Introduction
Medication adherence is an important factor affecting blood pressure control and a challenge for the management of hypertension worldwide. The adherence to hypertension medication in mainland China is lower than that in most developed countries, and effective improvement measures are urgently needed1. Recently, the "Chinese Expert Consensus on Improving Drug Medication Adherence and Improving Blood Pressure Control in Patients with Hypertension"1 (hereinafter referred to as the "Compliance Consensus") was published in the third issue of the Chinese Journal of Hypertension. The recommendations for physicians in the "Consensus on Adherence" point out that the treatment regimen should be simplified, the initial combination therapy should be highly valued, and the single-tablet combination preparation (SPC) should be preferred, so as to improve the inertia of treatment. This recommendation affirms the role of SPC in improving adherence to hypertension medication and improving blood pressure control in mainland China. In this article, we will interpret some of the contents of the "Consensus on Adherence" and discuss the advantages and options of SPC for the benefit of readers.
Medication adherence is still unsatisfactory, and effective improvement measures are urgently needed
Drug treatment compliance refers to the degree of acceptance and implementation of medical instructions after medical treatment, mainly including taking medication on time, according to dosage and frequency, and reaching a certain course of treatment, that is, the accuracy and length of medication. The Consensus on Adherence mentions five categories of factors that affect medication adherence, including socioeconomic factors, healthcare system factors, treatment-related factors, conditionality factors, and patient factors. Among them, treatment-related factors mainly include complex treatment regimens, a large number of drugs and inability to dispense all drugs at the same time, frequent changes in treatment regimens, ineffective treatment, frequent medication, long-term difficulty in controlling blood pressure, and adverse reactions1.
At present, the adherence to medication in patients with hypertension is generally low, and there has been no significant improvement in the past 10 years. Regionally, the non-adherence rates in Asia, Europe, and Canada/the U.S. were 45%, 43%, and 35% (questionnaire method), and 49%, 40%, and 26% (prescription dispensing record method), respectively, with Asian patients having the highest non-adherence rates (Figure 1). Survey research shows that the medication compliance of hypertensive patients in different regions and hospitals of different levels in mainland China is 20%~83%. Inadequate adherence to medication can lead to poor blood pressure control and increase the risk of cardiovascular events. Good adherence to medication can lead to improved blood pressure control, and the benefits of blood pressure control will further translate into cardiovascular benefits1. It can be seen that how to improve drug treatment compliance is very important, and it is also a major challenge for the management of hypertension worldwide, and effective improvement measures are urgently needed.
Figure 1. Non-adherence rates in Asia, Europe, Canada/USA
Expert recommendations to improve medication adherence and improve blood pressure control
The Consensus on Adherence gives suggestions from the perspectives of doctors, patients, and the healthcare system, and the recommendations for doctors are: (1) strengthen doctor-patient communication, continuously carry out health education and follow-up feedback through various methods, and provide feedback on patient-level recommendations at the healthcare system level, (2) give full play to the intervention role of primary medical workers in drug treatment compliance, (3) clinical pharmacists or nurses and other health care personnel should actively participate in the management of hypertension medication adherence, and (4) (5) In the treatment of comorbidities in hypertensive patients, multidisciplinary diagnosis and treatment is needed, and (6) home blood pressure monitoring (HBPM) and remote blood pressure monitoring are promoted1.
Recommendations for patients are as follows: (1) patients with hypertension should fully understand the dangers and severity of hypertension, (2) patients with hypertension should pay attention to lifestyle improvement, (3) patients with hypertension should follow the doctor's advice and do not stop or reduce medication on their own, (4) patients with hypertension can set medication reminders, and (5) patients with hypertension should receive family social support1.
The recommendations for the healthcare system are as follows: (1) Government departments should continue to improve the medical insurance service system, continue to promote the essential drug system, and include telemedicine, pharmacist services, and SPC in medical insurance, so as to reduce the out-of-pocket burden of patients. (2) Grassroots hospitals and convenient drug dispensing clinics ensure that the variety of drugs is comprehensive, and all drugs are dispensed at one visit;(3) Continuously promote the application of smart medical services and health big data1.
Figure 2. Flow chart of clinical management of medication adherence to hypertension
Evidence-based verification + guideline recommendation, SPC can greatly improve drug treatment adherence
The Consensus on Adherence summarizes evidence from recent studies to improve medication adherence in patients with hypertension in mainland China, including a systematic review and meta-analysis of 44 studies that showed that SPC can improve treatment adherence and durability in patients with hypertension and lead to better blood pressure control compared with free association1. Multiple consensus guidelines also explicitly recommend the use of SPC to improve medication adherence (Table 1)1-3. However, there are many types of SPCs, so how do you choose them?
Table 1. Consensus/guideline recommendations and related content
Guidelines for SPC drug combinations recommend: RASI+CCB/diuretic SPC is preferred as the initial treatment regimen
The 2023 Guidelines for the Management of ESH Arterial Hypertension3 mentions that in order to improve the speed, efficiency and predictability of blood pressure control, it is recommended that most patients with hypertension initially choose SPC dual therapy, preferably a combination of renin-angiotensin inhibitors (RASIs) and calcium ion antagonists (CCBs) or thiazide (T)/thiazide-like (TL) diuretics. If the combination of therapy does not control blood pressure to the target level, a triple combination of RASI, CCB, and T/TL diuretics may be an option.
Evidence-based validation of diuretic selection: indapamide has advantages over hydrochlorothiazide
Although hydrochlorothiazide is currently more commonly used, many hypertension guidelines such as ISH and ACC consider indapamide to be superior to hydrochlorothiazide4-6. Studies have also shown that indapamide has a stronger antihypertensive effect than hydrochlorothiazide, and does not increase the incidence of hypokalemia, hyponatremia, blood glucose and serum total cholesterol7-8.
Evidence-based Validation of "RASI" Selection: Perindopril-based SPC Improves Adherence
In one meta-analysis, perindopril alone significantly reduced all-cause mortality by 13% across RASIs, with no other angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs)9. In terms of safety, studies have shown that among ACE inhibitors, the incidence of cough was lower in the perindopril group, less than 5%10, and that the combination of ACE inhibitors and CCBs/diuretics significantly reduced the incidence of dry cough11. For perindopril-based SPC, a number of evidence-based evidence confirms that it has many advantages, such as strong blood pressure, significant reduction of cardiovascular and cerebrovascular event risk, and improvement of compliance. In terms of adherence, the EMERALD study showed that the adherence rate of 1 tablet per day with perindopril-based SPC for 4 months was as high as 98%12.
summary
The prevalence of hypertension in mainland China is high, the control rate is low, and the management situation is grim. Improving adherence to medication is key to achieving blood pressure targets and requires the joint efforts of doctors, patients, and the healthcare system at all levels. In terms of drug selection, SPC can be a potent and long-term antihypertensive and improve patients' medication compliance, and has been recommended by many guidelines as the preferred regimen for the initial treatment of hypertension, or can promote blood pressure attainment and improve disease outcomes.
Bibliography:
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12. Curr med res opin. 2016;32:1605-1610.
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