BLEBEA Nicoleta Mirela1, NEGREȘ Simona²
1Pharmacology and Clinic Pharmacy Department, Faculty of Pharmacy, Ovidius University from Constanta, Romania
²Pharmacology and Clinic Pharmacy Department, Faculty of Pharmacy, Carol Davila UMF from Bucharest,Romania
Pharmaceutical care may offer the pharmacist the real possibility of a professional responsibility in health care . The presence of the pharmacist in the therapeutic management of hypertensive patients results in a control of hypertension .The combination of this disease with multiple risk factors required the pharmacist to provide a responsible drug therapy in order to obtain positive results, to improve the patient’s health  by following blood pressure (BP) values.
Keywords: adherence, chronic hypertension, compliance, pharmaceutical care
Pharmaceutical care is an innovative approach, aimed at improving the quality of life for hypertensive patients. In Romania, cardiovascular diseases remain the main cause of mortality, with a percentage over 35%. Although the benefits of antihypertensive medication are clearly established, only 70% of hypertensive patients are currently treated, and only about 40% are adequately controlled therapeutically .
The aim of the study was to observe and quantify whether hypertensive patients participating in the pharmaceutical care program have a better reduction in BP compared to the treatment reduction of a group not participating in this program.
Material and method
The study was prospective, longitudinal, randomized, controlled and was performed on 2 groups of hypertensive patients who go to the same community pharmacy from Constanța:
-lot of 15 patients with hypertension to whom a pharmaceutical assistance program was applied;
-control group of 15 patients with hypertension in whom the release of drugs was performed according to the usual, traditional model, with a minimum training of the patient in the pharmacy, offering standard pharmaceutical services.
We monitored the hypertensive patients in the study group, measuring BP before the start of the study and at the end of the study. We performed monthly pharmaceutical care and whenever patients in the group returned to the pharmacy. We compared the BP values at the end of the pharmaceutical period with those of the control group with the initial values.
The study group and the control group were divided into several sublots according to:
-number of drugs administered
-non-pharmacological regimens (hyposodium diet).
Pharmaceutical assistance plan
The pharmaceutical assistance took place in the pharmacy in a confidential area.
During the first discussion, the patients signed a consent for participation in the study, according to international norms. The pharmacist kept the confidentiality of all socio-demographic and pathological data of the patients. The patients received a notebook from the pharmacist in which they noted the irregularities in the administration of the drug. Adherence to treatment is determined by using the report on the notebook by the patients, how many times they took their medication regularly, daily, according to the treatment regimen of one month, if there were days when the drugs were not administered, if they took all or part of the prescribed drugs.
The monthly pharmaceutical care of the study group compared to the control group consisted of:
-training on the correctness of the treatment administration, the patient’s ability to administer his medicines;
-clarification of problems related to use, order of use and the need for continuous administration, without interruption of medication;
-eventual training of the patient to control his / her own BP values at home using his / her own measuring device;
-detection of problems related to side effects (identification of signs and symptoms related to drugs) and the relationship with the family doctor to remedy them;
-information patients on the proper storage of medicines at home;
-encouraging patients to use non-pharmacological methods, namely nutritional measures such as low-sodium diet (about 3 g / day NaCl), diets according to weight status, diet rich in fruits, vegetables, low fat, especially unsaturated, minimal use of processed foods that contain a lot of salt), quitting smoking, reducing excessive alcohol consumption, coffee;
-following the changes in salty taste induced by some antihypertensive so that the hyposodic diet is accepted correctly, as well as the sweet taste in diabetics modified by antidiabetic treatment;
-implementation of strategies to increase adherence to patients’ drug therapy.
Each patient’s notebook included:
– socio-demographic data (age, sex,)
– personal pathological antecedents;
– main biochemical values
– general state of health;
– history of the disease;
– history of medication used and medication used at the start of the study;
– lifestyle (diet, frequency and amount of tobacco or alcohol used, degree of activity or sedentary lifestyle, frequency and intensity of exercise);
– during the study, lifestyle changes, adherence to the drug regimen and the existence of adverse drug reactions were periodically included in the notebook;
– problems and needs identified by the patient, related to the disease;
– the date of release of the medicinal product, in order to check for any missed dose or dose reduction;
– blood pressure values measured in the pharmacy every month for 3 months, and initially and at the end of the study body weight, body mass index BMI;
The non – pharmacological treatment in the case of the hypertensive patient consists in
-combating risk factors (reducing salt intake to 5-6 g / day, giving up foods rich in cholesterol and saturated fats, excluding smoking and coffee, reducing alcohol consumption below 30g ethanol / day for men and below 15 g / day for women, avoiding sedentary lifestyle, fighting obesity, avoiding stress)
-employment of sanogenetic factors (hyposodium diet, hypolipidemic and hypocaloric diet, optimal intake of K, Ca, Mg through a diet rich in vegetables, fruits and dairy products, employment of easy exercise as walking, for 30-60min / day, stress management measures through psychotherapy and relaxation techniques.
Pharmacological treatment becomes necessary when non-pharmacological treatment is insufficient, is permanent and should not be abandoned, in case of essential hypertension, it should be adapted to the degree, risk group and stage of hypertension, as well as to the evolution of the disease.
Results and discussions
Following the study, the following statistical data were obtained:
- degree of hypertension (66.66% – grade 2 and 33.34% grade 1);
- type of hypertension (93.33% – essential and 6.67% – secondary);
- cardiovascular risk (very high – 66.66%, high – 13.33%, medium – 6.66%)
- obesity (26.6% of patients studied are obese)
The patients with hypertension who come in to the pharmacy that included pharmaceutical care are 8 women (53.33%) and 7 men (46.67%), aged between 26 and 72 years, with an average age of 60.86 years.
Regarding the associated comorbidities, the evaluated patients presented in a percentage of 33.3% diabetes and aortic valve sclerosis. 13.33% of patients have a personal history of left ventricular hypertrophy, congestive heart failure and left or right limb blocks.Congestive heart failure was found in 2 of the patients who received pharmaceutical care.Regarding the myocardial infarction, in the studied group there was only one patient who presented this pathology in the antecedents. Congestive heart failure was found in 2 of the patients who received pharmaceutical care.
Hepatic steatosis (20%) and angina pectoris (26%) were 2 pathologies found in the patients included in the study, as well as hypertriglyceridemia, hypertensive retinopathy and chronic obstructive pulmonary disease, but in a much lower percentage (6.66%) .
We compared the BP values at the end of the pharmaceutical care with those of the control group with the initial values. For the control group, BP values were measured by the pharmacist at the beginning and end of the study; the rest of the time the BP monitoring was performed by the patients, with the help of personal automatic blood pressure measurements.
Thus, the initial values of systolic and diastolic blood pressure at the beginning of the study had an average of: systolic BP – 143 mmHg, diastolic BP – 89.66 mmHg, and at the end of the study systolic BP – 122.6 mmHg and diastolic BP – 87.3 mmHg.
Antihypertensive treatment was administered either alone or in combination with several pharmaceutical classes. Nine of the patients included in the study group received treatment with a single class of antihypertensive drugs (60%), and the remaining 6 – combinations of drug classes (40% – diuretics + AT1 receptor antagonists + calcium channel blocker (BCC), BCC + diuretic, conversion enzyme inhibitors (ACE inhibitors) + diuretic, BCC + ACE inhibitors + diuretic.
The analysis of the percentage decrease in BP values at the end of the study compared to the beginning of the study shows that, in most cases, the percentage decrease is higher in patients with pharmaceutical care than in those with minimal pharmaceutical care, a clear argument in favor of pharmaceutical care.
Regarding the cardiovascular risk of the examined patients, 66.6% of them have a very high cardiovascular risk, 13.3% high risk and only a percentage of 6.6% average cardiovascular risk. Of these, only one patient was diagnosed with secondary hypertension, the remaining 93.3% – essential hypertension. Another very important factor of the study is the association of the increased weight index with hypertriglyceridemia, hypercholesterolemia, atheromatosis and hypertension, 26.6% of the patients studied being obese.
Very often in medical practice we are in the situation where we have to communicate to the patient the need to perform a long-term drug treatment (months, years) sometimes a lifetime (depressed patient, diabetic, asthmatic, hypertensive) . The therapeutic success may depend on the way in which we make this communication and on the percentage in which the recommendations of the doctor or pharmacist regarding the drug therapy are received and accepted by the patient, on the way of administering the drugs. However, patient non-compliance to antihypertensive treatment recommendations remains a global problem and promoting patient compliance is a major clinical barrier that is needed to reduce cardiovascular morbidity and mortality . A first step in understanding compliance or lack of compliance is to evaluate or measure it.
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