The struggles of compliance

I remember the long-distance truck driver I saw, maybe 25 years ago. He was 52, with hypertension. His GP put him on a diuretic. When I saw him, he admitted his control was poor—for obvious reasons. He wasn’t taking his 1-cent pill every morning. “I can’t pull over every couple of hours to pee, can you find something different?” In his case, Adalat XL 60mg was his salvation—and 135/85 his blood pressure average. It got me to thinking. We all believe we do a great job of (a) prescribing and (b) fine-tuning medications. But patients don’t always understand their pills, or take them. Issues with perceived side effects (betablocker slow you down), pharmacy scares (the fliers with every box of meds, citing adverse side events without incidences or mention of benefit), cost (some pills cost $3 a day!) and co-morbidities (if you have BPH and prostatism, you won’t react kindly to a diuretic prescription). Read: Exploring the science of success The most common side effect I see is ankle edema, when the amlodipine dose is pushed to 10 mg or more. This isn’t a ‘side-effect’, it represents dilatation of the arteries in the lower legs, allowing accumulation of tissue fluid. This isn’t heart failure either. It is cosmetic, and represents successful vessel relaxation. It can be countered by (a) lowering the dose (b) leg elevation (c) support stockings. We used to worry about hypokalemia from diuretics (seldom symptomatic), wheeze and cold extremities from betablockers (often in smokers with PAD), cough from ACE inhibitors (yes, in 20%) and muscle aches from statins (10%). Then we quit screening on a regular basis, and management remained the same. Keep an open mind, use combinations, and focus on home-average-BP-targets. Sometimes your threshold of concern is truly justified, such as with amiodarone (hypothyroidism, neuropathy, lung toxicity, etc.) And some rare complications will crop up whatever you do (pancreatitis with CCBs, good grief). I read an article that more or less said, if you prescribe a diabetic 10 pills (for glycemia, pressure, dyslipidemia and atherosclerosis), the 10th pill is often dropped—in favour of paying the rent or buying dinner. Many elderly patients don’t have extended medical and spend their children’s inheritance on pills. Many frail elderly patients have poor vision, poor memory, poor hearing and limited understanding of cardiopulmonary pathophysiology (no surprise!). And yet we give them 10 medications (on top of their supplements) to consume reliably every day. This is optimism at its best! Blood pressure is a good example of how LIFESTYLE advice is so difficult to enforce (although, physicians are not in the policing business). Tell an overweight, 66-year-old smoker who drinks three beers a day to cut out salt, anti-inflammatories and lose 20 lbs—and give up his addictions—and your chance of persuading him to spend $3 a day on an asymptomatic disease is zip. “Sure, stroke sounds terrible, but it happens to the other guy, right? And I’m only 66. I don’t know what LVH means, my kidneys still make pee, and I don’t get headaches.” It all goes back to education, about health and disease, starting in school and running lifelong. And what about compliance with other diseases, like CPAP for OSA, carbohydrate intake for diabetes, exercise for claudication, social adjustments for addiction, anticoagulants for atrial fibrillation? Do we have the trust and understanding of millions that we have their best interests at heart? The retraction of the medical profession at the beginning of COVID-19 eroded trust, and what should have been universal practice (vaccination) became a tough sell. Humans weren’t born to follow rules. They evolved by learning to fight adversity, whether it be from famine and war, homelessness and unemployment. In Roman times, obesity was a mark of success. Advertising used to tell patients cigarettes conferred status and well-being. Alcohol, a tax-generating substance, became a socially acceptable sedative. Ubiquitous transport means exercise is something you need to think about, rather than have to do. And doctors have limited time for a limited number of problems, a huge disadvantage when it comes to lifestyle education. I would like to see ‘Health and Disease’ be one of the main courses in every school, every college. A mandatory series of lectures and exams, not necessarily complex, but focused on avoiding the challenges of each stage of life, from substance abuse to depression, obesity to sloth. And somewhere in there, classes on the degenerative illnesses, like hypertension, diabetes, MI and stroke. It’s something we doctors attempt to teach, albeit in a post-hoc fashion. Further reading: https://www.wikidoc.org/index.php/Compliance_(medicine) Drug Compliance and Adherence to Treatment. Manmohan, T et al. Journal of Evolution of Medical and Dental Sciences 2022, 1(3):142-159 Medication Adherence: The Elephant in the Room. Kim, J et al. US Pharmacist, Jan 2018

Casebook of a Community Internist

The struggles of compliance

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Hector Baillie

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