Chris L. Bryson, MD, MS; David H. Au, MD, MS; Haili Sun, PhD; Emily C. Williams, MPH; Daniel R. Kivlahan, PhD; Katharine A. Bradley, MD, MPH
Medication nonadherence is common and is associated with adverse outcomes. Alcohol misuse may be a risk factor for nonadherence; however, evidence is limited.
To identify whether alcohol misuse, as identified by a simple screening tool, is associated in a doseâ€“response manner with increased risk for medication nonadherence in veterans attending primary care clinics.
Secondary analysis of cohort data collected prospectively from 1997 to 2000 as part of a randomized, controlled trial.
7 Veterans Affairs primary care clinics.
5473 patients taking a statin, 3468 patients taking oral hypoglycemic agents, and 13Â 729 patients taking antihypertensive medications.
Patients completed the Alcohol Use Disorder Identification Testâ€“Consumption (AUDIT-C) questionnaire, a validated 3-question alcohol misuse screening test. Their scores were categorized into nondrinkers; low-level alcohol use; and mild, moderate, and severe alcohol misuse. Medication adherence, defined as having medications available for at least 80% of the observation days, was measured from pharmacy records for either 90 days or 1 year after the alcohol screening date. Logistic regression was used to estimate the predicted proportions of adherent patients in each AUDIT-C group and adjusted for demographic and clinical covariates.
The proportion of patients treated for hypertension and hyperlipidemia who were nonadherent increased with higher AUDIT-C scores. For 1-year adherence to statins, the percentage of adherent patients was lower in the 2 highest alcohol misuse groups (adjusted percentage of adherent patients, 58% [95% CI, 52% to 65%] and 55% [CI, 47% to 63%]) than in the nondrinker group (66% [CI, 64% to 68%]). For 1-year adherence to antihypertensive regimens, the percentage of adherent patients was lower in the 3 highest alcohol misuse groups (adjusted percentage of adherent patients, 61% [CI, 58% to 64%]; 60% [CI, 56% to 63%]; and 56% [CI, 52% to 60%]) than in the nondrinker group (64% [CI, 63% to 65%]). No statistically significant differences were observed for oral hypoglycemics in adjusted analyses.
This observational study cannot address whether changes in drinking lead to changes in adherence and may not be generalizable to other populations.
Alcohol misuse, as measured by a brief screening questionnaire, was associated with increased risk for medication nonadherence.
Is alcohol misuse associated with medication nonadherence?
This study of primary care patients attending 7 Veterans Affairs clinics found a graded, linear decrease in adherence to statins and hypertension medications with increasing levels of alcohol misuse.
Alcohol misuse was measured with a brief screening questionnaire that was mailed to patients. Adherence was measured by pharmacy refills.
Alcohol misuse may be associated with increased risk for medication nonadherence.
ACQUIP = Ambulatory Care Quality Improvement Project; AUDIT-C = Alcohol Use Disorder Identification Test–Consumption.
* Drug cohorts are not mutually exclusive. Cohorts are defined as patients who received both 1 or more fills of the drug class within 2 years before the date on which the AUDIT-C was returned (index date) and 1 or more fills in the year after the index date.
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UTCOM Internal Medicine Resident
December 8, 2008
Alcohol drinking recommendations for abstainers and rare drinkers
I read with interest this observational study about Alcohol Screening Scores and Medication Non-adherence. Probably randomized, controlled trials will add more reliable information about that association.
In the mild alcohol misuse groups; 1-year adherence to antihypertensive and statin medication use was lower. (Adjusted percentage of adherent patients, 61% and 63 % respectively compare to non-drinker group (64% and 66 %) with P value of < 0.001 and 0.001 respectively.
Although moderate alcohol use is associated with a mortality benefit relative to abstention or rare drinking in patients with coronary heart disease (1-4), ischemic stroke (5) and Diabetes (6); these above findings emphasize the fact that alcohol drinking should not be recommended for abstainers and rare drinkers as coronary heart disease risk factor modification because that association between even mild drinking and non adherence.
According to a 2001 AHA Science Advisory (7) "Moderate intake of alcoholic beverages (one to two drinks per day) is associated with a reduced risk of CHD in populations. There is no clear evidence that wine is more beneficial than other forms of alcohol, although further research is needed. If wine does have additional effects, it appears that many of the same additional biological effects may be achieved with grape juice. Despite the biologic plausibility and observational data in this regard, it should be kept in mind that these are insufficient to prove causality. Although moderate use of wine and other alcohol-containing beverages does not appear to lead to significant morbidity, alcohol ingestion, unlike other dietary modifications, poses a number of health hazards. Without a large-scale, randomized, clinical endpoint trial of wine intake, there is little current justification to recommend alcohol (or wine specifically) as a cardioprotective strategy. "
According to lifestyle recommendations from the AHA in 2006 "If alcoholic beverages are consumed, they should be limited to no more than 2 drinks per day for men and 1 drink per day for women, and ideally should be consumed with meals".
The bottom line: The consumption of alcohol should not be recommended solely for cardiovascular disease risk factors modification.
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(2) How much alcohol and how often? Population based case-control study of alcohol consumption and risk of a major coronary event. McElduff P; Dobson AJ. BMJ 1997 Apr 19;314(7088):1159-64.
(3) Alcohol consumption and coronary heart disease morbidity and mortality. Rehm JT; Bondy SJ; Sempos CT; Vuong CV. Am J Epidemiol 1997 Sep 15;146(6):495-501
(4) Prospective study of alcohol drinking patterns and coronary heart disease in women and men. Tolstrup et al. BMJ. 2006 May 27;332(7552):1244-8. Epub 2006 May 3.
(5) Alcohol consumption and risk of stroke: a meta-analysis. Reynolds et al ; JAMA 2003 Feb 5; 289(5):579-88.
(6) Alcohol consumption and risk of coronary heart disease by diabetes status. Ajani et al. Circulation 2000 Aug 1; 102(5):500-5.
(7) Goldberg, IJ, Mosca, L, Piano, MR, Fisher, EA. Wineand Your Heart: A Science Advisory for Healthcare Professionals From the Nutrition Committee, Council on Epidemiology and Prevention, and Council on Cardiovascular Nursing of the American Heart Association. Circulation 2001; 103:472.
(8) Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Lichtenstein AH Circulation. 2006 Jul 4;114(1):82-96. Epub 2006 Jun 19.
Bryson CL, Au DH, Sun H, Williams EC, Kivlahan DR, Bradley KA. Alcohol Screening Scores and Medication Nonadherence. Ann Intern Med. 2008;149:795-803. doi: 10.7326/0003-4819-149-11-200812020-00004
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Published: Ann Intern Med. 2008;149(11):795-803.
Prevention/Screening, Tobacco, Alcohol, and Other Substance Abuse.
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