypertension in rural communities in South Asia – Bangladesh, Pakistan, and Sri Lanka’ reported that 56.5% on treatment for hypertension in a rural community of Sri Lanka had uncontrolled hypertension and that it was 67.9% in an urban population in the Gampaha District per A. Kasturiratne, T. Warnakulasuriya, J. Pinidiyapathirage, N. Kato, R. Wickremasinghe and A. Pathmeswaran's ‘Epidemiology of hypertension in an urban Sri Lankan population’. The prevalence of uncontrolled hypertension in the clinic setting is expected to be lower than the prevalence in the community as those who visit the clinic regularly are likely to be more motivated towards achieving BP control. W.A. Kumara, T. Perera, M. Dissanayake, P. Ranasinghe and G.R. Constantine's ‘Prevalence and risk factors for resistant hypertension among hypertensive patients from a developing country’ found 41% to have uncontrolled hypertension. What the instant study observed was lower than that.

Among those with uncontrolled hypertension, the great majority (97.3%) had at least one correctable factor. The most common correctable factor was non-adherence to anti-hypertensive medications. A total of 70% showed non-adherence. This is different to what has been found in Kumara et al. where more than 90% were adherent to antihypertensive medications. Globally (M. Burnier and B.M. Egan's ‘Adherence in hypertension. A review of the prevalence, risk factors, impact, and management’, G. Mazzaglia, E. Ambrosioni, M. Alacqua, A. Filippi, E. Sessa, V. Immordino, C. Borghi, O. Brignoli, A.P. Caputi, C. Cricelli, and L.G. Mantovani's ‘Adherence to antihypertensive medications and cardiovascular morbidity among newly diagnosed hypertensive patients’ and M. Tomaszewski, C. White, P. Patel, N. Masca, R. Damani, J. Hepworth, N.J. Samani, P. Gupta, W. Madira, A. Stanley and B. Williams' ‘High rates of non-adherence to antihypertensive treatment revealed by high-performance liquid chromatography-tandem mass spectrometry urine analysis’), non-adherence to medications is seen in 10-80% of hypertensive patients and it is one of the key factors for poorly controlled hypertension. O. Jung, J.L. Gechter, C. Wunder, A. Paulke, C. Bartel, H. Geiger and S.W. Toennes's ‘Resistant hypertension? Assessment of adherence by toxicological urine analysis’ has shown that low adherence to the prescribed medications is seen in many patients with apparently resistant hypertension. The importance of evaluating treatment adherence as a major cause of poor BP control is thus emphasised. In the instant study, no association was found between the rate of non-adherence and the socio-demographic or clinical characteristics of the patients though previous reports indicate that poor adherence is inversely correlated with the number of pills prescribed.

The reasons for suboptimal adherence include patient beliefs and behaviours, poor patient-clinician relationship, the complexity and tolerability of the medication regimen, and deficiencies in the healthcare system such as the unavailability of medications. In the study population, the two most commonly reported reasons for non-adherence were being busy and forgetting to take the medications. Both were patient related factors. Being busy has emerged as a reason because patients do not consider taking treatment for hypertension as a priority. One fifth of the population reported that they did not feel that they needed medications for hypertension. To improve the situation, better communication between the patient and the clinician is needed. If time is a limiting factor, other health professionals such as clinical pharmacists could contribute. Better communication will improve patients' perception regarding the disease and its treatment, which in turn would likely improve the adherence. In the instant study, the number of medications was not associated with the rate of non-adherence. However, nearly one fourth gave the reason for non-adherence as “I was supposed to take them too many times”. 

The usage of concomitant medications causing increased BP is a well-recognised factor associated with uncontrolled hypertension (C. Faselis, M. Doumas and V. Papademetriou's ‘Common secondary causes of resistant hypertension and rationale for treatment’) and it was seen in a considerable proportion of the patients in this study population. When analgesia is needed in a patient with hypertension, clinicians need to make a careful evaluation to see whether the pain could be managed without non-steroidal anti-inflammatory drugs (NSAIDs) and if NSAIDs are unavoidable, they should be prescribed for the minimum required duration. The instant study findings highlight that in a patient who fails to achieve adequate control of BP, clinicians need to pay attention to identify concomitant medications contributing to raised BP and to make appropriate adjustments to the prescription.

In the study population, the poor control seemed to be multi-factorial in many. While 70% were non-adherent to treatment, almost 90% had one or more non-medication-related factors contributing to poor BP control. Two thirds of the population lacked physical activity and it was a bigger problem among women. Obesity was seen in almost half of the study population and it was more common among women which was compatible with having higher rates of inadequate physical activity among them. A considerable proportion had self declared high salt consumption. A total of 40% admitted to adding salt to rice cooked at home. This is a significant source of salt in households which could be easily prevented by patient education. Sleep related problems were also common. One third had inadequate sleep duration and close to half reported snoring during sleep. The proportions with obesity and snoring were almost similar (45% and 43.8%) suggesting that undetected obstructive sleep apnoea (characterised by episodes of a complete or partial collapse of the upper airway with an associated decrease in oxygen saturation or arousal from sleep, which disturbance results in fragmented, non-restorative sleep) is likely to be a cause for uncontrolled hypertension in a significant proportion of patients. Obesity and snoring both were more common among the younger age group (age less than 60 years). Excess or the binge consumption of alcohol was found only in a small proportion. However, it was a contributing factor in nearly one 10th of the men. Overall, these findings indicate that there is much room for improvement of BP control through intensifying the modification of lifestyle factors. At the same time, attention needs to be paid to identify and rectify secondary causes such as obstructive sleep apnoea.

Chronic kidney disease (CKD) is another secondary cause for uncontrolled hypertension. It was seen in 7% of the population. However, true resistant hypertension associated with CKD was seen only in a single patient. Clinician inertia (physicians’ failure to take appropriate therapeutic action in patients with uncontrolled hypertension) as a factor for poor BP control was not common (less than 5%) though it was reported to be 28% by Kumara et al. The overall rate of true resistant hypertension in the study population was less than 3%. It was reported to be 19% by Kumara et al. where more than 90% were adherent to treatment, whereas in the instant study, only 30% were adherent to treatment. The low adherence rate in the instant study could have been a factor masking the true prevalence of resistant hypertension.

One of the limitations of the study was that the BP was measured at a single visit to the clinic which could have led to an overestimation of the prevalence of uncontrolled hypertension.

True resistant hypertension is seen in only a small proportion of the population with uncontrolled hypertension.