To Work as Expected, Do as Directed

Medical adherence — following doctor’s orders — is a huge issue in medicine. Adherence comprises both lifestyle and medication prescriptions. Neither can work as expected if not used as directed. Typically, doctors prescribe various lifestyle changes to address the underlying causes of high blood pressure (HBP), and some of these are challenging. “There are a variety of strategies to assist patients and families who are trying to improve their diet, increase physical activity or moderate their intake of alcohol,” said Paul Whelton, clinical professor and Show Chwan Health System Endowed Chair in Global Public Health at Tulane University in New Orleans. Whelton is the chair of the AHA committee that wrote the new blood pressure treatment guidelines. “A good therapist who understands how to change behavior can be invaluable. Not all clinicians or dietitians will have the requisite skill set.”

As for medication, it is not uncommon for a person with HBP to take more than one medication to control it. That is because different prescriptions work on different mechanisms. For instance, one may act as a diuretic while another reduces blood vessel constriction. As important as how many drugs someone takes is how often those drugs must be taken. From a medical adherence standpoint, once a day is best. “We know that can have a big impact on adherence,” Whelton said. “Fortunately, we now have once daily medications for all of the major classes of antihypertensive drug therapy. When more than one antihypertensive medication is required, it is desirable to treat with a combination drug if one is available in the correct doses. We provide a listing of combination agents in our guideline.”

Sometimes side effects cause patients not to comply with their prescriptions. Whelton says this is rarely a problem with HBP meds, and if it is contact your doctor because there’s plenty that can be done. “The lovely thing about high blood pressure is we have got a very nice selection of different classes of agents and different agents within a class,” he said. “The good news is that there is a lot of flexibility in what we can prescribe. We can deal with almost any side effect.”

Whelton urges patients to take both their drug and non-drug prescriptions seriously because they are there to prevent strokes and heart attacks. “Given the diet we eat now and all the means we have for avoiding physical activity like escalators and elevators and cars, it is not surprising that we have pressures that are too high,” he said. “But patients have the power to deal with this in ways that are pretty straightforward and simple. They’re not easy, but they are simple.

“Be careful about what goes into your body. Make sure that you stay physically active. If you are not consuming alcohol, don’t; because alcohol clearly raises blood pressure. If you’re an adult and you have children, you’re the role model. If you’re the person who prepares the meals, encourage everybody to be healthy as well. And if you need meds on top of that, by all means, take medications.

“But the first point of business is to try to deal with the underlying problems. It should be improving your diet, increasing physical activity and avoiding excessive alcohol intake. These are non-drug strategies that drive blood pressure down for most of us.”

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