E-drug: Re: HOT: can we turn WHO around? (cont)
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Robert Marsall's point about the HOT study is well-taken. There is one
counterpoint, however, to the idea that drug therapy should be aggressively
escalated until patients respond. It is based on recent work from the
hypertension group at University of Lausanne, recently presented at regional
meetings in Switzerland, but which will be presented at the American Heart
Association conference on patient compliance in Boston , April 29-30, and at
the American Society for Hypertension meetings in New York in the 3rd week of
May. The key finding is that half or more of patients who are having their
treatment escalated in the usual stepped-care scheme for managing hypertension
are in fact clinically unrecognized noncompliers. This conclusion is based on
data from electronically monitored compliance (eDEM Monitor, AARDEX Ltd, Zug,
CH) with prescribed antihypertensive drugs. The work comes from the group of
Prof. Hans-R. Brunner at the University Hospital in Lausanne; the principal
investigator is Prof. Michel Burnier. Its main implication that a
disappointing treatment response in stepped care is as likely to indicate
clinically unrecognized noncompliance as it is pharmacologic nonresponse.
Unfortunately, the clinical recognition of poor compliance is poor, so it is
probably necessary to resort to objective measurements of compliance. Relying
on the patient is the simplest approach but is highly unreliable because so
many patients are reluctant to acknowledge that they have omitted many
prescribed doses. Fortunately, the cost of electronic monitoring is now down
in the range of 1-2 months' supply of recently introduced, chronic-use oral
pharmaceuticals.
About a month ago the Swiss Association of Pharmacists published a 21-page
monograph on how and why to implement electronic monitoring in Swiss community
pharmacies. Thus, electronic monitoring has been only a research tool for the
past decade, recent changes in manufacturing economics and documentation of the
problems of unrecognized noncompliance in stepped-care pushes this method
toward use in clinical practice.
It is poor economics and bad medicine to step up to more powerful treatments
when the basic problem is poor compliance with prescribed regimens.
John Urquhart, MD, FRCP(Edin)
Prof. of Pharmaco-epidemiology, Maastricht University, Maastricht, NL
Prof. of Biopharmaceutical Sciences, UCSF, San Francisco, CA, USA
Chief Scientist, AARDEX Ltd., Zug, CH
urquhart@ix.netcom.com
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