• Peter Hayes, Monica Casey, Liam G Glynn, Gerard J Molloy, Hannah Durand, Eoin O'Brien, Eamon Dolan, Kishor Das, John Newell, David Finn, Brendan Harhen, Ann Conneely, and Andrew W Murphy.
• Graduate Entry Medical School, University of Limerick, Limerick; Discipline of General Practice, National University of Ireland (NUI) Galway, Galway, Ireland.
• Br J Gen Pract. 2019 Sep 1; 69 (686): e621-e628.

BackgroundApparent treatment-resistant hypertension (aTRH) is defined as uncontrolled blood pressure (BP) in patients taking three or more antihypertensive medications. Some patients will have true treatment-resistant hypertension, some undiagnosed secondary hypertension, while others have pseudo-resistance. Pseudo-resistance occurs when non-adherence to medication, white-coat hypertension (WCH), lifestyle, and inadequate drug dosing are responsible for the poorly controlled BP.AimTo examine the feasibility of establishing non-adherence to medication, for the first time in primary care, using mass spectrometry urine analysis. Operationalisation would be established by at least 50% of patients participating and 95% of samples being suitable for analysis. Clinical importance would be confirmed by >10% of patients being non-adherent.Design And SettingEligible patients with aTRH (n = 453) in 15 university research-affiliated Irish general practices were invited to participate.MethodParticipants underwent mass spectrometry urine analysis to test adherence and ambulatory BP monitoring (ABPM) to examine WCH.ResultsOf the eligible patients invited, 52% (n = 235) participated. All 235 urine samples (100%) were suitable for analysis: 174 (74%) patients were fully adherent, 56 (24%) partially adherent, and five (2%) fully non-adherent to therapy. A total of 206 patients also had ABPM, and in total 92 (45%) were categorised as pseudo-resistant. No significant associations were found between adherence status and patient characteristics or drug class.ConclusionIn patients with aTRH, the authors have established that it is feasible to examine non-adherence to medications using mass spectrometry urine analysis. One in four patients were found to be partially or fully non-adherent. Further research on how to incorporate this approach into individual patient consultations and its associated cost-effectiveness is now appropriate.© British Journal of General Practice 2019.

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