What should providers do about intentional nonadherence, and what strategies should they try to get their patients to take their hypertension medicine? At a session at the American Society of Nephrology's (ASN) Kidney Week 2019, physicians discussed direct observation therapy (DOT), drug monitoring, case studies, and other published work about patients who don’t take their medications.

Then they heard from a directly from a patient who shared why she stopped taking her medication and the scary consequence that developed as a result.

Gabi Morales, 25, of Florida, went on dialysis at the age of 3, after being born with 1 underdeveloped kidney and the other not developed at all. At 5, she received a kidney transplant from her father. At 10, she had high blood pressure and began gaining weight, or, as she put it, “I fell in love with food.”

Her nephrologist told her family she was at risk for diabetes, so her parents made a decision to eat healthier and exercise with their daughter. She also started her first blood pressure medication.

In 2015, the donated kidney from her father failed, and she was put on dialysis while she was added to 3 transplant lists. Her blood pressure would spike while undergoing treatment, and the center would give her clonidine, which made her feel sick. Her doctor started her on nifedipine, which also made her feel sick, and she stopped and then started it again, making 3 tries to stay on the medication. Eventually, she stopped taking it without telling her doctor.

Without the drugs, her blood pressure soared to 220/180; one day she woke up with blurred vision and the day ended in an emergency department (ED) when she lost her vision. Two seizures later, while still in the ED, she was diagnosed with Posterior Reversible Encephaophalopathy Syndrome (PRES). She recovered but was left with lesions all over her brain.

Morales shared advice for both patients and their doctors.

Be honest, she said. “The physicians can’t help you if you aren’t open about how the meds make you feel or whether or not you’re taking them,” adding, “physicians, please take into consideration everything that the patient is saying.”

Many of the physicians appeared touched by her story, with more than one asking what, in the doctor-patient relationship, would have made the difference between adherence and nonadherence. For instance, did she already know that that she would be nonadherent when her doctor asked her to try again?

Morales said she has very good and close relationship with her physician, and even though she didn’t want to make repeated attempts at a medication she knew gave her awful side effects, she said, “I was willing to try because that’s what he wanted me to do.”

In an interview with The American Journal of Managed Care^®, she reiterated some of the suggestions that came out of the question-and-answer session.

For instance, if doctors explained side effects more clearly “in advance, so that people know what to look for. If you prescribe a medication and they go home and they take it and they have these side effects, they’re just going to stop taking it, and then by the time of their next visit, you don’t know how long its been since they’ve been taking blood pressure medications or not.”

She also liked the idea from one doctor who suggested that more communication from the physician side to reassure the patient that wanting to quit taking the medicines is normal, likening it to the experience of being a rebellious teenager who did not want to take her immunosuppressants every day. Her mom, fortunately, had been warned by doctors years earlier that this would happen.

The session, called “The Spectrum of Nonadherence in Hypertension,” began with Sandra Taler, MD, a professor of medicine at the Mayo Clinic, calling the issue of nonadherence “the elephant in the room.”

A 2014 study was the first to reveal rates of nonadherence among patients on hypertension medication referred for renal denervation, and the authors recommended the use of high-performance liquid chromatography-tandem mass spectrometry (HP LC-MS/MS) urine analysis to screen for the presence of hypertension medications.¹ Of the 208 patients examined, 25% were nonadherent.

Nonadherence is difficult to recognize, and it is a costly problem, Taler said.

A study published earlier this year, looking at Medicare fee-for-service patients using Part D and taking drugs for diabetes, heart failure, hyperlipidemia, and hypertension, found nonadherence cost billions of spending, millions in hospital days, and thousands of ED visits that could have been avoided.² Looking at hypertension alone, if the 25% of beneficiaries with hypertension who were nonadherent became adherent, Medicare could save $13.7 billion annually, averting over 100,000 emergency department visits and 7 million inpatient hospital days.

Another presenter, nephrologist Marcel Ruzicka, MD, PhD, at the University of Ottawa’s Heart Institute, discussed the use of DOT, where his patients who appear nonresponsive to hypertension medication are brought into the clinic to take their medicine in the presence of staff and then observed and monitored. Because hypertension medications have a short half-life, effects can be seen that day.

However, DOT is complicated, as it requires staff for monitoring, as well as the ability to handle emergencies. If a patient had been prescribed multiple medications for chronic conditions that they may or may not have been taking consistently or not at all, complications can arise.

In that case, providers may have to make judicious choices in what they decide to trial that day, he noted.

References

1. Tomaszewski M, White C, Patel P, et al. High rates of non-adherence to antihypertensive treatment revealed by high-performance liquid chromatography-tandem mass spectrometry (HP LC-MS/MS) urine analysis. Heart. 2014;100(11):855-61. doi: 10.1136/heartjnl-2013-305063.

2. Lloyd JT, Maresh S, Powers CA, Shrank WH, Alley DE. How much does medication nonadherence cost the Medicare fee-for-service program? Med Care. 2019;57(3):218-224. doi: 10.1097/MLR.0000000000001067.