Home' Australian Pharmacist : Australian Pharmacist May 2012 Contents 378 Australian Pharmacist May 2012 I © Pharmaceutical Society of Australia Ltd.
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COUNSELLING IN PRACTICE
two drugs, possibly because regulators
are still balancing the pros and cons of
combination therapy described above.
What other ways are there to reduce
the number of tablets I take?
Individuals should address all modifiable
risk factors for CVD. In addition to
hypertension and hypercholesterolaemia,
these include physical inactivity, high
body mass, tobacco use, and low fruit and
Lifestyle modifications (e.g. smoking
cessation, having a healthy diet, reducing
body mass index to <25 kg/m2, increasing
physical activity and moderating alcohol
consumption) have been shown to directly
reduce the risk of cardiovascular events.
For example, it has been proposed that
70% of stroke and >80% of coronary heart
disease might be preventable through
Such lifestyle modifications will also
improve blood pressure and lipid levels,4,13
and consequently may reduce the need
for the number of medications required for
I don’t always take my medicines;
is it dangerous not to take
Non-adherence to cardiovascular
medicines is common. For example, it has
been shown that:14
• 18% of patients prescribed an ACE
inhibitor fail to collect the second
prescription, and only 45% are persisting
with the therapy at 33 months
• for patients prescribed calcium channel
blockers, 28% fail to collect the second
prescription, and only 31% are persisting
with the therapy at 33 months
• adherence to statins is dependent
on the indication for which they are
prescribed, with 40% of patients
adherent after two years when they
have been prescribed for acute coronary
syndrome but only 25% adherent when
they have been prescribed for primary
The potential danger of not taking these
medicines is that the intended reduction in
CVD risk will not be achieved:14
• Poor adherence in hypertension and
hypercholesterolaemia results in higher
rates of hospitalisation.
• Patients with hypertension who take
their medicine less than 20% of the time
are twice as likely to be hospitalised as
those who take their medicine more
than 80% of the time.
• Poor adherence to a medicine regimen
post-myocardial infarction results in a
two- to six-fold increase in the risk of
death within a year of the event.
Factors underlying non-adherence to
medicines are diverse. They may relate
to the health condition being treated,
treatment prescribed, health care system,
socioeconomic context, and individual
patient characteristics.14 As such,
non-adherence should not just be viewed
as a shortcoming in the patient.
When pharmacists suspect non adherence,
it is important to explore the extent,
pattern and underlying causes, and
then undertake interventions aimed at
addressing the causes in that individual.
For example, a simplified regimen such
as that achieved with combination
therapies may improve adherence if the
underlying causes are related to having to
take a large number of medicines, or the
cost associated with so many medicines.
However, it is unlikely to be successful
if the underlying causes are related to
swallowing difficulties, adverse effects, a
rejection of the diagnosis, or a loss of faith
If my blood pressure and/or
cholesterol levels improve can I stop
taking this medicine?
The decision to prescribe, or continue
prescribing, a medicine is one that the
doctor makes with their patient according
to their health goals, based on a clinical
review of the patient’s condition(s) and the
best available evidence.
If an individual’s blood pressure and/or
cholesterol levels improve, the doctor will
review the medicines being taken and
make adjustments as required. This may
involve the cessation of a medicine.
However, with fixed dose combination
products, it may be more likely that the
combination medicine will be replaced
with one or the other of the drugs within
that product, rather than cessation of both
at the same time.
Case study continued
You explain to John that this new medicine
will replace two of the medicines he has
already been taking, as it combines both
of them at the doses he has been using.
You highlight that altogether he will be
taking three tablets each day. These three
tablets will incorporate five drugs – aspirin,
three drugs for hypertension and one drug
You reinforce the importance of lowering
blood pressure and cholesterol levels to
prevent cardiovascular events such as
strokes and heart attacks. You show him
the Absolute Cardiovascular Risk Chart,
highlighting that a number of factors that
can place a person at risk and that it is
important to address all of them. You discuss
his level of risk and lifestyle modifications he
could make, along with taking his medicines,
to reduce his risk.
The medicines that have been prescribed
by the doctor have been selected to best
reduce his risk of cardiovascular disease.
By combining some drugs into single tablets,
it will be a simpler dosing regimen for
John to take, and the availability of several
different dose combinations will still allow
the doctor to select the drugs and doses
according to John’s specific needs.
You recognise that John’s non-adherence to
his medicines may be a result not only of a
complex regimen, but of other factors such
• hypertension and hypercholesterolaemia
being asymptomatic conditions and
John not understanding the benefits
that can be achieved from treating
• John experiencing adverse effects
(e.g. a cough from his ACE inhibitor,
myalgia from his statin, frequent urination
from his diuretic) which may deter him
from adhering to his medicines
• John having unstable living conditions
(e.g. problems at home or travelling
When pharmacists suspect non‐adherence, it is important
to explore the extent, pattern and underlying causes, and
then undertake interventions
Compliance and monitoring - inter-related factors in oral anticoagulation
Compliance and effective monitoring...
...two essential components for optimising oral anticoagulation therapy
Warfarin – a particular case in point
• It is increasingly prescribed as lifelong therapy for patients with mechanical heart valves, atrial fibrillation
or thrombophilic disorders, effectively preventing arterial embolism in a wide range of conditions3
• Maintaining INR within its therapeutic range is effectively achieved through monitoring
• Patients on warfarin who have had a heart valve replacement, there was a 32% difference in survival at
15 years between patients with low and high variability in anticoagulation control4
The obvious choice is partnering VKA and CoaguChek® XS for
The importance of compliance
• Compliance rate with long-term medication in general has been estimated at between 50% and 60%1
• Evidence shows that INR monitoring improves the quality of oral anticoagulation between 50% and 85%2
Roche Diagnostics Australia Pty Limited., 31 Victoria Ave Castle Hill NSW 2154,
Phone: 02 9860 2222 ABN 29 003 001 205
1. DiMatteo MR. Formulary 1995; 30: 596–8, 601–2, 605. 2. Heneghan C, Alonso-Coello P, Garcia-Alamino JM,
Perera R, Meats E, Glasziou P. Self-monitoring of oral anticoagulation: a systematic review and meta-analysis. Lancet
2006;367:404-411. 3. Ansell J et al. Int J Cardiol 2005; 99: 37–45. 4. Butchart EG et al. J Thorac Cardiovasc Surg 2002;
123: 715-23. 5. CoaguChek PI.
COAGUCHEK, BECAUSE IT’S MY LIFE are trademarks of Roche.
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