Four Times a Day, Really?

Let me start out by saying that I am sharing personal health information and I have waived my right to privacy on this specific matter.

I recently went to see my primary care provider. He is an excellent physician whom I trust. He prescribed an antibiotic for a local infection. We spoke about the options for antibiotics and decided on a medication that would most likely cover the microbial that had caused the infection while taking into consideration side effects and cost. Away I went with my prescription to the local retail pharmacy. That is when the problem began. I was to take the medication 4 times a day approximately 6 hours apart. If that was not enough, I had to make sure that I was taking the medication on an empty stomach, 1 hour prior to eating and 2 hours after my last meal. As many of you may know, I have spent a great deal of my career over the last 10 years on the issue of medication adherence. I am aware of the challenges that dosing and timing can bring to an individual and how they can affect adherence. That being said, I never really understood how significant that challenge can be. I tried—believe me—to fi nd a way to adhere to this medication. First, I wanted to rid myself of the infection and the evil germs that had caused the infection. Secondly, I felt that I needed to “walk the talk” regarding medication adherence. It did not seem appropriate for an adherence spokesperson to be nonadherent. This was no easy task. I found myself having to call my local pharmacist not once but twice over a 48-hour period to fi nd out how strict I had to be on the “every 6 hours” timing. I then had to call again to fi nd out if could I shorten the “empty stomach” rule some and by the way, does empty stomach include liquids?

So what were the lessons learned here and why does it matter? First off, if we want people to be adherent to their medications we need to take timing and directions into consideration. This means that the healthcare consumer, the doctor, and the payer have to be thoughtful of the matter. Physicians need to be aware that taking a medication 4 times a day is very difficult. Six AM, noon, 6 PM, and midnight is not a schedule that most people, including myself, can keep for any length of time. In addition this creates a very small window of opportunity to eat and still follow the directions on the medication. I would argue that these issues are as important as medication effectiveness, side effects, and cost. Secondly, patients need to be realistic about their capability to follow their provider’s directions and speak up prior to agreeing to take the medication. Lastly, it is important that the Pharmacy and Therapeutics (P&T) committees be thoughtful of the scheduling realities of QID medications. Most P&T committees look at dosing as one of the attributes of a drug when evaluating coverage. Unfortunately, it often looked at on the basis of patient convenience only. I think we need to broaden our thought processes.

I do understand that there are some conditions that absolutely require medications that are taken more often than most of us would like; historically, human immunodeficiency virus medications come to mind. That being said, I do believe from personal experience that even the most adherence-conscious people will find medications that need to be taken 4 or, in some cases, even 3 times a day a significant challenge. As we continue to chase the holy grail of medication adherence, we need to be mindful of reality and work together to create our best chance of success.