Half of patients do not take meds as prescribed, yet no effective interventions in place

General Practice

When patients do not take their medications as prescribed, it can significantly impact on their health outcomes. Now, an updated review assessing previous research that aimed to tackle this issue suggests there are no effective approaches to help these patients.


The research, led by Robby Nieuwlaat at McMaster University in Canada, is published in The Cochrane Library.

Previous studies have found that patients prescribed medicines only take about half of their doses, and many stop their treatment entirely. In other cases, patients do not properly follow the instructions for taking their meds.

But when effective drug treatments are available for a condition, they can significantly improve the patient’s health, according to medical experts. As such, researchers have tested ways to assist in better adherence to medication.

The team from this updated study reviewed data from 182 such trials that tested different approaches aiming to increase medication adherence and, as a result, to increase patient health.

However, though the current review included the best studies on the topic to date, many of them had problems in design, making it difficult to identify which approaches were effective. What is more, trial evidence was often “unreliable and inconsistent.”

In detail, the team found that the studies differed widely in terms of patients, treatments, adherence intervention types, medicine adherence measurement and clinical outcomes.

“The studies varied so much in terms of their design and their results that it would have been misleading to try to come up with general conclusions,” says Nieuwlaat.

Only five trials suggested improvements in adherence and patient health

To conduct their analysis, the team assessed trials studying various medical conditions, including HIV and psychiatric disorders, as well as those that trialled medication adherence interventions.

The reason it was difficult for the researchers to come to any conclusions about whether any of the interventions was effective is that they all showed wide-ranging effects on adherence and patient health. In addition, the effects were measured using wide-ranging methods.

Many of the trials were unreliable on their own, casting doubt on the validity of their results. As such, Nieuwlaat says there need to be “larger and higher quality trials, which better take in account individual patient’s problems with adherence.”

Of the 182 trials they reviewed, the researchers found that only 17 were of high quality because they tested combinations of different approaches, including family and pharmacist support, education and counselling.

And only five of these trials suggested improvements in health outcomes for patients and increased medication adherence.

Commenting on their findings, the researchers write:

“It is uncertain how medicine adherence can consistently be improved so that the full health benefits of medicines can be realized. We need more advanced methods for researching ways to improve medicine adherence, including better interventions, better ways of measuring adherence and studies that include sufficient patients to draw conclusions on clinically important effects.”

As a result of their findings, the team is calling on the research community as a whole to come together to address these issues. They have even created a database of the trials from their review so that they can be made available for more in-depth analyses.

“By making our comprehensive database available for sharing,” says Nieuwlaat, “we hope to contribute to the design of better trials and interventions for medication adherence.”

“We need to avoid repeating the painful lessons of adherence research to date and begin with interventions that have shown some promise, or at least have not produced repeatedly negative results,” he concludes.

A recent study from Washington University School of Medicine in St. Louis suggested that coaching parents over the phone improves children’s asthma treatment.

Written by Marie Ellis




The heart’s own immune cells can help it heal


The heart holds its own pool of immune cells capable of helping it heal after injury, according to new research in mice at Washington University School of Medicine in St. Louis.

Most of the time when the heart is injured, these beneficial immune cells are supplanted by immune cells from the bone marrow, which are spurred to converge in the heart and cause inflammation that leads to further damage. In both cases, these immune cells are called macrophages, whether they reside in the heart or arrive from the bone marrow. Although they share a name, where they originate appears to determine whether they are helpful are harmful to an injured heart.

In a mouse model of heart failure, the researchers showed that blocking the bone marrow’s macrophages from entering the heart protects the organ’s beneficial pool of macrophages, allowing them to remain in the heart, where they promote regeneration and recovery. The findings may have implications for treating heart failure in humans.

The study is now available in The Proceedings of the National Academy of Sciences Early Edition.

“Researchers have known for a long time that the neonatal mouse heart can recover well from injury, and in some cases can even regenerate,” said first author Kory J. Lavine, MD, PhD, instructor in medicine. “If you cut off the lower tip of the neonatal mouse heart, it can grow back. But if you do the same thing to an adult mouse heart, it forms scar tissue.”

This disparity in healing capacity was long a mystery because the same immune cells appeared responsible for both repair and damage. Until recently, it was impossible to distinguish the helpful macrophages that reside in the heart from the harmful ones that arrive from the bone marrow.

The new research and past work by the same group – led by Douglas L. Mann, MD, the Tobias and Hortense Lewin Professor of Medicine and cardiologist-in-chief at Barnes-Jewish Hospital – appear to implicate these immune cells of different origins as responsible for the difference in healing capacity seen in neonatal and adult hearts, at least in mice.

“The same macrophages that promote healing after injury in the neonatal heart also are present in the adult heart, but they seem to go away with injury,” Lavine said. “This may explain why the young heart can recover while the adult heart can’t.”

Because they are interested in human heart failure, Lavine and his colleagues developed a method to progressively damage mouse cardiac tissue in a way that mimicked heart failure. They compared the immune response to cardiac damage in neonatal and adult mouse hearts.

The investigators found that the helpful macrophages originate in the embryonic heart and harmful macrophages originate in the bone marrow and could be distinguished by whether they express a protein on their surface called CCR2. Macrophages without CCR2 originate in the heart; those with CCR2 come from the bone marrow, the research showed.

Lavine and his colleagues asked whether a compound that inhibits the CCR2 protein would block the bone marrow’s macrophages from entering the heart.

“When we did that, we found that the macrophages from the bone marrow did not come in,” Lavine said. “And the macrophages native to the heart remained. We saw reduced inflammation in these injured adult hearts, less oxidative damage and improved repair. We also saw new blood vessel growth. By blocking the CCR2 signaling, we were able to keep the resident macrophages around and promote repair.”

Some CCR2 inhibitors are being tested in phase 1 and 2 clinical trials for treating rheumatoid arthritis. But before these drugs can be evaluated in people with heart failure, more work must be done to find out whether the same mechanisms are at work in human hearts, according to the researchers.

“We have identified similar immune cell subtypes that are present in the human heart,” Lavine said. “We need to find out more about their roles in heart failure in patients and understand more about how macrophages that reside in the heart promote repair.”




Heightened risk of anxiety, depression among women after heart attack


A new study by researchers from Lithuania claims women are more likely to experience anxiety and depression following a heart attack than men. Furthermore, patients with depression may be at much higher risk of death in the 6 months after a heart attack than those without depression.


Study author Prof. Pranas Serpytis and colleagues presented their findings at the annual meeting of the Acute Cardiovascular Care Association – a part of the European Society of Cardiology – in Geneva, Switzerland.

To reach their findings, the team analyzed 160 patients who were admitted to the Vilnius University Hospital Santariskiu Clinics in Vilnius, Lithuania, with a heart attack.

The researchers interviewed patients around 1 month after their heart attack to gather demographic information, such as age, sex education and marital status, and to determine whether they had a history of mental illness.

The team also collected clinical information from the patients – such as whether they had experienced a heart attack before and whether they had a history of high blood pressure or diabetes – and determined if they had any other risk factors for cardiovascular disease, including smoking and lack of physical activity.

The Hospital Anxiety and Depression Scale (HADS) was used to assess patients. Those who had a score of 0-7 had nodepression or anxiety, a score of 8-10 indicated possible depression and anxiety, while a score of 11 or more suggested mild to moderate levels of depression and anxiety.

The risks of anxiety, depression and death after heart attack

Almost 25% of patients were depressed, the researchers say, and 28.2% of these had used antidepressants.

The team found, however, that women were more likely to be depressed and anxious than men after a heart attack. Men had an average depression score of 6.87, while women’s average score was 8.66. For anxiety, men had an average HADS score of 7.18 and women had an average score of 8.20.

The researchers say that further studies are needed to determine why women appear to be at higher risk of anxiety and depression following a heart attack than men.

Commenting on this finding, Prof. Serpytis says:

“Women are misrepresented in many clinical studies on myocardial infarction (heart attack) even though they often have worse outcomes. Our study shows that women are more likely to develop anxiety and depression after myocardial infarction than men but until now this issue has been largely unnoticed.

Clinicians should assess myocardial infarction patients, particularly women, for anxiety and depression so that timely treatment can be started.”

Earlier this year, Medical News Today reported on a study suggesting the reverse effect – that depressed women are at higher risk of heart attack.

The researchers of this latest study also found that patients with depression following a heart attack were almost six times more likely to die in the 6 months after a heart attack, compared with patients who were not depressed.

“Major depression follows myocardial infarction in approximately 18% of cases and is an important predictor of disability and poor quality of life in the year post-myocardial infarction,” notes Prof. Serpytis.

“The increased risk of death in patients with depression persists up to 18 months after the myocardial infarction. But despite the fact that post-myocardial infarction depression is common and burdensome, the condition remains under-recognised and undertreated.”

Smoking increases anxiety risk, while lack of physical activity linked to depression

Furthermore, the team found an increased risk of anxiety among patients who smoked; the average HADS score for anxiety among smoking patients was 10.16, compared with an average score of 7.3 for patients who had never smoked and 4.55 for patients who stopped smoking more than 2 years before.

No link was found between smoking and depression after a heart attack, the researchers say.

However, a small link was found between lack of physical activity and depression. The 64% of patients who were physically inactive had an average HADS depression score of 8.96.

Commenting on the team’s overall findings, Prof. Serpytis says:

“Our study suggests that encouraging patients to quit smoking and increase their physical activity levels should reduce their risks of anxiety and depression after myocardial infarction. More research is needed on the links between myocardial infarction and mental health problems.”

MNT recently reported on a study by researchers from Duke University Medical Center in Durham, NC, claiming theeffects of mental stress on the heart differ between men and women.

Written by Honor Whiteman




Genetic test reveals risk of atrial fibrillation and stroke


Many of those who are genetically predisposed to develop atrial fibrillation, which dramatically raises the risk of stroke, can be identified with a blood test. This is shown by new research from Lund University in Sweden.

The number of people affected by atrial fibrillation is rising rapidly, partly as a result of the ageing population.

Over recent years, a research group at Lund University in Sweden, working with other universities and hospitals in Europe and the USA, has identified twelve genetic variants in the human genome that increase the risk of atrial fibrillation. The research group has now studied the possible clinical benefits of a DNA test:

“One in five people have a genetic weakness that means they have twice as high a risk of developing atrial fibrillation as those with a low genetic risk. This genetic risk is therefore one of the strongest risk factors for atrial fibrillation that we know of in people without overt cardiac disease. It increases the risk as much as high blood pressure, for example”, said Olle Melander, Professor of Internal Medicine, and Gustav Smith, Associate Professor in Cardiology, both from Lund University.

Since the symptoms of atrial flutter can be weak and unclear, they are sometimes difficult to pick up. However, even those with weak or absent symptoms of atrial flutter are at significantly higher risk of stroke.

“In patients who are suspected of having temporary but recurrent episodes of atrial fibrillation, or in people with high blood pressure, it can be important for doctors to look at their genetic predisposition using a blood test. The test can give guidance as to how often and how intensively doctors need to screen for presence of atrial fibrillation in these individuals. We also consider that more widespread treatment of high blood pressure may be justified in those with a high genetic risk of atrial fibrillation”, explained Professor Melander.

Patients already diagnosed with atrial fibrillation were also studied, and the researchers observed that if they had the risk genes, their risk of stroke was increased by a further 70-80 per cent.

If an individual with atrial fibrillation is regarded as having a sufficiently high stroke risk, lifelong treatment with anticoagulant drugs such as warfarin is required in order to lower the risk.

“There are also benefits of checking the genetic risk of those who have already been diagnosed with atrial fibrillation. The test makes it easier to correctly assess whether anticoagulant medication is necessary to prevent stroke, especially for those under 65″, said Olle Melander.

The research data was taken from a long-term follow-up of 27 400 participants in a population study.

“The present results are one of several examples of how genetics research is not only an effective way of identifying new disease mechanisms, but can also have clinical applications and help doctors and patients to decide on the right tests and treatment”, said Olle Melander.




Inflammation may be the reason high blood sugar levels damage blood vessels


Inflammation may be the reason high blood sugar levels damage blood vessels, raising the possibility that anti-inflammatory medications might someday be used to lower the risk of blood vessel disease in people with diabetes, according to a study presented at the American Heart Association’s High Blood Pressure Research Scientific Sessions 2014.

“These findings may explain why good blood sugar control is not sufficient to avoid the development of diabetes-induced cardiovascular diseases,” said Carlos F. Sánchez-Ferrer, M.D., Ph.D., study author and professor of pharmacology at the Universidad Autónoma de Madrid, Spain. “We need to find new medications focused on reducing inflammation.”

Using cultured smooth muscle cells from the main human artery (aorta), researchers found:

  • In the absence of inflammation, excess glucose in the culture fluid didn’t enter the cells.
  • When extra glucose was forced into the cells, no harm was done in the absence of inflammation.
  • When the inflammation-stimulating protein interleukin-1 (IL-1) was introduced, more glucose entered the cells.
  • With IL-1, the glucose entering the cells was metabolized via chemical pathways that spur escalating inflammation, overwhelming the cells’ ability to counteract it.
  • In the presence of the anti-inflammatory drug anakinra, which blocks the activity of IL-1, the deleterious changes didn’t occur.

“We need to reduce the inflammatory environment associated with diabetes,” Sánchez-Ferrer said. “Changes in life-style, such as physical exercise and weight reduction, are important not only because they reduce blood sugar but because they reduce inflammation.”

The researchers plan to test whether the effect is similar in cultured cells from the lining of blood vessels and explore the blood sugar/inflammation connection in animals.



Keeping fit aids bone and joint health whilst aging


Being physically active may significantly improve musculoskeletal and overall health, and minimize or delay the effects of aging, according to a review of the latest research on senior athletes (ages 65 and up) appearing in the September issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS).

It long has been assumed that aging causes an inevitable deterioration of the body and its ability to function, as well as increased rates of related injuries such as sprains, strains and fractures; diseases, such as obesityand diabetes; and osteoarthritis and other bone and joint conditions. However, recent research on senior, elite athletes suggests usage of comprehensive fitness and nutrition routines helps minimize bone and joint health decline and maintain overall physical health.

“An increasing amount of evidence demonstrates that we can modulate age-related decline in the musculoskeletal system,” said lead study author and orthopaedic surgeon Bryan G. Vopat, MD. “A lot of the deterioration we see with aging can be attributed to a more sedentary lifestyle instead of aging itself.”

The positive effects of physical activity on maintaining bone density, muscle mass, ligament and tendon function, and cartilage volume are keys to optimal physical function and health. In addition, the literature recommends a combined physical activity regimen for all adults encompassing resistance, endurance, flexibility and balance training, “as safely allowable for a given person.” Among the recommendations:

Resistance training. Prolonged, intense resistance training can increase muscle strength, lean muscle and bone mass more consistently than aerobic exercise alone. Moderately intense resistance regimens also decrease fat mass. Sustained lower and upper body resistance training bolsters bone density and reduces the risk of strains, sprains and acute fractures.

Endurance training. Sustained and at least moderately intensive aerobic training promotes heart health, increases oxygen consumption, and has been linked to other musculoskeletal benefits, including less accumulation of fat mass, maintenance of muscle strength and cartilage volumes. A minimum of 150 to 300 minutes a week of endurance training, in 10 to 30 minute episodes, for elite senior athletes is recommended. Less vigorous and/or short-duration aerobic regimens may provide limited benefit.

Flexibility and balance. Flexibility exercises are strongly recommended for active older adults to maintain range of motion, optimize performance and limit injury. Two days a week or more of flexibility training – sustained stretches and static/non-ballistic (non-resistant) movements – are recommended for senior athletes. Progressively difficult postures (depending on tolerance and ability) are recommended for improving and maintaining balance.

The study also recommends “proper” nutrition for older, active adults to optimize performance. For senior athletes, a daily protein intake of 1.0 to 1.5 g/kg is recommended, as well as carbohydrate consumption of 6 to 8 g/kg (more than 8 g/kg in the days leading up to an endurance event).

“Regimens must be individualized for older adults according to their baseline level of conditioning and disability, and be instituted gradually and safely, particularly for elderly and poorly conditioned adults,” said Dr. Vopat. According to study authors, to improve fitness levels and minimize bone and joint health decline, when safely allowable, patients should be encouraged to continually exceed the minimum exercise recommendations.




Risks of long-term aspirin use ‘outweighed by cancer benefits’


Past research has linked long-term aspirin use to adverse side effects, such as internal bleeding. But according to a new study, the benefits of longstanding aspirin therapy outweigh such risks; it can significantly reduce the risk of major cancers of the digestive tract, including stomach, bowel and esophageal cancers.


The research team, led by Prof. Jack Cuzick, head of the Centre for Cancer Prevention at the Queen Mary University of London in the UK, recently published their findings in the journal Annals of Oncology.

Aspirin, also known as acetlylsalicylic acid (ASA), is a salicylate drug commonly used to reduce minor aches and pains, inflammation and fever. In long-term low doses, the drug is also used as an antiplatelet for patients at high risk of heart attackand stroke.

There has been much debate surrounding the benefits of long-term aspirin therapy. Previous studies have suggested it can reduce risk of ovarian cancer and improve colon cancer survival, while others claim it can cause harm, with one study suggesting it increases the risk of age-related macular degeneration.

In this latest research, Prof. Cuzick and his team set out to determine whether the health benefits of continued aspirin use outweigh the risks.

Taking daily aspirin ‘important for reducing cancer risk’

To reach their findings, the team conducted an analysis of all available evidence from an array of studies looking at the beneficial and harmful effects of aspirin use.

The researchers estimated that if individuals aged 50-65 took a daily 75-100 mg dose of aspirin for 5-10 years, the number of bowel cancer cases could be reduced by 35% and deaths by 40%, while rates of stomach and esophageal cancers could be cut by 30% and deaths by 35-50%.

Overall, they estimate that daily aspirin use for 5-10 years could provide a 9% reduction in the number of cancers, strokes and heart attacks in men, and a 7% reduction in women. Over a 20-year period, they estimate the number of deaths from all causes could be reduced by 4%. No benefits were found until individuals used aspirin for a minimum of 3 years.

But the researchers note that continued aspirin use does increase the risk of bleeding in the digestive tract. They found that individuals aged 60 who took aspirin daily for 10 years increased their risk of gastrointestinal bleeding by 1.4%, from 2.2% to 3.6%. However, they note that this is only likely to be life-threatening in around 5% of people.

“The risk of bleeding depends on a number of known factors which people need to be aware of before starting regular aspirin, and it would be advisable to consult with a doctor before embarking on daily medication,” notes Prof. Cuzick.

In addition, they found that continuing aspirin use increased the risk of peptic ulcer by 30-60%.

But despite these side effects, Prof. Cuzick believes that long-term aspirin therapy could be vital to cancer prevention:

“It has long been known that aspirin – one of the cheapest and most common drugs on the market – can protect against certain types of cancer. But until our study, where we analyzed all the available evidence, it was unclear whether the pros of taking aspirin outweighed the cons.

Whilst there are some serious side effects that can’t be ignored, taking aspirin daily looks to be the most important thing we can do to reduce cancer after stopping smoking and reducing obesity, and will probably be much easier to implement.”

The team notes that further research is warranted to better pinpoint those who are most likely to benefit from long-term aspirin use and who is at highest risk of gastrointestinal bleeding.

Earlier this year, Medical News Today reported on a consumer update from the US Food and Drug Administration (FDA), stating that while daily low-dose aspirin use can prevent heart attack or stroke for those who have already had one, there is insufficient evidence to support its use for prevention of first-time heart attack or stroke.

Written by Honor Whiteman