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      ACE Inhibitor-Based, Directly Observed Therapy for Hypertension in Hemodialysis Patients

      a , b , a

      American Journal of Nephrology

      S. Karger AG

      ACE inhibitor, Hypertension, Hemodialysis

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          Background: Hypertension is present in nearly 80% of dialysis patients yet adequately controlled in less than half. We designed a stepped antihypertensive regimen using long-acting antihypertensives (trandolapril, atenolol and amlodipine) administered thrice a week (TIW) after each hemodialysis, and compared blood pressure (BP) control, medication cost and pill burden to each patient’s prior daily antihypertensive prescriptions. Methods: Patients were continued on their daily medications, pre-dialysis sitting BP was measured and a 44-hour interdialytic ambulatory BP monitoring (ABPM) was obtained. Then, their medications were stopped and replaced with trandolapril (2 mg TIW). Atenolol and/or amlodipine were also given TIW if the patients had any member of these classes of drugs as part of their daily regimen. Medications were titrated every 2 weeks to achieve a pre-dialysis mean arterial pressure (MAP) of <107 mm Hg. After 2 consecutive weeks with a pre-dialysis MAP of <107 mm Hg, a second 44-hour ABPM was obtained. Results: Ten patients completed the study. A persistent MAP of <107 was maintained in all 10 patients after conversion to TIW dosing. The systolic BP decreased from 122.2 ± 7.1 to 116.4 ± 11.6, and the diastolic BP decreased from 75.3 ± 10.4 to 70.4 ± 11.4 mm Hg. Pill burden and cost of medications were also significantly less. Conclusions: This pilot study found that ACE inhibitor-based, directly observed TIW therapy to be effective in hemodialysis patients with mild to moderate hypertension. Larger trials of directly observed therapy for hypertension in dialysis patients are warranted.

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          Most cited references 19

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          Prevalence, treatment, and control of hypertension in chronic hemodialysis patients in the United States.

          Hypertension is common in chronic hemodialysis patients, yet there are limited data on the epidemiology of hypertension in these patients in the United States. We assessed the prevalence, treatment, and control of hypertension in a cohort of 2535 clinically stable, adult hemodialysis patients who participated in a multicenter study of the safety and tolerability of an intravenous iron preparation. Hypertension was defined as an average predialysis systolic blood pressure >150 mm Hg or diastolic blood pressure >85 mm Hg, or the use of antihypertensive medications. Hypertension was documented in 86% (n = 2173) of patients. The prevalence of hypertension, in contrast to that observed in the general population, did not increase linearly with age and was not affected by sex or ethnicity. Hypertension was controlled adequately in only 30% (n = 659) of the hypertensive patients. In the remaining patients, hypertension was either untreated (12% [252/2173]) or treated inadequately (58% [1262/2173]). Control of hypertension, particularly systolic hypertension, in chronic hemodialysis patients in the United States is inadequate, despite recognition of its prevalence and the frequent use of antihypertensive drugs. Optimizing the use of medications and closer attention to nonpharmacologic interventions, such as adjustment of dry weight, a low-sodium diet, and exercise, may improve control.
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            The effect of prescribed daily dose frequency on patient medication compliance.

            The objective of this study was to determine the relationship between prescribed daily dose frequency and patient medication compliance. The medication compliance of 105 patients receiving antihypertensive medications was monitored by analyzing data obtained from special pill containers that electronically record the date and time of medication removal. Inaccurate compliance estimates derived using the simple pill count method were thereby avoided. Compliance was defined as the percent of days during which the prescribed number of doses were removed. Compliance improved from 59.0% on a three-time daily regimen to 83.6% on a once-daily regimen. Thus, compliance improves dramatically as prescribed dose frequency decreases. Probably the single most important action that health care providers can take to improve compliance is to select medications that permit the lowest daily prescribed dose frequency.
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              How can we improve adherence to blood pressure-lowering medication in ambulatory care? Systematic review of randomized controlled trials.

              Lack of adherence to blood pressure-lowering medication is a major reason for poor control of hypertension worldwide. The objective of this study was to determine the effectiveness of interventions to increase adherence to blood pressure-lowering medication. We performed a systematic review of randomized controlled trials and searched for all-language publications in the Cochrane Controlled Trials Register, MEDLINE, EMBASE, and CINAHL in April 2002. We included 38 studies testing 58 different interventions and containing data on 15 519 patients. The studies were conducted in 9 countries between 1975 and 2000. The duration of follow-up ranged from 2 to 60 months. Because of heterogeneity between studies in terms of interventions and the methods used to measure adherence, we did not pool the results. Simplifying dosing regimens increased adherence in 7 of 9 studies, with a relative increase in adherence of 8% to 19.6%. Motivational strategies were partly successful in 10 of 24 studies with generally small increases in adherence up to a maximum of 23%. Complex interventions comparing more than 1 technique increased adherence in 8 of 18 studies, ranging from 5% to a maximum of 41%. Patient education alone seemed largely unsuccessful. Reducing the number of daily doses appears to be effective in increasing adherence to blood pressure-lowering medication and should be tried as a first-line strategy, although there is so far less evidence of an effect on blood pressure reduction. Some motivational strategies and complex interventions appear promising, but we need more evidence on their effect through carefully designed randomized controlled trials.

                Author and article information

                Am J Nephrol
                American Journal of Nephrology
                S. Karger AG
                September 2007
                16 August 2007
                : 27
                : 5
                : 522-529
                aDepartment of Internal Medicine, Renal Division, Chromalloy American Kidney Center and Washington University School of Medicine, Saint Louis, Mo., and bWellStar Health System, Austell, Ga., USA
                107490 Am J Nephrol 2007;27:522–529
                © 2007 S. Karger AG, Basel

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                Page count
                Figures: 3, Tables: 4, References: 26, Pages: 8
                Original Report: Patient-Oriented, Translational Research

                Cardiovascular Medicine, Nephrology

                ACE inhibitor, Hemodialysis, Hypertension


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