Exploratory Research in Clinical and Social Pharmacy 11 (2023) 100313

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Exploratory Research in Clinical and Social Pharmacy

journal homepage: www.elsevier.com/locate/rcsop

Hypertension management and drug-related problems. A case report of the

23-year history of Mr. Jonas
Indre Treciokiene a, b, *, Jurate Peceliuniene b, c, Bjorn Wettermark b, d, Jolanta Gulbinovic e,
Katja Taxis a
a
Department of PharmacoTherapy, -Epidemiology & -Economics, Faculty of Science and Engineering, University of Groningen, Antonius Deusinglaan 1, 9713, AV,
Groningen, Netherlands
b
Pharmacy and Pharmacology center, Institute of Biomedical Science, Faculty of Medicine, Vilnius University, M. K. Ciurlionio str.21, 03101 Vilnius, Lithuania
c
Clinic of Internal Diseases, Family Medicine and Oncology, Faculty of Medicine, Vilnius University, M. K. Ciurlionio str.21, 03101 Vilnius, Lithuania
d
Department of Pharmacy, Faculty of Pharmacy, Uppsala University, Husargatan 3, 752 37 Uppsala, Sweden
e
Department of Pathology, Forensic Medicine and Pharmacology, Faculty of Medicine, Vilnius University, M. K. Ciurlionio str.21, 03101 Vilnius, Lithuania

A R T I C L E I N F O A B S T R A C T

Keywords: Arterial hypertension is a lifelong disease, which management is recognized as the most effective way to reduce
Hypertension cardiovascular mortality. Even though there is extensive evidence on the benefits of lifestyle modification and
Hypertension management antihypertensive treatment, many patients with hypertension do not reach blood pressure targets. This paper
Drug related problems
aims to review the history of antihypertensive treatment of one patient and identify the drug related problems
Pharmacistintervention
that occurred over the study period. In this case report, the patient’s health record was studied, guidelines
checked and a semi-structured interview conducted. Drug related problems were identified and possible phar­
macist interventions were introduced. Drug related problems that could have contributed to the lack of hyper­
tension control were adherence, side effects and disease-drug interaction. Identified pharmacists’ interventions
ranged from managing self-medication, to collaboration with general practitioner to change prescribing, and
counselling the patient on medication use, including adherence. Even though the drug related problems were not
that serious in the studied case, the patient could have valued from pharmacist intervention.

1. Background comprehensive prevention strategies at the individual and population

level. International guidelines emphasize the importance of an inter­
Globally, it is estimated that 32% of adult men and 34% of adult disciplinary team approach in the management of CVD.8 A team
women have hypertension.1Arterial hypertension (AH) is considered the approach that includes a pharmacist appears to represent the most
number one risk factor for mortality and morbidity from cardiovascular efficient healthcare delivery model, as pharmacist interventions have
diseases (CVDs). Despite the extensive evidence of benefits of lifestyle been shown effective for most patients with cardiovascular diseases.9
interventions and antihypertensive treatment, many patients with AH Examples of effective pharmacist interventions include counselling,
do not reach target blood pressures.2,3Treatment coverage is at most health education, and medication review.10 But practical integration of
80% and control rates were <70% in high income countries.4 Subopti­ pharmacists in multidisciplinary teams to manage CVD seem to be
mal adherence with medication, which includes failure to initiate advancing only slowly. Therefore, we use a clinical case following a
pharmacotherapy, to take medications as often as prescribed, and to patient with hypertension over a long time, to illustrate and discuss the
persist on therapy are long-term are factors contributing to the poor role of the pharmacist in management of those problems. The case report
control of blood pressure.5 Patients’ beliefs about hypertension and its is from Lithuania, a country where around 32% of the adult population
treatment, low health literacy and lack of social support are some of the has a diagnosis of arterial hypertension11 which makes hypertension one
underlying barriers for lack of adherence.6,7 of the most prevalent chronic diseases in the country.12
Successful control of hypertension can be achieved through The aim of this clinical case report is to explore the history of a male

* Corresponding author at: Faculty of Medicine, Vilnius University, M. K. Ciurlionio str. 21, 03101 Vilnius, Lithuania.
E-mail addresses: [email protected], [email protected] (I. Treciokiene), [email protected] (J. Peceliuniene), bjorn.wettermark@farmaci.
uu.se (B. Wettermark), [email protected] (J. Gulbinovic), [email protected] (K. Taxis).

https://doi.org/10.1016/j.rcsop.2023.100313
Received 20 July 2023; Accepted 21 July 2023
Available online 24 July 2023
2667-2766/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
I. Treciokiene et al. Exploratory Research in Clinical and Social Pharmacy 11 (2023) 100313

(65 years) patient with hypertension, to review his over 20 years’ The patient was also prescribed some other medications over time,
antihypertensive treatment and identify the drug related problems that including pentoxifylline for flickering in the eyes and numbness in the
occurred over time with a focus on the role of the pharmacist in man­ limbs, nimesulide and diclofenac for upper back and neck pain. Some
aging those problems. episodes of infectious diseases were recorded with antibiotics and an­
tivirals prescribed. His health record reveals use of some over-the-
2. Case presentation counter (OTC) medicines and food supplements that were suggested to
him, such as the cough medicine ambroxol and some medicines to
Mr. Jonas is a white Lithuanian man, first diagnosed with hyper­ relieve flu symptoms such as pseudoephedrine, along with magnesium,
tension in November 1998. Over the studied period, Mr. Jonas had 207 vitamin B6 and Omega-3 supplements. For some stomach pain episodes’
general practitioner (GP) visits recorded, with0 an average 9 visits a omeprazole and ranitidine were prescribed concordantly. The record
year. At the first record visit in 1998, Mr. Jonas is a 41 years old chief also showed that silymarin 140 mg tablets were prescribed several times
executive at higher education school who visited the GP with symptoms for fatty liver. In 2021, the patient took 3 medications chronically. Di­
of flickering in the eyes and numbness in the limbs. Lipids and glucose agnoses, the medicines prescribed, and last test results recorded are
level were not documented at that time. His blood pressure (BP) was presented in Table 1.
measured as 150/110 mmHg. There was no information in the record
how BP was measured. The GP prescribed a beta blocker atenolol 25 mg 3. Drug related problems over time
twice a day for 25 days. No further GP visits were documented until
January 2000, when he visited the GP with complaints of dryness of the A general practitioner (JP, unrelated to the patient) and a pharma­
mouth and thirst. In that year, Mr. Jonas was diagnosed as being hy­ cist, (IT, daughter of the patient), both not previously involved in pa­
pertensive (160/100 mmHg), having elevated glucose level (5.9 mmol/l tient’s treatment, studied the patient’s medical record from the GP
(106 mg/dl) and being obese. No medicines were prescribed then. From practice, taking relevant treatment guidelines for hypertension into
March 2001 onwards he was prescribed antihypertensive medication, account.
initially a beta blocker (nebivolol 5 mg) and a calcium channel blocker Over the span of the 23 years, European hypertension management
(nitrendipine 20 mg). From that point Mr. Jonas renewed his pre­ guidelines had changed several times.13–16 The changes of drug classes
scriptions for antihypertensives regularly. Over the following years, his and combinations prescribed for the patient, might be due to those
antihypertensive medication was changed from time to time, switching changes. In general, prescribing was in line with the guidelines, even the
within and between drug classes, ranging from monotherapy to triple use of rilmenidine was recommended as an additional treatment in
therapy. His BP ranged between 130/100 mmHg and 160/100 mmHg in Lithuanian guidelines when it was prescribed. The main reason for the
this period. From 2010 onwards, he received some of his antihyper­ frequent GP visits was probably the need for medicines to be prescribed
tensives as fixed-dose combination. as reimbursed medicines could be prescribed for the maximum period of
In 2008, he was prescribed rilmenidine, a centrally acting agent 3 months till the beginning of 2014.17
rarely used in hypertension management, for about 5 years. He was The patient gave written consent. A semi structured interview was
found to have dyslipidemia and was prescribed fenofibrate for two conducted with the patient and patients’ comments on distinguished
months in 2007 and atorvastatin for three months in 2008. Over the episodes were collected (Table 2). The patients’ medical record and the
years, cardiovascular disease risk was not formally assessed. There were patient information from an interview was used to identify drug related
no hospitalizations due to hypertension. He also had a thyroidectomy problems in the studied period.
and levothyroxine treatment was started in 2010. The patient was Drug related problems were classified using PCNE Classification for
diagnosed with type 2 diabetes in 2019 and metformin 1000 mg was Drug-Related Problems V9.1.18. Possible interventions were also sug­
prescribed twice a day. The patient stayed with the same primary care gested using the same PCNE tool. Identified problems, causes and
practice over the whole study period. The treating GP changed in 2016. possible pharmacist’s interventions are presented in Table 3.
Fig. 1 shows the timeline of the prescribed antihypertensives and According to medical health record patient was not consulted on
Fig. 2 the timeline of his diagnoses between 1998 and 2021. lifestyle change (diet, smoking cessation) and no educational

Fig. 1. Time line of antihypertensive medicines initiated and office blood pressure (BP) at time of prescription The atenolol was only prescribed once; the other
medicines were prescribed regularly until the treatment was changed.
* Fixed combinations.
BP – office blood pressure where first number is systolic blood pressure (SBP), second – diastolic blood pressure (DBP), measurements in mmHg.
Note: only time points when the treatment was initiated or changed are showed in this time line; patient continued to use prescribed medications, accept atenolol
started 1998.

2
I. Treciokiene et al. Exploratory Research in Clinical and Social Pharmacy 11 (2023) 100313

Fig. 2. Chronic non-communicable diseases recorded in the patients’ medical record from 1998 to 2021.
Note: diagnoses that have been suspected, but rejected or specified and acute diagnoses like pain, infectious diseases are not recorded in this figure.

Table 1
Diagnoses recorded and medicines prescribed at the end of 2021.
Diagnose Diagnose Medication ATC code Use recommendation Test results Norms
code*

I11.9 Hypertensive heart disease without Perindopril et amlodipine 10/ C09BB04 Once a day in the morning SBP 144 mmHg <135
heart failure 10 mg** DBP 85 mmHg <85
E11.9 Type 2 diabetes mellitus without Metformin 1000 mg** A10BA02 Twice a day morning and TC 4.10 mmol/l (158,55 0.90-
complications evening mg/dl) 8.40
LDL 2.42 mmol/l (93.58 0.00-
g/dl) 3.37
TG 1.5 mmol/l (58.00 0.00-
mg/dl) 1.70
HbA1c 5.4% 4,0-6,0
CREA 65 mcmol/l*** 59-104
E89.0 Postprocedural hypothyroidism Levothyroxine 75 μg** H03AA01 Once a day in the morning TSH 4.14 mclU/ml 0.25-
5.00
E55.9**** Vitamin D deficiency, unspecified Colecalciferol 25000TV A11CC05 Once a week (8 weeks) –
K29.9 Gastroduodenitis, unspecified Esomeprazole 40 mg A02BC05 Once a day (2 month) –
E66.0 Obesity due to excess calories –
H40.0 Glaucoma suspect –
H52.1 Myopia –
H25.0 Age-related incipient cataract –

SBP – systolic blood pressure, DBP – diastolic blood pressure, TC- total cholesterol, LDL – low density cholesterol, TG- triglycerides, HbA1c - haemoglobin A1c, TSH -
thyroid-stimulating hormone, CREA – creatinine.
*
ICD-10-AM (The International Statistical Classification of Diseases and Related Health Problems).
**
medications taken chronically.
***
possible because CREA was in norms, other renal function tests were not performed.
****
no record of vitamin D concentration test was found.

intervention to address cardiovascular risk or cardiovascular disease/ 4. Discussion

hypertension management was recorded. The patient did not recall that
he was informed about cardiovascular risk either. His first diet and Over the time span of 23 years of hypertension, Mr. Jonas’ treatment
physical activity recommendation were recorded in 2005 by his general has been revised several times. Mr. Jonas visited the doctor regularly.
practitioner. During this time the patient developed comorbidities such as diabetes

3
I. Treciokiene et al. Exploratory Research in Clinical and Social Pharmacy 11 (2023) 100313

Table 2 pharmacists’ work, other interventions require additional efforts and

Patient’s comments about different episodes. service implementation. Medication review interventions have been
Episode from the medical record Patient’s comments from the semi- found to be effective, not only in detecting and solving drug related
structured interview problems, but also improving cardiovascular disease management -
Initiation of treatment with BB Patient did not remember the episode control of blood pressure, cholesterol, and type 2 diabetes mellitus22 and
(Atenolol) when he was first prescribed
SBP23,24. Medication reviews vary from a brief revision of the prescribed
antihypertensive treatment.
Continuation of treatment with BB Patient was provided with some leaflets medicines to more complex interventions involving interdisciplinary
(Nebivolol) about DASH diet and home BP monitoring, teams (patients, physicians and other health care professionals), which
but he failed following the allow the detection of pharmacological interactions and medicine-
recommendations. He was in a responsible related problems such as adverse drug reactions, effectiveness prob­
stressful job position. He took medicines
lems, non-adherence, and self-medication. More advanced interventions
prescribed daily, but did not feel ok, his
home BP was not stable, he had require an integrated, interdisciplinary approach and improve pro­
experienced headaches, tension and fessionals’ guideline adherence, support informed decision-making and
tinnitus often. Patient had doubts whether patient-centred care.8,25Pharmacist-led interventions in hypertension
these were because of his job or the
have been shown to improve adherence.26,27 Examples include
treatment.
Starting free combination therapy with He often failed to takemedicines three employing special medication packaging, dose modification, patient
ACEi plus CCB (Quinapril and times a day. This medication regimen was self-monitoring of medication-taking and written instructions.28 More
Lacidipin) difficult to adapt to the work/day specifically, when antihypertensive treatment is started patient educa­
schedule. tion, including addressing motivation, teaching blood pressure moni­
Use of OTC medicines with When he used hot flu drink his BP
toring and emphasizing medication adherence could be provided. A
Pseudoephedrine increased. He thought it was because of
virus infection and didn’t link it with the recent study showed that such adherence enhancing interventions
medicine taken. In later years he used the improved patients’ BP control and medication adherence and increased
same medicine for similar flu symptoms adherence correlated with improved BP control.29 Additional pharma­
until he was recommended other
cist intervention could also have addressed life style changes 30,
medicines in the pharmacy.
Possible adverse drug reactions No side effects were noted by patient.
including smoking cessation.31
When pharmacist had specified some In some countries pharmacists already play an important role in
possible events, patient reported that management of chronic diseases.32 A number of advanced services are
sometimes/rarely: common and offered in >50 countries worldwide, including medication
reviews, disease management programmes (diabetes, hypertension,
• his head spins when he stands up
quickly, and sudden movements are asthma) as well as measuring of clinical parameters (blood pressure,
avoided blood sugar, body mass index etc.). Cardiovascular disease primary and
• drowsiness takes over in the middle of secondary prevention is done mainly through patient education and
the day, especially after eating.
counselling, medication safety management, medication review, moni­
• has a dry mouth.
• patient reported that he gets up 2-3
toring and reconciliation, detection, and control of specific risk factors,
times at night to go to the toilet, but this e.g., smoking cessation. Screening individuals at-risk who are not on
does not bother him. medication are provided in some pharmacies in 26, first time dispensing
• patient had no constipation, in fact quit interventions (New Medicines Service) in 5 and therapeutic adherence
opposite.
support in 4 European countries. Medication review services such as
Adherence to medications Patient admitted that sometimes he forgets
to take his morning metformin dose, but medication therapy management, home medicines review and medi­
not other medicines. Overall patient was cines use review have been offered by community pharmacists in several
satisfied with the treatment and felt that countries.33,34
his condition is under control. In Lithuania no services beyond dispensing are implemented in
BB – beta blocker, ACEi – angiotensin converting enzyme inhibitor, CCB – cal­ pharmacies except inhaler technique service for asthma or COPD pa­
cium channel blocker, OTC – over-the-counter. tients. The only service that might directly enhance adherence is
authorization to dispense 30 days’ supply of prescription medicines to
and hyperlipidaemia. He had a thyroidectomy, but was never hospital­ chronic patients with evidence of previous prescription. This interven­
ized due to hypertension. According to the recorded office-blood pres­ tion only addresses a logistical barrier to adherence – renewal of med­
sure measurements, the patient never reached the target BP. At least icines, but not other factors contributing to medication adherence.35
eight drug related problems, four of which were related to hypertension Despite the evidence that pharmacists can improve clinical outcomes
treatment were identified. in a wide array of chronic diseases36 there are structural barriers and
The drug related problems were adherence, side effects, and disease barriers due to the perception of pharmacists and or other health pro­
drug interaction. Those drug related problems are very common in fessionals to implement services. For example, in Lithuania, pharmacists
practice 19 and are very typical in a lifelong disease treatment. The are seen as pharmaceutical care specialists that do not provide health
problems identified were clinically not very serious, but had impact on care or disease management services.37 This influences the perception of
the patient’s overall wellbeing. Furthermore, some of the drug related pharmacists’ competencies and limits pharmacy services to dispensing
problems contributed to the lack of hypertension control which only thus preventing pharmacy intervention programs or pharmacist
increased the patient’s risk for CVDs. Other drug related problems were involvement in interdisciplinary teams in Lithuania. The main structural
not related to hypertension treatment, but were related to the patient’s barriers for pharmacy services include lack of comprehensive access to
co-morbidities and polypharmacy. Unnecessary drug use is also common medical records and lack of remuneration. A related issue is poor,
in practice.20,21 sometimes non-existent, collaboration between the different healthcare
We identified a number of possible pharmacist-led interventions to professionals.38
solve the drug related problems. These interventions ranged from A case report, as a research design has limitations, yet describes
managing self-medication to collaboration with the GP to change pre­ important scientific observations that are encountered in practice to
scribing and counselling of the patient on medication use, including expand our knowledge base. Limitations of this report include possi­
adherence. While managing self-medication is a daily routine of bility of recall bias and that some drug related problems were missed.
Also, no information on pharmacies’ activities in practice was recorded.

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Table 3
Drug related problems and possible pharmacist’s interventions identified.
Year Description Problem Cause Possible pharmacist’s
interventions

1998 Patient diagnosed with hypertension and prescribed P1.3 Untreated C7.1 Patient intentionally uses/takes less drug I2.1 Patient (drug)
with beta blocker; treatment was discontinued symptoms or indication than prescribed or counselling
does not take the drug at all for whatever reason
2000- Patient prescribed with beta blocker; patient P2.1 Adverse drug C1.1 Inappropriate drug according to I1.3 Intervention proposed to
2002 complaining having headache at every visit to GP event (possibly) guidelines/formulary prescriber
occurring I2.1 Patient (drug)
counselling
I3.1 Drug changed to other
antihypertensive.
2004- Combination of ACEi, CCB and diuretic prescribed; gaps P1.2 Effect of drug C7.1 Patient intentionally uses/takes less drug I2.1 Patient (drug)
2005 from 20 to 40 days with no medication were detected in treatment not optimal than prescribed or counselling
the health record. does not take the drug at all for whatever reason
2007 Pseudoephedrine combination*prescribed; BP increased P2.1 Adverse drug C1.1 Inappropriate drug according to I1.1 Prescriber informed only
event (possibly) guidelines/formulary C5.3 Wrong drug, strength I2.1 Patient (drug)
occurring or dosage advised (OTC) counselling
I3.1 Drug changed to other
symptoms relieving OTC
2017 Patient prescribed with omeprazole and ranitidine at the P3.1 Unnecessary drug- C1.4 Inappropriate duplications of therapeutic I1.4 Intervention discussed
same time. treatment group or active with prescriber
ingredient I3.5 Drug paused or stopped
2017- Silymarin was prescribed and recommended to be used P3.1 Unnecessary drug- C1.2 No indication for drug I1.4 Intervention discussed
2020 from time to time further for “fatty liver” treatment with prescriber
I3.5 Drug paused or stopped
2021 Patient forgets to take his Metformin tablets P1.2 Effect of drug C7.1 Patient intentionally uses/takes less drug I2.1 Patient (drug)
treatment not optimal than prescribed or does not take the drug at all counselling
for whatever reason
2021 Indication for Cholecalciferol 25000TV was not P3.1 Unnecessary drug- C1.2 No indication for drug I1.4 Intervention discussed
supported by test results treatment with prescriber
I3.1 Drug changed to food
supplement
*
Pseudoephedrine combinations are OTC medicines in Lithuania, yet it could also be prescribed by the doctor and in this case is considered as prescribed, as it is
recorded in the medical record of the patient.

Furthermore, we focused on the possible role of the pharmacist in this References

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