By P. Narkam. University of Wisconsin-Madison.
Significant improvement in the quality of the patient’s coping skills and interpersonal relationships may be required before medication can be discontinued order genuine glipizide online. Clinical experience suggests caution in discontinuing a successful antidepressant trial cheap glipizide 10 mg on line, especially if prior medication trials have failed effective 10 mg glipizide. In one study of patients with borderline personality disorder (45), one-half of the patients who failed to respond to fluoxetine subsequently responded to sertraline. At this point, the use of a benzodiazepine should be considered, although there is little systematic research on the use of these medications in patients with borderline personality disorder. Use of benzo- diazepines may be problematic, given the risk of abuse, tolerance, and even behavioral toxicity. Despite clinical use of benzodiazepines (52), the short-acting benzodiazepine alprazolam was associated in one study with serious behavioral dyscontrol (53). Case reports demonstrate some utility for the long half-life benzodiazepine clonazepam (54). In theory, buspirone may treat anxiety or impulsive aggression without the risk of abuse or tolerance. However, the absence of an immediate effect generally makes this drug less accept- able to patients with borderline personality disorder. Currently, there are no published data on the use of buspirone for the treatment of affective dysregulation symptoms in patients with bor- derline personality disorder. Fluoxetine has been shown to be effective for anger in patients with borderline personality disorder independent of its effects on de- pressed mood (44). Effects of fluoxetine on anger and impulsivity may appear within days, much earlier than antidepressant effects. Clinical experience suggests that in patients with se- vere behavioral dyscontrol, low-dose neuroleptics can be added to the regimen for a rapid response; they may also improve affective symptoms (50). However, they are not a first-line treatment because of concerns about adherence to required dietary restrictions and because of their more problematic side effects. Mood stabilizers are another second-line (or adjunctive) treatment for affective dysregula- tion symptoms in patients with borderline personality disorder. Lithium carbonate has the most re- search support in randomized controlled trials studying patients with personality disorders (although not specifically borderline personality disorder). However, these studies focused pri- marily on impulsivity and aggression rather than mood regulation (58–60). Nonetheless, lith- ium may be helpful for mood lability as a primary presentation in patients with a personality disorder (61). Lithium has the disadvantage of a narrow margin of safety in overdose and the risk of hypothyroidism with long-term use. Carbamazepine has demonstrated efficacy for impulsivity, anger, suicidality, and anxiety in patients with borderline personality disorder and hysteroid dysphoria (62). However, a small, controlled study of patients with borderline personality disorder with no axis I affective disor- der found no significant benefit for carbamazepine (63). Carbamazepine has been reported to precipitate melancholic depression in patients with borderline personality disorder who have a history of this disorder (64), and it has the potential to cause bone marrow suppression. Valproate demonstrated modest efficacy for depressed mood in patients with borderline per- sonality disorder in one small, randomized, controlled trial (65). Open-label case reports sug- gest that this medication may also decrease agitation, aggression, anxiety, impulsivity, rejection sensitivity, anger, and irritability in patients with borderline personality disorder (66). Al- though the use of carbamazepine and valproate is widespread, psychiatrists should be aware of the lack of solid research support for their use in patients with borderline personality disorder. Randomized controlled trials and open-label studies with fluoxetine and sertraline have shown that their effect on impulsive behavior is in- dependent of their effect on depression and anxiety (67). Clinical experience suggests that the duration of treatment following improvement of impulsive aggression should be determined by the clin- ical state of the patient, including his or her risk of exposure to life stressors and progress in learning coping skills. When the target for treatment is a trait vulnerability, a predetermined limit on treatment duration cannot be set. Although this combination has not been studied, random- ized controlled trials of neuroleptics alone have demonstrated their efficacy for impulsivity in pa- tients with borderline personality disorder. The effect is rapid in onset, often within hours with oral use (and more rapidly when given intramuscularly), providing immediate control of escalating im- pulsive-aggressive behavior. Nonetheless, studies in impulsive adults and adolescents with criminal be- havior (who were not selected for having borderline personality disorder) demonstrate that lith- ium alone is effective for impulsive-aggressive symptoms (58–60). In a placebo-controlled crossover study of women with borderline per- sonality disorder and hysteroid dysphoria, tranylcypromine was effective for the treatment of impulsive behavior (55). In another randomized controlled trial, phenelzine was effective for the treatment of anger and irritability (56, 68). The use of carbamazepine or valproate for impulse control in patients with borderline personality disorder appears to be widespread in clin- ical practice, although empirical evidence for their efficacy for impulsive aggression is limited and inconclusive. Carbamazepine has been shown to decrease behavioral impulsivity in patients with borderline personality disorder and hysteroid dysphoria. However, in a small controlled study that excluded patients with an affective disorder (63), carbamazepine proved no better than placebo for impulsivity in borderline personality disorder. Support for the use of valproate for impulsivity in borderline personality disorder is derived only from case reports, one small randomized control study, and one open-label trial in which impulsivity significantly improved (65, 66, 69, 70). Preliminary evidence suggests that the atypical neuroleptics may have some ef- ficacy for impulsivity in patients with borderline personality disorder, especially severe self- mutilation and other impulsive behaviors arising from psychotic thinking. One open-label trial (71) and one case report (72) support the use of clozapine for this indication. The newer atypical neuroleptics have fewer risks, but there are few pub- lished data on their efficacy. Further investigation is warranted for their use as a treatment for refractory impulsive aggression in patients with borderline personality disorder. However, empirical support for this approach is very preliminary, since their efficacy has been demonstrated only in case reports and small case series. This recommendation is strongly supported by randomized, double-blind controlled studies and open-label trials involving a variety of neuroleptics in both inpatient and outpatient settings and in adult and adolescent populations (50, 51, 55, 73–78). Low-dose neuroleptics appear to have a broad spectrum of efficacy in acute use, improving not only psychotic-like symptoms but also depressed mood, impulsivity, and anger/hostility. Patients with cognitive symptoms as a primary complaint respond best to the use of low-dose neuroleptics. Patients with borderline personality disorder with prominent affective dysregulation and labile, depressive moods, in whom cognitive-perceptual distortions are secondary mood-congruent features, may do less well with neuroleptics alone. In this case, treatments more effective for affective dysregulation should be considered. Duration of treatment may be guided by the length of treatment trials in the literature, which are generally up to 12 weeks. Prolonged use of neuroleptic medication alone in patients with borderline personality disorder (i. There is currently a paucity of research on the use of neuroleptic medication as long-term maintenance therapy for patients with borderline personality disorder, although many clinicians regularly use low-dose neuroleptics to help patients manage their vulnerability to disruptive anger. One Treatment of Patients With Borderline Personality Disorder 29 Copyright 2010, American Psychiatric Association.
Trazodone dosed at <150 mg/day and bupropion would not be considered trials for this indication order discount glipizide. Abilify Oral Solutions: The patient has been started and stabilized on the requested medication cheap glipizide 10 mg. Trazodone dosed at < 150 mg/day would not be considered a trial for this indication order glipizide 10 mg amex. Risperdal Oral Solution: The patient has a documented intolerance to the generic product risperidone. Versacloz Oral Solution: The patient has a medical necessity for a non-solid oral dosage form and is unable to use clozapine orally disintegrating tablets. If the request is for generic Reclast Injection (zoledronic acid) (Quantity Limit = 5 Calcitonin Nasal Spray, the patient has had a docmented intolerance to brand mg (one dose)/year) Zoledronic Acid Injection† (compare to Reclast®) Miacalcin. Treatmetn failure is defined as documented continued bone loss or fracture after one or more years despite Fortical®† (calcitonin) treatment with an oral bisphosphonate. For re-approval after 3 months, the patient must have had an improvement in symptoms. When injected intramuscularly, botulinum neurotoxins produce a presynaptic neuromuscular blockade by preventing the release of acetylcholine from the nerve endings. As a consequence of the chemistry and clinical pharmacology of each botulinum neurotoxin product, botulinum neurotoxins are not terchangeable, even among same sterotype products. Units of biological activity are unique to each preparation and cannot be compared or converted into units of another. It is important that providers recognize there is no safe dose conversion ratio—i. Failure to understand the unique characteristics of each formulation of botulinum neurotoxin can result in under or over dosage. If the diagnosis is Clinic Vivitrol® (naltrexone for extended-release injectable alcohol dependence, there must be a clinically compelling reason for use (e. Note: Re-approval requires evidence of decreased parenteral nutrition support from baseline. Flo-Pred® (prednisolone acetate) oral suspension solution All Others: The patient has been started and stabilized on the requested medication. All Other Brands: The prescriber must provide a clinically valid reason for the use of the requested medication including reasons why any of the generically available preparations would not be a suitable alternative. Note: Renewal of Prior Authorization will require supply = 30 days) documentation of member response. Qty Limit = 2 pumps/8 weeks 111 This is not an all-inclusive list of available covered drugs and includes only managed categories. Other Note: Please refer to “Dermatological: Antifungals: topical dosage preparations preferred. Denavir (penciclovir) 1% C Note: See Anti-Infectives: Antivirals: Herpes: Oral for ® Acyclovir, Zovirax: If prescribed for the treatment of oral herpes simplex infection, ® Zovirax (acyclovir) 5% C, O Sitavig the patient has had a documented side effect, allergy, or treatment failure (at least Xerese® (acyclovir 5%/hydrocortisone 1%) C one course of four or more days) with Denavir. Topicort Spray) not Temovate®/Cormax®) spray covered – use alternate dosage forms. Criteria for Approval Age > 2 years (requests will be approved for up to 1 year): The patient has a diagnosis of atopic dermatitis (eczema). Sh=shampoo, Sp=spray, Ss=suspension 118 This is not an all-inclusive list of available covered drugs and includes only managed categories. Please see the Quantity limit = 6 syringes/28 days for the first month regular) Humira and Cimzia Prior Authorization/Patient Enrollment Form for (Crohn’s starter kit);2 syringes/28 days ® subsequently Entyvio (vedolizumab) instructions. Briova may supply Remicade upon request or you may continue to Quantity limit = 300mgX 3/42 days, 300mg X 1 every obtain through your usual supplier. Note: Humira and Cimzia have been shown to be effective in patients who have been treated with infliximab but have lost respone to therapy. For approval of ranitidine ® capsules, the patient must have had a trial of ranitidine tablets. Additionally, renal impairment is not considered a contraindication to allopurinol use. Increlex® (mecasermin) Serostim® provocative growth hormone stimulation tests (insulin, arginine, levodopa, Zorbtive® propranolol, clonidine, or glucagon) showing results (peak level) <10ng/ml. Subsequent requests can be approved for up to 1 year with documentation of positive response to treatment with growth hormone. Criteria for Approval Adult: The patient must have one of the following indications for growth hormone: Panhypopituitarism due to surgical or radiological eradication of the pituitary. Authorization for continued use shall be reviewed at least every 12 months to confirm patient has experienced disease stability or improvement while on therapy. Note: Re-approval requires confirmation that the patient has responded to therapy (i. Patients may only continue on this dose when new to Medicaid if the patient has been taking this dose for 12 or more months without evidence of muscle toxicity. If the request is for Zocor 80 mg, the patient must have met the prior treatment length requirement and have a documented intolerance to the generic equivalent. For approval of Caduet, the patient must have also had a documented intolerance to the generic equivalent. Other Statin Combinations Advicor: The patient is unable to take the individual drug components separately. Benlysta has 142 This is not an all-inclusive list of available covered drugs and includes only managed categories. Quantity limit = 2 capsules/day Samsca® tablets (tolvaptan) Quantity limit = 15 mg Robinul, Robinul Forte: The patient has had a documented intolerance to generic tablets (1 tablet/day), 30 mg tablets (2 tablets/day) glycopyrrolate. Note: Re- approval requires confirmation that the patient has experienced an objective response to therapy (i. Authorization for continued use shall be reviewed to confirm that the patient has experienced an objective response to the therapy. Somatuline: The diagnosis or indication for the requested medication is Acromegaly. Xenazine: The diagnosis or indication for the requested medication is Huntington’s disease with chorea. Robaxin * (methocarbamol) 500mg, 750 mg tablets Tizanadine capsules, Zanaflex capsules: The prescriber must provide a clinically (Quantity limit = 8 tablets/day) ® valid reason why generic tizanidine tablets cannot be used. All Others: Requested nutritional supplement will be administered via tube feeding. Alaway , Zaditor 155 This is not an all-inclusive list of available covered drugs and includes only managed categories. Mirapex (pramipexole) ® Azilect: The diagnosis or indication is Parkinson’s disease.
As pharmacists glipizide 10 mg with amex, we do not usually obtain a complete past history from a patient 10 mg glipizide otc; rather glipizide 10 mg mastercard, we rely on the informa- tion documented by a medical student, resident, or physician. However, sometimes it is appropriate to ask the patient about parts of his or her past history and/or to use any information gathered previously to determine the appropriate care for the patient. Therefore, it is vital to know the components of the past history and the questions that need to be asked. To ensure completeness, you may need to ask the question in various ways and, at times, gently probe. For example, if you notice that the patient is not sure what you mean by “medical conditions,” you might ask, “Do you have any medical conditions, such as diabetes or high blood pressure? You could ask the patient, “What childhood illnesses, such as measles or chickenpox, did you have as a child? The gyneco- logic history includes onset of menstruation, date of last period, use and type of birth control, and sexual function. Although the pharmacist does not typically gather this history, some of this information may be pertinent to patient care provided by the pharmacist. For example, knowledge of an infant’s birth weight can help you deter- mine whether the mother has a risk factor for diabetes, which, in turn, may influence whether you would recommend diabetes screening for the patient. One way to gather this information would be to ask directly, for example, “There are many risk factors for diabetes, including the birth weight of your children. In this situation, you might ask the patient questions such as, “When did the unprotected sex happen? Health Maintenance/Immunizations This part of the medical history includes information on what immunizations the patient has received, such as influenza, pneumococcal, tetanus, and hepatitis B, as well as the dates they were obtained. Based on this information, you can then recommend any new or booster immunizations the patient may need. The dates and results of screening tests, such as mammograms, Pap smears, and tuberculin tests, should also be included. Information on diabetes and cholesterol screenings may also be included in this section, even though these tests are part of the objective data. These screen- ing tests typically occur because of recommendations from guidelines and are meant to allow for preventative treatments and early diagnosis; therefore, asking the patient about this during the past history component of the patient interview enables you to make recommendations based on the information you have gathered. Family History The family history (Fh) is health information about the patient’s immediate rela- tives. These relatives include parents, grandparents, siblings, children, and grandchil- dren. Because many medical conditions have a genetic component, the purpose of the family history is to determine potential risks factors for the patient’s current and future health. Typically, relatives such as cousins, aunts, and uncles are not included in the family history; however, for certain medical conditions that carry a high genetic link questions about the patient’s family history may be appropriate. In addition, if the person is 18 chapter 1 / the patient interview deceased, ascertain the age at death and the cause of death. It is important to include 4 this specific information because it may determine certain risk factors a patient may carry. For example, if a patient’s father died at the age of 45 secondary to a myocardial infarction, the patient then has a risk factor for coronary artery disease. One way to deter- mine the patient’s family history is to ask, “Are your parents and grandparents alive? The basic social history consists of asking the patient about past and present use of tobacco, alcohol, and illicit substances. If these are currently consumed, you should inquire as to how much and how often each is utilized. In addition, if a patient is a former user of any of these substances, it is vital to ask the patient at subsequent visits if he or she remains abstinent or if relapse has occurred. Because many of the these questions can be very personal and some patients may be reluctant to share such information, either out of embarrassment or fear of being judged, you should ask these questions with sensitivity and respect. However, it is important to be direct so that patients realize these questions are important with regard to their care. For both former and current tobacco users, you should ask at what age they started (and quit); what form of tobacco they use or used, including cigarettes, chewing tobacco, and/or cigars; and quantify the amount. For cigarettes smokers, you should ask how many cigarettes or packs they smoke (or smoked) per day. It is necessary to ask specific questions, because although one drink is tech- nically considered to be 12 ounces of beer, 5 ounces of wine, or 1. It will help if you are straightforward and nonjudgmental when asking about illicit substance use. One way to ask this question is, “Do you currently take, or have you taken in the past, any illicit drugs? It includes the presence of any symptom, even one that the patient may not have deemed to be significant or may have forgotten because of his or her focus on the chief complaint. Additionally, pharmacists may also be part of a medical team, and therefore should be aware of all of the components of a patient interview even if they are not the ones ask- ing the questions. Prior to starting this part of the interview, let the patient know that you will be asking several questions to assess any potential symptoms he or she may be experiencing. Oftentimes, some of these systems may be addressed concurrently with another part of the interview. For example, after checking the patient’s blood pressure, you may ask if the patient has had any dizziness or palpitations. They are taught to develop their own systematic approach to ensure a thorough and accurate physical exam. The comprehensive physical exam includes measurement of vital signs such as height, weight, temperature, blood pressure, and pulse, as well as the observation, inspection, and palpation of the patient’s body from head to toe. Although physicians often complete this part of the patient assessment, pharmacists are also skilled at completing parts of the physical exam. These parts include, but are not lim- ited to, measuring vital signs and inspecting and palpating parts of the body related to the patient’s complaint. For example, a pharmacist may assess the severity of lower leg edema by inspecting and palpating the area of swelling. Additionally, pharmacists may conduct mental status examinations or assess the effects of a stroke by examining the patient for facial droop, arm drift or strength, and speech abnormalities. The medication history provides insight into the patient’s current and past medications, adverse drug reactions or allergies, adherence, the patient’s own understanding about his or her medications, and any other concerns a patient may have regarding his or her medications. Asking 9 pertinent questions with a systematic approach, utilizing appropriate technique, and actively listening to the patient will enable you to collect a thorough and accurate medication history. This, in turn, will enable you to identify, prevent, and/or resolve any active or potential drug-related problems. For example, a patient who is taking warfarin may also tell you she is taking ibu- profen 200 mg twice daily for arthritis pain. This information provides you with an opportunity to assess the patient’s arthritis pain and inquire about what other agents have been tried to treat the pain. After evaluating the patient, you may determine that acetaminophen is the more appropriate drug for this patient.
Therefore purchase glipizide with visa, iis importanto prevenunnecessary costs and use adequa and effective treatments to reach the goals of hypernsion treatment discount 10 mg glipizide with amex. Ihas been estimad that order glipizide 10 mg fast delivery, in France, Germany, Italy, Sweden and GreaBritain, health care costs of 1. In a 42 corresponding national study carried ouin the years 1996-1997, 81 % of men and 80 % of women had blood pressures higher than the targelevel (which was 140/90 mmHg according to the older criria) (Takala eal. In 1997, population samples of 25- to 64-year-olds from Northern Karelia, Kuopio, south-wesrn Finland and Helsinki-Vantaa region showed thathe mean systolic blood pressures in men ranged from 135 to 138 mmHg and those in women from 128 to 132 mmHg, and the corresponding diastolic blood pressures in men were 83 to 85 mmHg and those in women 80 mmHg (Kastarinen eal. From 1982 to 1997 in Northern Karelia, Kuopio and south-wesrn Finland, systolic blood pressure in men decreased by 6-7 mmHg and thain women by 7-10 mmHg. Diastolic blood pressure also decreased in Northern Karelia and Kuopio by 2 to 3 mmHg in men and by 3 to 4 mmHg in women, while there was no change in south-wesrn Finland. Furthermore, the study showed thathe age-adjusd prevalence of hypernsion (systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg or antihypernsive medication) had decreased in Northern Karelia and Kuopio by 16 to 18 percentage points in men and by 13 to 15 percentage points in women. The corresponding figures in south-wesrn Finland were 11 percentage points for men and 9 percentage points for women. Furthermore, 31% of them were unaware of their hypernsion, and only 23% both had medical treatmenfor their hypernsion and had reached a blood pressure under 140/90 mmHg. Erdine (2000) also repord thaonly 4 to 33 % of hypernsive patients in nine European countries had blood pressure readings lower than 140/90 mmHg. A Scottish study showed that, especially in men, the control of blood pressure is accordanwith the rule of halves, which means thahypernsion goes undecd in half of patients, hypernsion remain untread in half of the rest, and hypernsion remains uncontrolled in half of the res(Smith eal. Starting and continuing of antihypernsive treatmenSeveral studies have shown that, afr starting antihypernsive medication, the problem is thamany hypernsive patients stop taking their medications. In all of the five drug groups, 6 to 9% of patients changed the antihypernsive drug firsprescribed to them to a drug from another group. A huge number of non-compliance studies have been produced, buwe still face enormous problems of non-compliance. We know thanon-compliance is very common and 44 pontially presenin practically every medical treatment. We have several methods for measuring non-compliance, bunobody has been able to crea a standardized method thawould produce reliable results. Research has been able to recognize several factors associad with non-compliance, buour possibilities to improve compliance are very limid. We know thanon-compliance is associad with poor treatmenoutcomes in many diseases, including hypernsion. The high discontinuation ras of antihypernsive medications, aleasin the early stages of treatment, have been found to be more than alarming. On the other hand, hypernsion research has been able to recognize several factors associad with poor blood pressures, butoday, only a minority of hypernsive patients reach the targelevels of blood pressure in Finland as well as in many other countries. To describe the prevalence of differenperceived problems and attitudes in the treatmenof hypernsion. To evalua the association of perceived problems and attitudes with non- compliance with antihypernsive drug therapy. To evalua the association of perceived problems and attitudes as well as non- compliance with the control of blood pressure with antihypernsive drug therapy. To be eligible to participa in the study, the patients had to fulfil the following criria: born in the year 1921 or lar, buying antihypernsive medication for himself/herself and entitled to receive special reimbursemenfor antihypernsive medication under the national sickness insurance program. Of the patients invid to participa (n = 971), 105 refused and 866 agreed and received a questionnaire to be compled ahome (Figure 1). Of the respondents, 54 were excluded from the analyses due to missing data on aleasone variable. Men Women Total Characristic n % n % n % Age < 50 years 47 24 41 18 88 21 50 � 64 years 104 52 98 43 202 47 65 � 75 years 48 24 90 39 138 32 Education primary 75 38 126 55 201 47 secondary 97 49 87 38 184 43 academic 27 14 16 7 43 10 Years of treatmen< 5 45 23 48 21 93 22 5 � 9 57 29 47 21 104 24 10 � 19 56 28 64 28 120 28 > 20 41 21 70 31 111 26 Number of antihypernsive drugs 1 96 48 100 44 196 46 2 75 38 103 45 178 42 3 � 5 28 14 26 11 54 13 4. These findings motivad the initiation of a new study on the treatmensituation and problems in hypernsion care in 1996-1997. Thirty health centres ouof the a total of 250 health centres in Finland were randomly selecd by stratified sampling as representative of the basic population in rms of size and geographical location. Twenty-six health centres with a total of 255 general practitioners agreed to participa in the study. During one week in November 1996, these general practitioners identified all of the hypernsive patients who visid them (n = 2. During the following three 48 months, public health nurses sento these patients two questionnaires and an invitation to a health examination. Athe health examination a trained public health nurse checked any missing data in the firsquestionnaire. The second questionnaire, which contained confidential data on the local doctors, nurses and health care sysm, was handed to the nurse in a closed envelope to be mailed to the university. Eighty-four per cenof the patients had aleasthree blood pressure readings from the year 1996 and the early parof 1997. In these measurements, the patients had had mean systolic and diastolic blood pressures 2. The prevalence of patient-perceived problems analyses were also carried ouon the medically untread population, which consisd of 220 patients, 90 (40. If the systolic and diastolic blood pressure values had been calculad based on the smaller of the two recorded readings, the respective values would have been 149. Men Women Total Characristic n % n % n % Age < 55 years 144 23 186 20 330 21 55 � 64 years 183 30 224 24 407 26 65 � 74 years 217 35 308 33 525 34 > 75 years 71 12 228 24 299 19 Education a lower 431 71 739 79 1170 75 b higher 180 29 200 21 380 25 Duration of hypernsion < 5 years 166 27 228 24 394 25 5 � 9 years 134 22 186 20 320 21 > 10 years 312 51 525 56 837 54 Number of antihypernsive drugs 1 331 54 462 49 793 51 2 223 36 375 40 598 38 3 � 5 59 10 105 11 164 11 a basic school, junior secondary school, primary school or parts of these curricula b academic education, occupational school, vocational school, senior secondary school Pharmacy-based study population Primary health care based study population 971 Were invid to participa 2219 Were invid to participa 105 Refused to participa 437 Did noparticipa 866 Agreed to participa 1782 Participad 384 Did noreturn the 1 Was excluded due to questionnaire missing data 482 Returned the questionnaire 1781 Study population with adequaly filled questionnaires 54 Were excluded due to 220 Medically untread missing data population 428 Final study population 1561 Final study population Figure 1. The two questionnaires included a total of 82 questions aboulifestyle, health care sysm, medication, blood pressure measurements and the patient�s experiences relad to the treatmenof hypernsion. These areas were identified from the lirature as being critical for good hypernsion care. The original questions were answered on a five- poinLikerscale (1 = absoluly agree, 2 = somewhaagree, 3 = somewhadisagree, 4 = absoluly disagree, 5 = does noconcern me) or a three-poinscale (14 questions: 1 = correct, 2 = nocorrect, 3 = does noconcern me). Using factor analysis with varimax rotation on these 82 questions, 21 factors were identified (eigenvalue of > 1. Four factors, including aspects of nonpharmacological treatmenof hypernsion, such as weighreduction (three factors) and use of salt, were excluded. The questions in the factors were dichotomized as 1 (those with a problem: absoluly agree, somewhaagree, and correct) and 0 (those withoua problem: somewhadisagree, absoluly disagree, nocorrect, does noconcern me, and missing data). On the basis of reliability and inrnal validity analyses, some questions and four of the factors were excluded. One factor was splibecause of its poor inrnal validity, and a total of 14 problem areas covered by 45 questions were thus identified. Experiences concerning the symptoms of hypernsion and adverse 51 drug effects were elicid by asking the patienwhether his/her hypernsion (or drug treatment) had caused any symptoms (adverse effects).