Medication Non-Adherence in Resistant Hypertension: Detection, Drivers, and Practical Solutions

Most patients with hypertension cannot reach goal blood pressure with lifestyle modification alone, so hypertension control relies heavily on patients taking medications as prescribed. This review synthesizes recent literature on the role of medication non-adherence in apparent resistant hypertension, with attention to the definition of non-adherence, who is at risk, how it is detected, what it costs patients, and how clinicians can address it.

When patients with apparent resistant hypertension undergo objective therapeutic drug monitoring, 25 to 80% are found to be non-adherent, and a substantial minority have no detectable drug at all. Neither clinicians nor patients reliably identify non-adherence by gestalt or self-report. Single-pill combinations consistently improve adherence and persistence relative to free-equivalent combinations, and in observational studies are associated with better cardiovascular outcomes. New pharmacologic agents that target the aldosterone and endothelin pathways produce substantial blood pressure reduction in true resistant hypertension but are not yet widely available, strengthening the case for confirming adherence before intensification of pharmacotherapy. Confirming adherence is a key initial step in the workup of apparent resistant hypertension. The weight of the evidence suggests that blood pressure reduction in this setting requires lowering barriers to adherence: simplifying regimens, lowering costs, and pairing objective measurement with non-judgmental conversation.