This article is more than 5 years old. Information may no longer be current.
Compliance still often a missing link in glaucoma therapy
Economics and patient education can play a role in patients’ adherence to glaucoma treatment regimes.
Click Here to Manage Email Alerts
Despite advances in glaucoma therapeutics, patients’ adherence to their glaucoma medical regimen remains a key issue in management of the disease, according to one expert.
|
|
![Alan L. Robin, MD [photo]](/images/commonart/robin.jpg)
Alan L. Robin, MD, OSN Glaucoma Section Member, said that, despite the introduction of new glaucoma laser procedures such as selective laser trabeculoplasty and new surgical procedures such as nonpenetrating deep sclerectomy, ophthalmologists in the United States still turn predominantly to eye drops as the initial approach to lowering IOP in glaucoma or ocular hypertension.
Thus compliance remains a major issue in the efficacy of glaucoma therapy, he said, and physicians must learn that it is important for them to address the issue with their glaucoma patients.
In a telephone interview with Ocular Surgery News, Dr. Robin said he has had patients who have expressed high levels of satisfaction after undergoing glaucoma surgery because they no longer had to use their daily eye drops.
Because compliance continues to be an impediment to treatment, key future developments in glaucoma therapeutics may include long-term drug-delivery options, Dr. Robin said. In early testing, juxtascleral depot administration of anecortave acetate has lowered IOP in glaucoma patients for up to a year, he said.
But until such long-term delivery options become available, he said, clinicians must learn to address the issue of compliance with their patients.
Barriers to compliance
Dr. Robin noted that many older patients are taking multiple medications because of systemic health problems. They may be taking statins to lower cholesterol, or other medications for high blood pressure, diabetes, thyroid problems or arthritis. Some women may be using hormone replacement therapy.
“We, as ophthalmologists, tend to treat patients in a vacuum,” he said. “By that I mean, we forget that they are on different medications outside of ophthalmology. Many patients are on multiple medications, and adding another medication for an asymptomatic disease is sometimes the straw that may break the camel’s back.”
Another roadblock is that patients know how to take pill medications, but they may have no idea how to administer eye drops, Dr. Robin said. Older or infirm patients may have difficulty steadying the bottle and effectively placing the drop in the conjunctival sac. Instructional videos alone do not fully educate patients on the procedure, he said. Sometimes an instructional session in the office is called for.
Ophthalmologists must also understand their own role in assisting patients in taking their medication, Dr. Robin said. He said research has shown that, unless there is a strong doctor-patient interaction that includes the patient as a team member, patients will be less likely to comply with their medical regimen and more likely to sue in the event of a poor outcome.
Another factor that doctors should be aware of is the relative simplicity or complexity of the medication regime they prescribe.
“Often, if one medication is not working, we add two medicines and three and four. If you pick one efficacious medicine, that might be the best,” Dr. Robin said. “The more complex the regime is, the less likely they are to comply.”
Economics and eduction
The cost of glaucoma therapy is a major issue affecting compliance for many patients, Dr. Robin said. Patients on fixed incomes, faced with a choice of purchasing either a medication for a systemic disease such as arthritis or an asymptomatic disease such as glaucoma, will choose the medication that they feel most directly benefits them, he said.
Patients may also reduce their intake of a medication to cut costs, he said. Doctors should be aware of this and should assist patients by prescribing the fewest possible medications and emphasizing the importance of glaucoma therapy for the patient’s vision.
Patient education on this point is vital, he said. If patients do not perceive the benefit of taking their glaucoma medications, they are less likely to take it, he said.
“Patients may feel that, no matter what they do, they’re going to go blind anyway, so why should they take a medicine,” he said. “Make sure you educate patients about what glaucoma is and its asymptomatic nature.”
He recommended using multiple media, including videos and pamphlets about glaucoma. Think of patients as consumers in this context, he said, and give them literature to take home with them from the office to help keep their medical regimen in their consciousness.
“All you need is a little brochure or something that you can hand the patient, instructing them how to take eye drops and what glaucoma is that makes it a big deal,” Dr. Robin said.
Compliance devices
Compliance devices are now available with some glaucoma medications to assist patients who have problems with compliance, Dr. Robin said. For instance, he said, a device attached to a bottle of Travatan (travoprost ophthalmologic solution 0.004%, Alcon) can record when patients take the medicine. Another type of compliance device is available for Lumigan (bimatoprost ophthalmic solution 0.03%, Allergan).
“In many studies it has been shown that we doctors have no idea if a patient is compliant or not,” he said. “That’s important. For doctors to have a better gauge of this, such devices are important.”
A simple technique to improve compliance is to ask patients in straightforward, easy-to-answer questions about their compliance, Dr. Robin said. This requires the physician to have good communication skills, he said. Appropriate questions can include, “How are you doing?” and “Do you have any problems or concerns?” He also recommended asking at the end of each exam, “Do you have any more questions?”
This interaction during the exam can enhance the doctor-patient relationship, Dr. Robin said.
“If you ask a patient point-blank, in a nice way, ‘Are you having any trouble remembering your medicines?’ rather than being accusatory, the patient might say, ‘I’m supposed to take my prostaglandin in the evening, but I fall asleep and forget.’ This offers you a chance for negotiation,” he said. “You can then negotiate with a patient, saying, ‘Have you ever thought about taking it at noon?’ or ‘Have you ever thought about taking it in the morning? Would that be easier?’ This way you’re bringing the patient into the decision-making aspect of his own therapy.”
For more information:
- Alan L. Robin, MD, can be reached at 6115 Falls Road, Suite 333, Baltimore, MD 21209; 410-377-2422; fax: 410-377-7960; e-mail: glaucomaexpert@cs.com.
- Erin L. Boyle is an OSN Staff Writer who covers all aspects of ophthalmology.