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BACKGROUND: Poor adherence to antihypertensive medication remains a significant barrier to blood pressure control in young patients. The objective of this study was to identify factors associated with antihypertensive medication adherence among young adults with hypertension.METHODS: From the Korean National Health Insurance Service database, we included 141,132 participants aged 20 to 39 years (80.4% male), without cardiovascular disease, who initiated antihypertensive medication between 2013 and 2018. Participants were categorized as exhibiting good adherence (proportion of days covered [PDC] ≥ 0.8) or poor adherence (PDC < 0.8) to antihypertensive medication during the first year of treatment. We investigated the associations of demographic, lifestyle, and clinical factors with good medication adherence based on logistic regression analysis.RESULTS: Only 43.3% ( = 61,107) of young adults with hypertension showed good adherence to antihypertensive medication. Male sex, older age, higher income, urban residence, non-smoking, and higher physical activity were associated with good medication adherence. Initial combination therapy, especially with single-pill combination (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.07-1.18), was associated with good adherence. Among patients under monotherapy, initial use of renin-angiotensin blockers (OR, 5.24; 95% CI, 4.47-6.15) or calcium-channel blockers (OR, 4.07; 95% CI, 3.47-4.78) was associated with better adherence than initial diuretics.CONCLUSIONS: Although antihypertensive medication adherence is generally poor among young adults, we identified potential demographic and clinical factors associated with good adherence to antihypertensive treatment. Initial use of a single-pill combination may promote adherence in young patients, and its long-term clinical outcomes warrant further investigation.