Medication Persistence Rates and Factors Associated with Persistence in Patients Following Stroke: A Cohort Study

Abstract Background Medication nonadherence can be as high as 50% and results in suboptimal patient outcomes. Stroke patients in particular can benefit from pharmacotherapy for thrombosis, hypertension, and dyslipidemia but are at high risk for medication nonpersistence. Methods Patients who were admitted to the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, with stroke between January 1, 2001 and December 31, 2002 were analyzed. Data collected were pre-stroke function, stroke subtype, stroke severity, patient outcomes, and medication use at discharge, and six and 12 months post discharge. Medication persistence at six and 12 months and the factors associated with nonpersistence at six months were examined using multivariable stepwise logistic regression. Results At discharge, 420 patients (mean age 68.2 years, 55.7% male) were prescribed an average of 6.4 medications and mean prescription drug cost was $167 monthly. Antihypertensive (91%) and antithrombotic (96%) drug use at discharge were frequent, antilipidemic (73%) and antihyperglycemic (25%) drug use were less common. Self-reported persistence at six and 12 months after stroke was high (> 90%) for all categories. In the multivariable model of medication nonpersistence at six months, people aged 65 to 79 years were less likely to be nonpersistent with antihypertensive medications than people aged 80 years or more (Odds ratio (OR) 0.11, 95% Confidence Interval (CI) 0.03–0.39). Monthly drug costs of Conclusion Patients reported high medication persistence rates six and 12 months after stroke. Identification of factors associated with nonpersistence (such as older age and prior disability) will help predict which patients are at higher risk for discontinuing their medications.</p

Thrombolytic Therapy for Acute Ischemic Stroke: The CAEP Position Statement: another perspective

The cautiously-worded Position Statement recently issued by the Canadian Association of Emergency Physicians (see Appendix 1) regarding the use of intravenous recombinant tissue-plasminogen activator (tPA, alteplase) for acute ischemic stroke underscores the reality that many physicians in Canada have been reluctant to embrace this therapy. Much of the caution expressed in the CAEP document is related to 2 major areas of concern: evidence of efficacy (i.e., did tPA really “prove” itself in randomized trials?) and effectiveness (i.e., are the trial results generalizable to everyday practice?). While we support the development of documents that help to clarify controversial treatments, and agree with much of what is presented in the CAEP Position Statement, we offer the following comments.</jats:p

Update on the third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke and baseline features of the 3035 patients recruited

Intravenous recombinant tissue plasminogen activator (rtPA) is approved in Europe for use in patients with acute ischaemic stroke who meet strictly defined criteria. IST-3 sought to improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of rtPA in acute ischaemic stroke, and to determine whether a wider range of patients might benefit

Canadian Stroke Best Practice Recommendations: Hyperacute Stroke Care Guidelines, Update 2015

The 2015 update of the Canadian Stroke Best Practice Recommendations Hyperacute Stroke Care guideline highlights key elements involved in the initial assessment, stabilization, and treatment of patients with transient ischemic attack (TIA), ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and acute venous sinus thrombosis. The most notable change in this 5th edition is the addition of new recommendations for the use of endovascular therapy for patients with acute ischemic stroke and proximal intracranial arterial occlusion. This includes an overview of the infrastructure and resources required for stroke centers that will provide endovascular therapy as well as regional structures needed to ensure that all patients with acute ischemic stroke that are eligible for endovascular therapy will be able to access this newly approved therapy; recommendations for hyperacute brain and enhanced vascular imaging using computed tomography angiography and computed tomography perfusion; patient selection criteria based on the five trials of endovascular therapy published in early 2015, and performance metric targets for important time-points involved in endovascular therapy, including computed tomography-to-groin puncture and computed tomography-to-reperfusion times. Other updates in this guideline include recommendations for improved time efficiencies for all aspects of hyperacute stroke care with a movement toward a new median target door-toneedle time of 30 min, with the 90th percentile being 60 min. A stronger emphasis is placed on increasing public awareness of stroke with the recent launch of the Heart and Stroke Foundation of Canada FAST signs of stroke campaign; reinforcing the public need to seek immediate medical attention by calling 911; further engagement of paramedics in the prehospital phase with prehospital notification to the receiving emergency department, as well as the stroke team, including neuroradiology; updates to the triage and same-day assessment Conflict of interest: Leanne K. Casaubon: Medtronic (as an independent study patient assessor for a cardiac TAVI study); NoNO Inc. as site PI for the Frontier study of NA-1 neuroprotective in stroke; Covidien as an advisory board member. Jean-Martin Boulanger: conference speaker for BI Novartis, Sanofi Aventis, Merck, Merz, Allergan, Pfizer, Bayer, Boehringer Ingelheim. Gord Gubitz: speaker for Bayer, Boehringer Ingleheim, and BMS Pfizer. Dr. Michael D. Hill: Heart and Stroke Foundation of Alberta Board Chair, salary award holder; Vernalis Group Ltd and Merck Ltd Consultant; Hoffmann-LaRoche Canada, provided drug for clinical trial, consultancy and CME lecturer; Coviden, research grant holder; Servier Canada, CME lecturer (funds donated to charity); BMS Canada, consultancy (funds donated to charity); Alberta Innovates Health Solutions, program grant award; principal investigator, ESCAPE trial. Brian Moses: speaker for AstraZeneca, Bayer, Boehringer Ingelheim, Sanofi Aventis, and Servier; speaker and advisory board member for BMS, Eli Lilly, Merck, NovoNordisk, Pfizer; advisory board member for Medtronic. Funding: The development of the Canadian Stroke Best Practice Recommendations is funded in their entirety by the Heart and Stroke Foundation, Canada. No funds for the development of these guidelines come from commercial interests, including pharmaceutical and medical device companies. All members of the recommendation writing groups and external reviewers are volunteers and do not receive any remuneration for participation in guideline development, updates, and reviews. All participants complete a conflict of interest declaration prior to participation. of patients with transient ischemic attack; updates to blood pressure recommendations for the hyperacute phase of care for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The goal of these recommendations and supporting materials is to improve efficiencies and minimize the absolute time lapse between stroke symptom onset and reperfusion therapy, which in turn leads to better outcomes and potentially shorter recovery times