Medication Adherence and Persistence as the Cornerstone of Effective Antihypertensive Therapy

Achieving optimal outcomes in the treatment of hypertension—a prevalent and largely asymptomatic disease—necessitates that patients take their medications not only properly (medication adherence) but also continue to do so throughout long-term treatment (persistence). However, poor medication-taking behavior is a major problem among patients with hypertension, and has been identified as one of the main causes of failure to achieve adequate control of blood pressure (BP). In turn, patients with hypertension who have uncontrolled BP as a result of their poor medication-taking behavior remain at risk for serious morbidity and mortality (eg, stroke, myocardial infarction, and kidney failure), thereby accounting for a significant cost burden through avoidable hospital admissions, premature deaths, work absenteeism, and reduced productivity. Improving medication-taking behavior during antihypertensive therapy therefore represents an important potential source of health and economic improvement. Whereas many factors may contribute to poor medication-taking behavior, the complexity of dosage regimens and the side effect profiles of drugs probably have the greatest therapy-related influence. Central to any strategy aimed at improving outcomes for patients with hypertension, therefore, are efficacious antihypertensive agents that facilitate good medication-taking behavior through simplified dosing and placebo-like tolerability, along with the development of programs to detect poor medication adherence and to support long-term medication persistence in daily practic

Fixed combinations in the pragmatic management of hypertension: focus on aliskiren and hydrochlorothiazide as a single pill

A majority of hypertensive patients need more than one antihypertensive drug to control their blood pressure. For this reason, most guidelines have introduced the possibility of prescribing fixed-dose combination therapies as first-line treatment in hypertension. Today, the concept of fixed-dose combinations has evolved and the term single pill combination might become more appropriate to reflect the large choice of drug combinations available on the market. Recently, a new single pill combination has been launched which combines the first direct renin inhibitor aliskiren and low doses of hydrochlorothiazide. This paper reviews the potential advantages of single pill combinations and presents the first results obtained with the aliskiren/HCTZ single pill combination in hypertension

Response to "Assessment of Blood Pressure Dipping: Is the Evaluation Method Important?”

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Female sex hormones, salt, and blood pressure regulation

There are gender-associated differences in blood pressure (BP) in humans, with men having higher BP than age-matched pre-menopausal women and being at greater risk for cardiovascular and renal diseases. The mechanisms responsible for the gender differences in BP control and regulation are not clear, although there is some evidence that interactions between sex hormones and the kidneys could play a role. However, the response to salt in pre- and post-menopausal women, and in particular the influence of exogenous and endogenous female sex hormones on renal hemodynamics and tubular segmental sodium handling, have been poorly investigated. Recently we have shown that both endogenous and exogenous female sex hormones markedly influence the systemic and renal hemodynamic response to salt. We have found that BP in young normotensive women, regardless of oral contraceptive use, is rather insensitive to salt. However, the renal hemodynamic and the tubular responses to salt vary significantly during the normal menstrual cycle and with the administration of oral contraceptives. Furthermore, after the menopause, BP tends to become salt sensitive, a pattern that could be due to aging as well as to the modification of the sex hormone profile. These observations provide new insights pertaining to potential mechanisms explaining the lower incidence of cardiovascular disease and progression of renal disease in pre-menopausal women (which tend to disappear with the menopause); these observations also emphasize the importance of considering more carefully the phase of the menstrual cycle whenever conducting physiologic studies in women and enrolling women in clinical studies. Finally, increased salt sensitivity in menopausal women strongly encourages the use of diuretics. Am J Hypertens 2004;17:994-1001 © 2004 American Journal of Hypertension, Lt

State-of-the-art treatment of hypertension: established and new drugs

The treatment of essential hypertension is based essentially on the prescription of four major classes of antihypertensive drugs, i.e. blockers of the renin-angiotensin system, calcium channel blockers, diuretics and beta-blockers. In recent years, very few new drug therapies of hypertension have become available. Therefore, it is crucial for physicians to optimize their antihypertensive therapies with the drugs available on the market. In each of the classes of antihypertensive drugs, questions have recently been raised: are angiotensin-converting enzyme (ACE) inhibitors superior to angiotensin II receptor blockers (ARB)? Is it possible to reduce the incidence of peripheral oedema with calcium antagonists? Is hydrochlorothiazide really the good diuretic to use in combination therapies? The purpose of this review is to discuss these various questions in the light of the most recent clinical studies and meta-analyses. These latter suggest that ACE inhibitors and ARB are equivalent except for a better tolerability profile of ARB. Third generation calcium channel blockers enable to reduce the incidence of peripheral oedema and chlorthalidone is certainly more effective than hydrochlorothiazide in preventing cardiovascular events in hypertension. At last, studies suggest that drug adherence and long-term persistence under therapy is one of the major issues in the actual management of essential hypertensio