Hypertension affects approximately 14 million adults in England, according to the British Heart Foundation. It is the single largest modifiable risk factor for cardiovascular disease, stroke and chronic kidney disease. Yet adherence to antihypertensive medicines remains stubbornly poor: a systematic review published in the International Journal of Cardiology found that approximately 50% of patients prescribed antihypertensives discontinue treatment within the first year.

Community pharmacists are the healthcare professionals who see hypertension patients most frequently — every time they collect their prescription. This regular contact creates a natural opportunity to support adherence in ways that GP consultations, typically spaced months apart, cannot.

Why patients stop taking antihypertensives

Understanding the reasons for non-adherence is the first step toward addressing it. Research consistently identifies several factors:

Asymptomatic condition. Hypertension rarely causes noticeable symptoms. Unlike pain medication, where the patient feels immediate benefit, the reward of antihypertensive therapy is invisible — preventing a cardiovascular event that may or may not have happened. This makes the cost-benefit calculation subjective and easily tipped by side effects.

Side effects. Each antihypertensive class has a characteristic side-effect profile that drives non-adherence:

Polypharmacy. Many hypertension patients take multiple medicines for other conditions. The complexity of a multi-drug regimen — different times, different instructions — can lead to missed doses and eventual abandonment.

Health beliefs. Some patients believe that once their blood pressure is controlled, they no longer need the medicine. Others express concern about long-term medication dependency. Both beliefs are addressable through clear, evidence-based counselling.

The pharmacy role in adherence support

New Medicine Service (NMS)

Antihypertensives are one of the most common NMS-eligible categories. The three-contact structure (initial, 7–14 day follow-up, 21–28 day follow-up) provides a structured framework to:

• Check the patient understands why the medicine was prescribed and what it does
• Ask about early side effects and reassure that some (e.g. diuretic frequency) improve with time
• Identify practical barriers (e.g. difficulty swallowing large tablets, confusion about timing)
• Reinforce the importance of continuing even when feeling well

Evidence from the NMS evaluation shows that patients who received the service were significantly more likely to be adherent at 10 weeks compared with controls. See: New Medicine Service Explained

Structured medication reviews

PCN pharmacists conducting structured medication reviews (SMRs) can address hypertension adherence as part of a comprehensive medicines optimisation review. The SMR provides an opportunity to:

• Reconcile what the patient is actually taking versus what is prescribed
• Simplify regimens where possible (e.g. combination tablets)
• Discuss deprescribing where appropriate (e.g. if blood pressure is consistently low on monitoring)
• Explore whether a different drug class might be better tolerated

See: Structured Medication Reviews Explained

Blood pressure monitoring in pharmacy

Community pharmacy blood pressure checking services serve a dual purpose: case-finding for undiagnosed hypertension, and monitoring for patients already on treatment. When a patient collects their antihypertensive and has their blood pressure checked in the pharmacy, the conversation naturally turns to adherence: "Your blood pressure is still a bit above target — are you managing to take your amlodipine every day?"

This is far more effective than simply asking "are you taking your medicine?" — which invariably elicits a "yes" regardless of reality.

Practical counselling tips

Timing advice. Help patients integrate their medicine into an existing routine. "Take it with your morning cup of tea" is more effective than "take once daily." For diuretics, advise morning dosing to minimise nocturnal urinary frequency.

Side effect management. Proactive counselling about expected side effects reduces surprise-driven discontinuation:

• ACE inhibitor cough: explain that it affects up to 15% of patients and that an ARB is an effective alternative if it persists beyond 8 weeks
• Amlodipine ankle swelling: elevating legs in the evening may help; if troublesome, the prescriber may add or switch to an ACE inhibitor which can counteract the oedema
• Thiazide urinary frequency: usually settles within 2–4 weeks

Combination tablets. Where a patient is taking two or three antihypertensives separately, a combination tablet (e.g. amlodipine + valsartan, or perindopril + indapamide + amlodipine) can reduce pill burden. Pharmacists can suggest this to the prescriber.

Multi-compartment compliance aids. For patients with cognitive difficulties or complex regimens, a dosette box or blister pack can support adherence — though evidence for their effectiveness in hypertension specifically is limited.

When to refer

Pharmacy teams should refer patients to their GP when they identify:

• Persistent non-adherence despite counselling and support — the patient may need a medication review to find a better-tolerated regimen
• Consistently elevated blood pressure on monitoring — treatment may need intensification
• Symptoms suggesting end-organ damage — new-onset headache, visual disturbance, chest pain, ankle swelling (beyond drug-related oedema)
• Very low blood pressure readings (systolic below 90) — possible over-treatment, especially in elderly patients
• Suspected white-coat effect — if pharmacy readings are consistently lower than clinic readings, ambulatory monitoring may be appropriate

Pharmacists with an interest in cardiovascular risk management can explore clinical and PCN roles through PharmSee's job search, where over 1,700 active pharmacy vacancies are currently listed across England.

Sources

• NICE NG136: Hypertension in adults — diagnosis and management (updated 2023).
• British Heart Foundation. High blood pressure statistics, 2024.
• Vrijens B et al. A new taxonomy for describing and defining adherence to medications. British Journal of Clinical Pharmacology, 2012.
• NHS England. NMS evaluation report.
• PharmSee pharmacy data: pharmsee.co.uk.