When the Patient Won't Take the Medicine

In light of the importance of drug therapyin clinical disease, nonadherencehas become a major public healthproblem. Nonadherence is estimated at~40%, with some studies showing that itmay be as high as 75%.^1-3 In terms ofcost, nonadherence rivals that of cancer,Alzheimer's disease, and diabetes.⁴ Itresults in reduced efficacy or diseasedeterioration, with detrimental effects onpatient health and quality of life, as wellas increased morbidity and mortality.

Nonadherence is a precursor to increaseddrug expenditures. The averagemonthly cost of drugs prescribed fornonadherent patients is almost 3 timeshigher than the cost of drugs for thosepatients who adhere to their drug regimen.^3,5 Studies have shown that $11 billionis spent annually servicing poortherapeutic outcomes associated withnonadherence.^2,5

Reasons for Nonadherence

All patients should be screened formedication adherence. Patients with thehighest risk for nonadherence are as follows^6,7:

• The elderly
• Patients taking >3 medications
• Patients seeing multiple physicians
• Patients with multiple disease state
• Patients with poor recall of their drugregimen
• Patients who develop excessive sideeffects or drug interactions

One study revealed that 59% of theelderly on long-term therapy make >1errors when taking their medications,with 26% making a potentially seriouserror and 66% of these errors beingerrors of omission.^8-10 Many elderlypatients who omit medications do sodeliberately. Many think that they do notneed the medication or that the dose istoo strong.

A large percentage of patients, especiallythe elderly, lack basic informationabout their medications. Many are notinformed about the drug name, purpose,dosage schedule, duration of therapy,side effects, and adverse consequences(eg, what happens if they stop taking themedication).

In a Seattle, Wash, study, only 44% ofpatients using prescription drugs couldrecall a pharmacist instructing them onthe drugs' use, whereas 80% recalledthat their physician had done so. Only52% reported that their physician hadinstructed them about possible sideeffects, and only 30% reported receivingthis information from their pharmacist.^3,11

Disease Deterioration

Nonadherence-induced disease deteriorationhas been observed in patientswith hypertension, diabetes, seizures,and HIV, as well as in patients who havehad an acute myocardial infarction (AMI).

A study by Newby and colleagues¹²showed that long-term adherence to secondary-prevention therapies for coronaryartery disease (CAD) remains poor. Nearly50% of the patients with CAD in the 7-year study admitted that they did notconsistently take -blockers, lipid-loweringtherapy, aspirin, or angiotensin-convertingenzyme inhibitors. The study alsorevealed that nonadherence was greateramong people with the highest risk ofpoor outcomes, who could benefit fromincreased medication adherence.

The results of 2 other studies showedthat nonadherence to medications iscommon among recent AMI patients andin patients with diabetes, resulting inhigher mortality. Nonadherence in theAMI study resulted in an almost fourfoldincrease in the death rate in the first yearafter hospital discharge.¹³ The diabetesstudy showed almost a twofold increasein mortality following nonadherence.¹⁴

A study by Chapman and associates¹⁵showed that, within 3 months of startingboth antihypertensive and lipid-loweringtherapies, less than half of the patientswere taking both medications as prescribed.

Polypharmacy

Nonadherence actually increases thepatient's risk of receiving additionalunnecessary medications. Nonadherenceand the disease deterioration itcauses can lead to the following⁶:

• Continuing existing drug therapy atan increased dose
• Adding a new medication to theregimen
• Stopping the initial medication that isperceived as ineffective and replacingit with another medication

Because polypharmacy can result innonadherence, a patient's drug regimenshould be assessed periodically, and thefollowing questions should be asked¹⁶:

• Is each drug necessary?
• Is the medication contraindicated inthe elderly?
• Does the patient have duplicatemedications in the regimen?
• Is the patient taking the lowesteffective dose?
• Is the medication intended to treat aside effect of another medication?
• Can the drug regimen be simplified?
• Does the regimen have potentialdrug interactions?
• Is the patient being adherent?
• Is the patient taking any OTC products,herbals, or other medications?

Cost

In order to increase medication adherence,cost needs to be considered.Researchers in Canada¹⁷ looked at 290chronically ill patients discharged fromthe hospital. The investigators discoveredthat drug cost was the primary reasongiven for nonadherence to their drugtreatment.

Physicians and pharmacists need toinquire about patients' ability to affordthe medications prescribed. The followingquestions may provide importantinformation¹⁸:

• Are there circumstances that makeit difficult for you to fill your prescriptions?
• If I changed your medication to a lessexpensive drug, would it be helpful?
• (For patients on managed care plans)Do you exceed your monthly orquarterly cap for medication coverage?
• (For patients with poorly controlleddiabetes) Are you testing your bloodsugar less often because you are tryingto conserve supplies?

Patient Education

Physicians and pharmacists must functionas teachers, motivators, and persuaders.Indeed, these health care professionalsare asking patients to takemedications for chronic disease fordecades. Communication is among themost important factors in order forpatients to adhere to their drug regimens.

Many elderly patients suffer from poorhearing, vision, and joint mobility. Patientsshould be asked to repeat informationthey are told to make sure that theyunderstand. Studies have demonstratedthat, if patients know why they are takinga medication, they will be more adherentand less likely to have another medicationprescribed.^6,19,20 Patients with arthritisshould be asked whether they canopen containers with a childproof cap.

Dr. Dutcher is a clinical pharmacistfor B&B Clinical Consultants, PuntaGorda, Fla.

References

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2. Lamy PP. Compliance in long term care. Geriatrika. 1985;1(8):32.

3. Coleman TJ. Non-redemption of prescriptions: linked to poor consultations. BMJ. 1994;308(6921):135.

4. www.ascp.com.

5. Bloom JA, Frank JW, Shafir MS, Martiquet P. Potentially undesirable prescribing and drug use among the elderly: measurable and remediable. Can Fam Physician. 1993;39:2337-2345.

6. Bosker G. Pharmatecture: Minimizing Medications to Maximize Results. 2nd ed. St. Louis, Mo: Facts and Comparisons; 1999.

7. Rosner F. Patient noncompliance: causes and solutions. Mt Sinai J Med. 2006;73(2):553-559.

8. Col N, Fanale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med. 1990;150(4):841-845.

9. McNally DL, Wertheimer D. Strategies to reduce the high cost of patient noncompliance. Md Med J. 1992;41(3):223-225.

10. Conn VS, Taylor SG, Kelley S. Medication regimen complexity and adherence among older adults. Image J Nurs Sch. 1991;23(4):231-235.

11. Beardon PH, McGilchrist MM, McKendrick AD, et al. Primary non-compliance with prescribed medication in primary care. BMJ. 1993;307(6908):846-848.

12. Newby LK, Allen NM, Chen AY, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006;113:203-212.

13. Ho PM, Spertus JA, Masoudi FA, et al. Impact of medication therapy discontinuation on mortality after myocardial infarction. Arch Intern Med. 2006;166:1842-1847.

14. Ho PM, Rumsfeld JS, Masoudi FA, et al. Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus. Arch Intern Med. 2006;166:1836-1841.

15. Chapman RH, Benner JS, Petrilla AA, et al. Predictors of adherence with antihypertensive and lipid-lowering therapy. Arch Intern Med. 2005;165:1147-1152.

16. Bushardt RL, Jones KW. Nine key questions to address polypharmacy in the elderly. JAAPA. Sept. 2006. Available at: http://jaapa.com/issues/j20050501/articles/polypharm0505.htm.

17. Macdonald ET, Macdonald JB, Phoenix M. Improving drug compliance after hospital discharge. BMJ. 1977;2:618-621.

18. Pavlovich-Danis SJ. Differentiating between inability to afford prescription medications and noncompliance. Geriatric Times. 2004:5(3).

19. Roth HP, Caron HS. Accuracy of doctors' estimates and patients' statements on adherence to a drug regimen. Clin Pharmacol Ther. 1978;23:361-370.

20. Park DC, Morrell RW, Frieske D, Kincaid D. Medication adherence behaviors in older adults; effects of external cognitive supports. Psychol Aging. 1992;7(2):252-256.