| Be aware of the problem and be alert to signs of patient nonadherence including missed appointments and no or minimal response to antihypertensive medications. Recognize that lifestyle patterns and habits such as high-salt diets or excessive alcohol use can blunt antihypertensive responses. |
| Establish the goal of therapy: To achieve goal blood pressure with minimal or no side effects |
| Educate the patient about the disease and its treatment |
- Involve the patient in decision-making on medications and lifestyle changes.
- Encourage family support.
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| Maintain contact with the patient |
- Encourage visits and telephone calls or electronic communications to allied health personnel.
- Engage the pharmacist in monitoring the response to and adherence with therapy.
- Give feedback to the patient on home blood pressure readings during office visits and between office visits, especially in patients with uncontrolled hypertension.
- Ask about adherence in a nonjudgmental manner and explore if any medication doses are missed.
- Acknowledge that medications can be expensive and have unwanted side effects.
- Make contact with patients who do not return for scheduled appointments.
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| Keep care inexpensive and simple |
- Do the least workup needed to rule out secondary causes.
- Obtain follow-up laboratory data only yearly unless indicated more often.
- Use home blood pressure readings.
- Use nondrug, no-cost therapies.
- Use the fewest daily doses of drugs needed; use single-pill combinations when possible and work with a pharmacy that consolidates refills for patients taking multiple prescription medications.
- Tailor medication to daily routines.
- Use generic drugs.
- Ask the patient to provide list of preferred drugs from insurance.
- Have a pharmacist suggest low-cost alternatives.*
- Use pill box(es), blister-packaging, or electronic reminders (eg, smartphone app).
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| Prescribe according to pharmacologic principles |
- Add one drug at a time, although it is sometimes appropriate to begin treatment with a single-pill combination.
- Use longer-acting drugs with less peak-trough blood pressure-lowering variation.
- Use moderately dosed combinations to minimize side effects (eg, ACE inhibitor or ARB with low-dose diuretic and/or amlodipine).
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| Other |
- Start with small doses, aiming for 5 to 10 mmHg reductions at each step.
- Have medication taken immediately upon awakening in the morning or after 4 am if patient awakens to void.
- Titrate gradually, particularly beta blockers.
- Be willing to stop unsuccessful therapy and try a different approach, especially in patients already taking multiple antihypertensive medications.
- Anticipate side effects.
- Adjust therapy to ameliorate side effects that do not spontaneously disappear.
- Continue to add effective and tolerated drugs, stepwise and in sufficient doses, to achieve the goal of therapy.
Have a case manager, pharmacist, or nurse identify and suggest solutions to barriers to adherence. |
