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When More is Not Better — Pill Burden Worsens Hypertension and Dyslipidaemia
Researchers led by Koh Kim Hwee and Tan Ngiap Chuan of SingHealth Polyclinic have revealed that less than 50 per cent of hypertension and dyslipidaemia patients in Singapore reach their blood pressure (BP) goals, attributing low success to complex medication regime.

Of the many risk factors of cardiovascular diseases, hypertension and dyslipidaemia are among the most well-known. Notably, the Singapore 2014 Primary Care survey report revealed that hypertension and dyslipidaemia were ranked as among the most frequently observed medical conditions in primary care clinics.

Hypertension refers to a condition of elevated blood pressure, while dyslipidaemia is better known as having abnormal levels of cholesterol or other lipids in the blood. These frequently concurring two conditions are reversible with the help of lifestyle changes and medications. As such, patients are often advised to make deliberate changes in diet and physical exercise. In more severe cases, patients are encouraged to consult medical professionals for life-long treatments with blood pressure-lowering medications and medical follow-ups. However, too much of a good thing can be counterproductive, and the saying has never rung truer.

Researchers from SingHealth Polyclinic have discovered that less than 50 per cent of patients with hypertension and dyslipidaemia in Singapore have reached their blood pressure (BP) goals, and this low success rate is largely attributed to complex medication regimes – in other words, a pill burden.

The study, led by Clinical A/P Tan Ngiap Chuan and Dr Koh Kim Hwee, examined the role of demographic and medication-related factors in achieving BP goals. Using a retrospective, cross-sectional study, the team collected health information of 850 Asian patients between the ages of 31 to 80 with hypertension and dyslipidaemia from Pasir Ris and Tampines Polyclinics. They specifically analysed the effects of the number and types of medications, presence of co-morbidities and attainment of low-density lipoprotein cholesterol (LDL-C) goals.

Their investigation revealed several surprising findings. Although more than half of the participants in the study were taking two or more BP-lowering drugs, only 49.7 per cent of patients achieved their BP goal. And their success was not attributed to taking many medications, in fact, quite the opposite. Patients who relied on diet control of only one medication (monotherapy) were found to be the ones more likely to reach their BP treatment goals. Several factors were taken into account to explain this trend, such as patients having milder cases of hypertension or dyslipidaemia, but more importantly, adherence to medication.

Medication adherence was ascertained to be a major contributor to success in BP treatment goal. Taking a large number of medications, or a high pill burden often involves complex medication regimes, which may decrease adherence to therapy and thus reduce the efficacy of drugs.

Dr Koh, Consultant and Clinical Lead for Musculoskeletal Workgroup explained, “We found that patients who were prescribed multiple medications were less likely to attain their BP goals. While such combined use of more than one class of medications increases the likelihood of achieving target BP in a shorter period of time, with fewer clinic visits and medication changes, patients may suffer from pill burden which affects their adherence to the medication therapy in the long run.”

Co-morbidities like being overweight, diabetes mellitus, coronary artery disease, renal diseases, and failure to achieve LDL-C cholesterol goals were also discovered to reduce the likelihood of achieving their BP goals. In part, this trend is ascribed to the fact that patients with co-morbidities are more likely to be on multiple medications, thus increasing the pill burden.

Despite established guidelines to direct treatments and effective medications at the disposal of clinicians and patients alike, the proportion of successful attainment of BP treatment goals has remained low, emphasising the need to urgently improve treatment measures. Researchers advise the use of single-pill or fixed-dose combinations to reduce pill burden and taking measures to improve the quality of polyclinics to detect gaps in treatment and aid patients to realise their treatment objectives.

“At SHP, numerous quality improvement measures have been put in place in each polyclinic to identify the gaps, and to increase the proportion of patients achieving their treatment goals. We have since introduced several combination drugs into the institution formulary to allow physicians to have greater flexibility in their choice of BP-lowering medications, especially when targeting patients with poor medication adherence. Ultimately, we hope to improve patients’ adherence to their medications and lifestyle modifications, so that they can better manage their chronic conditions,” added A/Prof Tan.


Tan, N., Koh, K. (2021, May 14). Study shows less than 50 per cent of patients with hypertension and dyslipidaemia in Singapore achieved their blood pressure (BP) goals [Webinar]. SingHealth Polyclinics.

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