Medical Academic (MA): What do you consider the most common patient-related barriers to long-term hypertension medication adherence?

Prof Brian Rayner (BR): Hypertension is generally an asymptomatic condition, and unless patients receive adequate education, they may not appreciate the importance of treatment. By three- to six-month, ~40% of patients are either not taking their medication or are taking it irregularly. Medication side effects are another barrier, although these can often be managed by adjusting or changing therapy. Administrative and system-level issues are also important, including access to appropriate medication, cost, and the need for repeat prescriptions in both public and private sectors. Pill burden due to comorbid conditions is another key factor. Strategies such as pill boxes and single-pill combination therapy can help reduce this burden. In older patients, memory impairment is also an important contributor to non-adherence.

MA: In your experience, how significant is the impact of medication burden, including side effects and complex regimens, on treatment adherence?

BR: Pill burden is highly important. Hypertension is often associated with multiple comorbidities, and patients may be taking more than five different medications. Studies have shown that increasing the number of tablets directly reduces adherence. In addition, once-daily dosing is preferable, as adherence declines further with twice- or three-times-daily regimens. Wherever possible, 24-hour acting medications should be used, ideally in single-pill combinations.

MA: How does clinical inertia among healthcare providers contribute to suboptimal BP control in practice?

BR: This is a significant issue. Failure by healthcare professionals to escalate or modify therapy appropriately is a global problem. Auditing organisational or individual clinical practice is an important first step in assessing the scale of the problem and implementing strategies to address it.

MA: What role do comorbidities such as diabetes, obesity, and chronic kidney disease play in complicating hypertension management?

BR: These comorbidities increase the risk of adverse outcomes and make hypertension more difficult to control, often requiring three or more antihypertensive agents. Pill burden is therefore a major challenge in managing these patients.

MA: How important is lifestyle modification in the long-term management of hypertension, alongside pharmacological therapy?

BR: Lifestyle modification is crucial. It assists in BP control and reduces the risk of adverse CV outcomes.

Table 1: European Society of Cardiology (ESC) lifestyle recommendations for BP and CVD risk reduction¹

MA: How do you approach patient selection and determine the appropriate time to initiate antihypertensive treatment?

BR: Most guidelines recommend initiating pharmacological therapy once hypertension is diagnosed, alongside lifestyle modification. The intensity of treatment is guided by the severity of hypertension. For example, if BP is >160/100mmHg, two agents are generally recommended, usually as a single-pill combination.

Table 2: BP classification according to the European Society of Hypertension and the ESC guidelines²

MA: At what point do you decide to escalate the dose or switch to an alternative antihypertensive agent in clinical practice?

BR: This depends on the severity of hypertension. In patients with blood pressure >180/110mmHg, escalation may occur within one week. On average, however, response is assessed over ~4- to 6-weeks before adjusting therapy.

Conclusion

Hypertension management remains a long-term, multifaceted challenge that extends beyond simply prescribing medication. As highlighted by Prof Rayner, successful BP control depends on addressing patient-related barriers, reducing pill burden, improving adherence, and overcoming clinical inertia within healthcare systems. Comorbidities such as diabetes, obesity, and chronic kidney disease further complicate treatment and often necessitate combination therapy. Lifestyle modification remains a cornerstone of care and should accompany pharmacological intervention at every stage. Ultimately, optimal outcomes are achieved through early treatment initiation, timely escalation when needed, and a patient-centred approach that integrates education, simplicity of regimens, and sustained clinical follow-up.

Additional reading

1.      McEvoy JW, McCarthy CP, Bruno RM, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension Developed by the task force on the management of elevated blood pressure and hypertension of the European Society of Cardiology (ESC) and endorsed by the European Society of Endocrinology (ESE) and the European Stroke Organisation (ESO). European Heart Journal, 2024.

2.      Zeniodi ME, Tsaganos T, Menti A, et al. European Hypertension Guidelines: Similarities and What the Practicing Physician Should Keep in Mind. J Clin Med, 2026.

Prof Brian Rayner is Senior Research Scholar in the Division of Nephrology and Hypertension at the University of Cape Town (UCT) and a past President of the Southern African Hypertension Society. He graduated MBChB from UCT in 1978, obtained Fellowship of the College of Medicine of South Africa in 1986, and holds a Master of Medicine and PhD from the University of Cape Town, with doctoral work focused on salt sensitivity in indigenous South African populations. He received the World Hypertension League Award for Notable Achievement in Hypertension in 2014. His research spans hypertension, kidney disease, genetics, and clinical guidelines, with extensive publications and international academic contributions.

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