Hypertension adherence

MAO Is have not been evaluated systematically for treatment of PD under the current diagnostic classification and generally are reserved for patients who are refractory to other treatments.48,49 MAOIs have significant side effects that limit adherence. Additionally, patients must adhere to dietary restriction of tyramine and avoid sympathomimetic drugs to avoid hypertensive crisis. 

Hypertension for 5 years it is often not well controlled because of poor patient adherence... 

This patient has the subjective symptoms of weight loss, decreased appetite, shortness of breath, and cough. Abnormal laboratory values include elevated temperature, decreased hemoglobin and hematocrit, and decreased CD4 count. Chest x-ray shows diffuse interstitial infiltrates bilaterally. Physical exam reveals thrush. The assessment is possible AIDS with CD4 count of 150 cells/mm3, thrush, a respiratory illness (possibly Pneumocystis jiroveci pneumonia), and anemia of chronic disease. He also has a history of hepatitis B, hypertension, and GERD (on famotidine), poor adherence to his anti hypertensive medications, and likely has an irregular daily regimen due to his occupation as a truck driver. 

Depending on the severity of the hypertension, treatment with antihypertensive drugs proceeds strategically in a specific order. It is understood that this order should be flexible and open to alternative ways, but a few general principles must be adhered to. 

III.c.6.2. Resistant hypertension. Hypertension should be considered resistant if the BP cannot be reduced to below 140/90 mmHg in patients who adhere to a triple-drug regimen that includes a diuretic, with all three drugs in near maximal doses. For older patients with isolated SBP, resistance is defined as failure of an adequate triple-drug regimen to reduce SBP below 160 mmHg. The various causes of true resistance are listed in Table 9. One of the most common causes is volume overload as a result of inadequate diuretic therapy. Patients who have resistant hypertension or who are unable to tolerate antihypertensive therapy may benefit from referral to a hypertension specialist. 

Coronary Drug Project Research Group (1980). Influence of adherence to treatment and response to cholesterol on mortality in the Coronary Drug Project. New England Journal of Medicine 303 1038-1041 Dahlof B, Lindholm LH, Hansson L etal. (1991). Morbidity and mortality in the Swedish trial in old patients with hypertension (STOP-hypertension). Lancet 338 1281-1285 Davis KL, Thai LJ, Gamzu ER et al. (1992). 

In addition to evidence of regional variahon, healfh services research had demonstrated decreased rates of adherence fo accepted evidence-based therapeutic guidelines. Despite widely known professional guidelines (i.e., sixfh report of the Joint National Committee, JNC-VI), medical consensus on the health benefits of blood pressure confrol, and availability of effective mediations, blood pressure is poorly controlled in the U.S. Data from a nahonal research study found fhaf only 68% of pafienfs with hypertension are aware of fheir condition, and of those treated, only 27% have their blood pressures controlled. 

Important susceptibility factors include age, endogenous coagulation defects, thrombocytopenia, hypertension, cerebrovascular disease, thyroid disease, renal insufficiency, liver disease, tumors, cerebrovascular disease, alcoholism, a history of gastrointestinal bleeding (peptic ulcer disease alone without past bleeding is not associated with an increased risk of bleeding), and an inability to adhere to the regimen. 

Morphologic studies of radiation nephropathy have documented injury to blood vessels, glomeruh, tubular epithelium and interstitium. Recent ultrastructural studies indicate that glomerular endothelium is an early site of visible injury [236] with endothehal disruption and leukocyte adherence. Later, tubular degeneration and atrophy occur. The second pathophysiologic hypothesis holds vascular injury as the main initial event [237] which helps understand the hypertension occurring in radiation nephritis but does not account for the glomerular lesions. 

The effects of NCX-4016 and aspirin on the release of thromboxane TNF-a interleukin-6 and expression and activity of tissue factor (TF) in stimulated, adherent human monocytes were recently investigated (70). These data showed that NCX-4016 inhibits thromboxane generation, cytokine release, and TF activity in human monocytes via NO-dependent mechanisms. Moreover, NCX-4016 also reduces blood pressure in hypertensive rats, not simply through the direct va-sodilatory actions of the NO released by this compound, but also through possible interference with endogenous pressor compounds (71). These properties, added to its antithrombotic effects, suggest that NCX-4016 may be a safer alternative to aspirin for use by hypertensive patients. 

Nonadherence to medication regimens remains a major problem in health care. The National Council on Patient Information and Education (NCPIE) has termed noncompliance America s other drug problem.Pharmacists are in an ideal position to assess and treat adherence-related problems that can adversely affect patients health outcomes. Strategies to monitor and improve adherence are key components of pharmaceutical care plans, especially for patients with chronic diseases, such as hypertension, diabetes, and atherosclerotic heart disease. Nonadherence is a behavioral disorder that can be assessed and managed through a carefully devised pharmaceutical care plan. 

Although medication nonadherence is the primary focus of this article, it is only one form of nonadherence. Poorer health outcomes may also result when a patient does not adhere to recommended lifestyle changes, such as exercise or smoking cessation, or to prescribed non-pharmacologic interventions, such as physical therapy or dietary plans. Pharmacists who counsel patients with chronic diseases, such as asthma, hypertension, or diabetes, need to assess and promote adherence to these non-pharmacologic treatments as well. 

Each chronic disease presents its own constellation of adherence problems. A brief overview of adherence strategies for two major public health problems—hypertension and type 2 diabetes—illustrates disease-specific risk factors for nonadherence and shows how pharmaceutical care services can enhance adherence. 

Because hypertension is usually a silent disease, most patients do not experience symptoms that remind them of the need for taking medications. Without symptoms, it is more difficult to establish a link in the patient s mind between taking the medication and controlling hypertension and its complications. Because patients often do not feel or perceive the benefits of their treatment, the first step in enhancing adherence is to educate them about hypertension and its serious complications, such as coronary heart disease, stroke, and renal failure. 

As with other chronic diseases, education of caregivers and family members is crucial. In one study, 70% of patients wanted their family members to know more about hypertension. The patients reported that negative attitudes, insufficient family support, and lack of confidence in the management of their blood pressure were contributing factors to their long-term adherence problems. Whenever possible, a family member or caregiver should be included in educational sessions to help the patient follow instructions and stay on track over time. 

There is a decrease in the consumption of red meat in response to concern about health effects of fat and cholesterol — which are implicated in coronary heart disease, hypertension, cancer, and obesity. Parallel to this is the increase in the use of poultry and fish. The dollar value of poultry in 1984 was 15.4 billion, an increase of 37% from 1983. Seafood per capita consumption was 13.6 pounds in 1984, an all-time high. The use of surimi, a restructured fish product, is on the rise and could reach a billion pounds in 1990. A simulated form of crab legs using surimi technology is gaining adherents. 

Osterberg LG, Rudd P. Medication adherence for antihypertensive therapy. In Oparil S, Weber MA, eds. Hypertension A Companion to Brenner and Rector s The Kidney. 2nd ed. Philadelphia Elsevier Mosby, 2005. 

Monoamine oxidase inhibitors (MAOIs), such as phenelzine, have been used in the management of refractory headache, but their complex adverse-effect profile limits their use to experienced prescribers. Strict adherence to a tyramine-free diet is necessary to avoid potentially life-threatening hypertensive crisis. 

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