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ASSOCIATION MEDICAMENTEUSE ET OBSERVANCE THERAPEUTIQUE: QUOI DE NEUF ?

Philippe van de Borne Service de cardiologie,Hopital Erasme,

Bruxelles,Belgique

Adherence, compliance, persistence: definitions

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.

•

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)

Persistence and adherence in hypertensive patients

WE HAVE A

PROBLEM !

Persistence and adherence in hypertensive patients typically falls over time

Vrijens et al. BMJ 2008;336:1114-7.

4783 patients in21 phase IVclinical studies

Fall in 

persistencebecause of 

discontinuation 

of treatment

Fall in adherencebecause of 

poor execution of 

dosing regimen

.Evaluated by medication event monitoring system

WHY SHOULD WE CARE ?

Adherence to Long Term Therapies: Evidence for action. WHO 2003

•

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

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

Bramley et al. J Manag Care Pharm 2006;12:239–45.*<140/90 mmHg (or <130/85 mmHg in patients with diabetes)

Patie

nts

with

BP

cont

rol*

(%)

Level of compliance

0

10

50

30

20

High

(≥80%)Medium

(50–79%)Low

(<50%)

43

34 33

Odds ratio = 1.45p=0.026 (controlling for age, gender and comorbidities)

40

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.

Corrao et al. J Hypertens 2011;29:610-8.

Cha

nge

in C

V ris

k (h

azar

d ra

tio)

RR 37%(95% CI 34-40%)

Corrao et al. J Hypertens 2011;29:610-8.

•

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

Ris

k of

cor

onar

y ou

tcom

e (h

azar

d ra

tio)

Adherence with antihypertensive medications:long-term coronary risk

Adherence calculated using medication possession ratio: total number of days supply of dispensed medication divided by duration of follow up

Persistence and adherence in hypertensive patients

WHAT ARETHE REASONS

?

MEDICATION ADHERENCE: IT’S IMPORTANCE IN CARDIOVASCULAR OUTCOME

: many apply to hypertension !

Persistence and adherence in hypertensive patients

WHAT CANYOU DO

?

•

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 compliance1

•

Reducing pill burden

through the use of fixed-dose combination

(FDC) therapy has an

important role to play in improving compliance2

1. Burnier et al. Int J Clin Pract 2009;63:790-8; 2. Redon et al. J Hypertens Suppl 2008;26:S1-14.

Simplify treatment to improve adherence/compliance

Persistence and adherence in hypertensive patients

IS THERE A MAGIC TOOLTO IMPROVE

COMPLIANCE ?

Persistence and adherence in hypertensive patients

YES:YOURSELF !

Physician motivation plays a key part

“…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 physician

More confidence & optimism

More empathetic & supportive

Higher rates of controlled BPHigher rates of controlled BP

Motivated physicians get higher rates of control

Consoli et al. J Hypertens 2010;28:1330-9.

Pro

babi

lity

of h

avin

g co

ntro

lled

BP

Persistence and adherence in hypertensive patients

WHAT CANYOU DO

?

11 BE CONVINCED AND YOU WILL CONVINCE

22 EDUCATE YOUR PATIENT

3 USE FIXED-DOSE COMBINATION

et ça marche….

Entre 2002 et 2007, 161585 patients initient un traitement hypotenseur

Bithérapie 21%

36%

p<0.001

Plus fréquent si HTA de stade 2:

Bithérapie 22%

45%

p<0.001

Année

2002

2007

Traitement combiné

initial:48% thiazide + diurétique d’épargne potassique41% thiazide+ IEC

Augmente les chances d’avoir une PA sous contrôle

après 12 mois de 1.2, après correction pour facteurs confondants,

p<0.001

Fixed dose combination in hypertensive patients

WHY DOES ITWORK

?

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

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 areseveral times greater with combining drugs than with up

titration of monotherapy.

Combination is better than Uptitration

Bref rappel:

NOVEMBRE 2003

AVRIL 2008

MARS 2010

AVRIL 2010

NOVEMBRE 2012

MERCI POUR VOTRE ATTENTION !!