BMJ Learning

Prescribing antihypertensives

د. حسين محمد جمعة
اختصاصي الامراض الباطنة
البورد العربي
كلية طب الموصل
2010

About the author

John Benson is a GP and university lecturer in general practice in Cambridge. He is interested in how patients' views influence their decisions to take antihypertensives. Dr Benson has published a number of papers in this field but is still working out how best to discuss the risks and benefits of antihypertensives and come to shared decisions with patients.
Why I wrote this article
"I am interested in what lies behind patients' views about medication. There is a variety of these stories and although some views are quite negative, many patients take their tablets nonetheless. I am also interested in developing a negotiated approach to prescribing where we give patients enough information for them to make an informed choice. Thus we will be more likely to give a prescription to patients who really want one."

Read

Hearing patients' thoughts about medicines
Patients' views about medicines are diverse. Their views arise from a variety of past experiences and often draw on non-medical sources as well as medical ones. These views may incline patients to make decisions about taking drugs different to those in conventional prescribing guidelines.

Key points

Patients have their own views about antihypertensives. They sometimes have reservations about taking tablets but when they do take them, their positive views often outweigh their reservations
For many patients, antihypertensives bring unwelcome side effects. But patients often come to accept these, balancing side effects with reasons to continue taking the drugs
There are several reasons why you should explore patients' views about antihypertensives:
to improve your own understanding of patients' beliefs
to reach a negotiated decision about prescribing (concordance)
to ensure prescriptions go to those who really want them with the so far unproved expectation that such patients are more likely to take their medicines as prescribed
A concordant prescribing decision should not just aim to persuade a patient to take tablets. You should instead aim to reach an agreed decision between you and your patient
Questions remain about how best to reach an agreed decision and how doctors and patients may deal with some of the possible consequences


It is all too easy to gloss over patients' views or to make assumptions about what these views might be. Some patients will offer a filtered version of their thoughts for your consumption, so you may need to encourage them to tell you more about their thoughts during consultations. 5 6 It is likely your patients will have their own views about taking antihypertensive drugs, just as they would with other medicines. But hypertension is an especially interesting example, because:
It is nearly always an asymptomatic condition so the patient doesn't usually feel any benefit from taking tablets
It is also a lifelong condition so patients will probably have to take tablets for many years
Treating people with hypertension benefits the population overall but not every individual will feel they have benefited personally.

Reservations about medicines generally

Most patients mentioned general reservations about medicines.
Some patients felt medicines were best avoided or "just not for them," but few gave this as their only explanation. Patients' other reservations included:
Medicines were seen as unnatural or unsafe
Reservations related to previous experiences, for example seeing others who were dependent on medicines
Taking tablets was seen as an unwelcome sign of ill health
A few patients spoke of doctors prescribing medicines too readily.
Some spoke of their parents discouraging the use of medicines.

Reasons to take antihypertensives

All patients mentioned reasons why they took their tablets and most were able to mention more than one reason.
Most mentioned positive experiences with their doctor as a factor that encouraged them to take their tablets. Some felt that it was "best to do as the doctor says," although others remained ambivalent about their doctor's advice. For some, it was a matter of trust for doctors generally, while others spoke of trusting their own doctor. Some patients were simply motivated by improved blood pressure readings.

Almost all patients spoke of taking tablets because of perceived benefits. Many spoke about general benefits but some specifically mentioned protection from heart trouble or stroke. A few saw tablets as protecting them from other risks to which they were exposed (such as diabetes). In contrast to medical convention, many patients said that taking their antihypertensives made them feel well or better and some enjoyed the peace of mind of knowing their blood pressure was under control.

Practicalities motivated some patients. A few patients saw no alternative way to control hypertension. A few spoke of having no symptoms by which they could judge blood pressure and medication use. For some, other health problems overshadowed their concerns about antihypertensives.


Reservations about antihypertensives specifically
Many patients also had specific reservations about taking antihypertensives:
Some said they wanted to stop their antihypertensives
Some wondered whether antihypertensive medication was still necessary
Some mentioned possible long-term risks or risks that remained hidden until later in life.
Side effects from antihypertensives
Most patients had experienced unwelcome side effects at some point and many continued to experience these side effects. However a few patients had side effects that they welcomed - the calming effect of beta-blockers is one example.

Coping with reservations and side effects

Patients generally weighed their reservations against reasons to take tablets in a way that made sense to them personally, but in the face of unwelcome side effects, some patients did stop their medication.
However, more patients changed the way they took their tablets (perhaps taking tablets at a different time or sometimes missing tablets) or changed their behaviour in some other way (such as not standing up too quickly, to avoid dizziness). Some patients continued taking tablets unchanged.

Although patients discussed stopping tablets with their doctor, they did not often discuss other changes in the way they took their tablets. Many patients continued to experience unwelcome side effects after taking these steps, but they accepted them by balancing them against reasons to continue.
In short, patients often took antihypertensives in the face of reservations or persistent side effects. Their reasons for doing so were different, but made sense to them in the light of their beliefs and experience.

Why explore patients' thoughts about prescribing?

Although doctors often explore patients' ideas and concerns in the first part of a consultation, they sometimes forget to do this later on when planning treatment.
With so much to do in so little time, why should doctors explore patients' beliefs about medication before writing a prescription? One reason is that patients welcome it. Doctors are also more likely to make decisions that fit with what the patient wants if they take time to explore their beliefs beforehand.

What's the difference between compliance and concordance?

Patients do not always take medicines as prescribed. This has been described as non-compliance (or non-adherence) but this implies that doctors tell patients what to do and "compliant" patients follow their instructions without question.
This is a problem in today's society both ethically and practically, as patients approach prescribing decisions with a range of views (some of which have been discussed earlier).
Clearly patients still value their doctor's advice but a negotiated approach would make it more likely that doctors only give a prescription to patients who really want one. Thus, you are able to let your patients make an informed decision.


The term "concordance" describes a more equal relationship in which patients and doctors reach an understanding together about whether or not to use medication.

What happens if the patient and doctor disagree?

"Concordance" means that doctors listen to patients' ideas. It does not mean finding sophisticated ways to persuade patients to do what doctors want.
Thus a concordant outcome may be that the patient does not take any antihypertensives, even if the doctor would advise medication from a medical standpoint: in this situation concordance means both parties agree to differ.
You can justify this approach in ethical terms, as competent adults are free to make their own decisions even if they disagree with you as their doctor. But there are still a number of issues which you must confront, such as how to make time for discussions and how to present information to patients.

How does concordance work in practice?

Concordance takes time because you need to lay out options for treatment and your patients need to think about these options and ask questions.
Patients will also differ in the extent to which they wish to share decisions. Some patients will want to play an active part while others are content to leave it all to their doctor. But if you suggest your patients become more involved, it's likely more will take up the offer than you might think.

Patients may make quite different choices about antihypertensives depending on how you present the benefits and risks of taking them. For example you could tell your patients that a certain drug will reduce their chances of having a stroke by 20% (relative risk reduction) and they would probably be quite impressed. However if you told them the same information in a different way, that is, that the drug will reduce their chances of having a stroke by 2% (absolute risk reduction), they may be much less impressed.
You need to develop skills that allow you to share decision-making with your patients without dumping the decision-making process entirely on them.

If "doing the best for patients" means accepting their informed choice, sometimes you will need to accept that a patient may not choose to minimise their chances of having a future illness.
And in the real world of the NHS, failing to achieve treatment targets will see your practice losing out in clinical quality indicators (unless you record patients as "informed dissenters" - but how will some of them feel about that?)

What are the benefits of using a patient-centred approach?

If you reach a mutually agreed understanding and plan your patients' medication with them, there is evidence that they are likely to be more satisfied with the decision making process and they may also be more likely to take their medication.
Shared decision-making will remain a challenging issue for practitioners and researchers for some time yet, but one thing is clear - patients come to consultations about their blood pressure with a range of views. These views bear strongly on their wishes and feelings about antihypertensives and on their decisions about whether or not to take them.


Putting it into practice
Video a few of your consultations that involve starting or reviewing antihypertensives. Look at the part of the video where you are discussing medication. Video is ideal, audiotape will do, memory is much better than nothing. Remember to get consent from your patient before you record your consultation
If you feel that you could do more to involve patients in prescribing decisions, start by making small changes, some of the time
Anticipate that everyone has some views about antihypertensives - ask what they are and where these views come from.

Be open about what you know and don't know about the pros and cons of taking an antihypertensive
Ask open questions: "How do you feel about taking these tablets? Have you had any problems with them so far?"
Tell the patient that there are options: "There are several courses open to us here. Let's run over them and see what you think."
Remember that when you change your consulting habits, it may feel worse before it feels better.

Reflect

How to reflect
Reflecting isn't just about closing your eyes and having a think. To really reflect you should ask yourself these questions:
What do I think this learning module was about?
Can I apply it in my work?
What barriers am I likely to come across?
How will I manage these barriers?
How will I know if I'm doing things better?

What sort of things have you heard your patients say about antihypertensive tablets?

You may have heard your patients say that:
They are wary of any side effects
Taking pills is a sign of being ill
It is unnatural to take medicines for a long time
A member of their family takes antihypertensive tablets.
Taking tablets is "just not for me."


What do you see as the purpose of exploring your patients' thoughts about antihypertensives?
Asking your patients to tell you their thoughts about taking antihypertensives will help you decide which of your patients are likely to take their medicine as directed. Some patients may be unwilling to take their tablets - it is best to know this before you write out their prescription.

How realistic do you feel it is to aim to reach a shared understanding with patients about prescribing antihypertensives?
Time is always a limited resource in a busy practice, and coming to a shared understanding with some patients could be rather time-consuming. You will also have to work on a new set of communication skills that succeed in encouraging your patient to express their thoughts about antihypertensives.
Finally, if you have just not made a habit of consulting patients about the medicines you prescribe, you will have to try to change your habits.

What would you explore with a patient with a sustained blood pressure of 190/110 mm Hg?

How would you feel and what would you do if a patient with a sustained blood pressure of 190/110 mm Hg decided not to take antihypertensives?