How to manage hypertensive urgency in patients with poor medication adherence?

Management of Hypertensive Urgency in Non-Adherent Patients

The most effective approach to managing hypertensive urgency in non-adherent patients requires a coordinated strategy that addresses medication regimen simplification, behavioral interventions, and appropriate blood pressure reduction while creating a blame-free environment to improve adherence. 1

Initial Assessment and Management

• Confirm elevated blood pressure with at least two additional measurements using a validated device with appropriate cuff size 2
• Distinguish between hypertensive urgency (severely elevated BP without acute end-organ damage) and hypertensive emergency (with acute end-organ damage) 3
• Create a blame-free, encouraging environment where patients can honestly discuss adherence challenges 1
• Assess for specific barriers to medication adherence using objective methods (pill counts, medication refill data) along with self-report tools 1

Immediate Blood Pressure Management

• For hypertensive urgency without end-organ damage, oral antihypertensive medications are appropriate rather than IV medications 3, 4
• Target blood pressure reduction should be gradual - aim to reduce BP by at least 20/10 mmHg initially, with a goal of <130/80 mmHg within 3 months 1, 2
• Avoid rapid, excessive BP reduction which can lead to organ hypoperfusion 4
• Consider brief observation (1-2 hours) to ensure initial BP response before discharge 5

Medication Strategy for Non-Adherent Patients

• Simplify medication regimens by prescribing once-daily dosing rather than multiple daily doses 1
• Use combination pills rather than individual components to improve adherence 1
• For non-Black patients, start with low-dose ACEI/ARB 1, 2
• For Black patients, start with low-dose ARB plus DHP-CCB or DHP-CCB plus thiazide-like diuretic 1, 2
• Prescribe long-acting antihypertensive agents that can maintain effectiveness even with occasional missed doses 6

Addressing Non-Adherence

• Identify specific barriers to adherence, which may include cost, complex regimens, side effects, or lack of understanding about hypertension 1
• Implement team-based care with involvement of nurses, pharmacists, and other healthcare professionals to reinforce adherence 1
• Schedule frequent follow-up visits (at least monthly) until target BP is reached 1
• Use electronic monitoring, pill counts, or medication refill data to objectively assess adherence 1
• Consider motivational interviewing techniques to improve compliance with treatment regimens 1

Follow-up Plan

• Schedule follow-up within 2-4 weeks to assess response to therapy and adherence 2
• Implement home blood pressure monitoring to track progress and improve patient engagement 1
• Gradually intensify therapy if BP remains uncontrolled despite adherence 1
• Consider referral to a hypertension specialist if BP remains uncontrolled despite multiple medications and adherence interventions 1, 2

Common Pitfalls to Avoid

• Avoid blaming patients for non-adherence, which can damage the therapeutic relationship and worsen adherence 1
• Don't prescribe complex regimens with multiple daily dosing, which decrease adherence rates from 71-94% (once daily) to much lower levels with multiple daily doses 1
• Avoid assuming that patient-reported adherence is accurate; up to 25% of patients don't fill their initial prescription, and during the first year of treatment, the average patient has possession of antihypertensive medications only 50% of the time 1
• Don't overlook the potential for secondary causes of hypertension, particularly in patients with resistant hypertension 1