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EDITORIALS: Knut Schroeder and Tom Fahey Improving adherence to drugs for hypertension BMJ 2007; 335: 1002-1003 [Full text]

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Education must include all effective treatments

David J. Reinhardt   (17 November 2007)

Value of non-pharmacological interventions is limited in hypertension

Knut Schroeder, Tom Fahey   (24 November 2007)

Education must include all effective treatments 17 November 2007
David J. Reinhardt, Health Psychologist Long Beach, California 90808 Send response to journal: Re: Education must include all effective treatments	BMJ's editorial "Improving adherence to drugs for hypertension" and the research article "Effect of general practitioner education on adherence to antihypertensive drugs: cluster randomised controlled trial" both fail to identify the real causes of poor adherence. Yes, physician education is vital, but adherence goals will never be reached by continuing to push antihypertensives as the only solution, as presented in the study. In this age of the internet patients can easy access medical information, and misinformation. They know that antihypertensives commonly cause fatigue, pain and sexual dysfunction. They also know that blood pressure can be reduced by biofeedback, relaxation and other psychotherapies, lifestyle changes, dietary changes, and a number of natural substances such as raw garlic, (as pointed out in Minerva in the same issue of BMJ.) A more effective educational program would have physicians becoming more knowledgeable of scientifically proven, less harmful ways to reduce blood pressure, and help them come up with effective, graduated treatment plans so that patients would be empowered. Patients will be more willing to comply with meds if and when they have proven to themselves that meds are necessary and that less harmful approaches have failed. To be credible, the physician must become the expert in blood pressure control, and not the expert in giving our antihypertensives. Competing interests: None declared
Value of non-pharmacological interventions is limited in hypertension 24 November 2007
Knut Schroeder, General Practitioner and Honorary Senior Clinical Lecturer, University of Bristol The Stokes Medical Centre, Tom Fahey Send response to journal: Re: Value of non-pharmacological interventions is limited in hypertension	David J Reinhard is incorrect in saying that the study by Qureshi et.al. presented the use of antihypertensives as the only solution. The authors clearly state that components of the training course for general practitioners included non-pharmacological as well as pharmacological interventions, as outlined in their ‘methods’ section. We agree that non- pharmacological interventions can be helpful in the initial treatment of mild hypertension with no complications of cardiovascular disease or damage to target organs, or as an adjunct to pharmacological therapies in more severe hypertension,(1) (2) (3) as advised by national and international guidelines.(4) However, their value is limited in that reductions in blood pressure are usually small (only about 1mmHg for salt reduction, for example),(3) and their effect on reducing morbidity and mortality from cardiovascular disease has not been proven.(1) (2) (3) The role of raw garlic and other treatments mentioned by David J Reinhard has as far as we are aware not been fully evaluated for the treatment of hypertension in primary care. In Qureshi’s study, general practitioners were indeed trained in how to provide satisfactory consultation sessions for patients and how to explain treatment. In our accompanying editorial we discussed issues around increasing adherence to drugs for hypertension, assuming that these would only be prescribed according to guidelines and in those patients in whom they are clinically indicated, that is, after non-pharmacological and lifestyle measures have failed to take the desired effect. References: (1) Mulrow CD, Chiquette E, Angel L, Cornell J, Summerbell C, Anagnostelis B, Brand M, Grimm R Jr. Dieting to reduce body weight for controlling hypertension in adults. Cochrane Database of Systematic Reviews 1998, Issue 3. Art. No.: CD000484. DOI: 10.1002/14651858.CD000484 (2) He FJ, MacGregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD004937. DOI: 10.1002/14651858.CD004937 (3) Hooper L, Bartlett C, Davey Smith G, Ebrahim S. Advice to reduce dietary salt for prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003656. DOI: 10.1002/14651858.CD003656.pub2 (4) Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, Sever PS, Thom SMG; for the BHS guidelines working party. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. British Hypertension Society. BMJ 2004;328:634–40. Competing interests: None declared