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ASSOCIATION MEDICAMENTEUSE ET OBSERVANCE THERAPEUTIQUE: QUOI DE NEUF ?
Philippe van de Borne Service de cardiologie,Hopital Erasme,
Bruxelles,Belgique
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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)
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Persistence and adherence in hypertensive patients
WE HAVE A
PROBLEM !
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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
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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
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Association between adherence to beneficial drug therapy and mortality
Simpson et al. BMJ 2006;333(7557):15.
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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
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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%)
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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
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Persistence and adherence in hypertensive patients
WHAT ARETHE REASONS
?
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MEDICATION ADHERENCE: IT’S IMPORTANCE IN CARDIOVASCULAR OUTCOME
: many apply to hypertension !
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Persistence and adherence in hypertensive patients
WHAT CANYOU DO
?
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•
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
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Persistence and adherence in hypertensive patients
IS THERE A MAGIC TOOLTO IMPROVE
COMPLIANCE ?
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Persistence and adherence in hypertensive patients
YES:YOURSELF !
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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
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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
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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
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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
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Fixed dose combination in hypertensive patients
WHY DOES ITWORK
?
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The increase in blood pressure occurs through the activation of a large variety of pathogenetic mechanisms.
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Fixed dose combination in hypertensive patients
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Fixed dose combination in hypertensive patients
In extreme cases, reflex
responses can nullify
any fall in
pressure
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Fixed dose combination in hypertensive patients
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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
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Bref rappel:
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NOVEMBRE 2003
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AVRIL 2008
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MARS 2010
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AVRIL 2010
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NOVEMBRE 2012
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MERCI POUR VOTRE ATTENTION !!