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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 !!