Improving Medication Compliance Among Glaucoma Patients

ByRichard A. Lewis, MD

The issue of medication compliance has become a ubiquitous problem in all fields of medicine. For ophthalmologists, the ideal glaucoma treatment plan would balance benefits with risks, use the least amount of a particular medication to achieve the desired result with the fewest side effects and make patient compliance a primary consideration in choosing a particular course of treatment.

In short, ophthalmologists would be able to individualize glaucoma treatment and focus on preserving vision and the optic nerve, not just on lowering IOP.

In reality, however, this is not the case. Many patients come to us with extensive lists of medications and dosage schedules that make the problem of compliance particularly acute.

Medication burden in glaucoma: One practice’s perspective

To determine the medication burden of my glaucoma patients, I conducted a medication chart review of new patients referred for glaucoma to my practice over a 12-month period ending September 2004.

Ophthalmologists must be aware of the burden posed by a patient’s multiple medical regimens, as well as the attendant financial costs and potential side effects.

— Richard A. Lewis, MD

We reviewed 119 patients, most of whom were women, with an average age of 72 years, which is typical for a glaucoma practice. Sixty-four percent had previous cataract, trabeculectomy and glaucoma surgery. In terms of comorbid conditions, 53% had hypertension and 29% had arthritis. The mean group IOP was 18.8 mm Hg, ranging from 5 mm Hg to 68 mm Hg.

Surprisingly, the number of medications averaged five per patient, ranging from one to 15 medications, with an average of 2.1 ocular therapies per patient. The dosage for most medications is between one and four times per day, which would require patients to administer drops five to 10 times per day. This type of regimen is onerous in terms of remembering the regimens, convenience issues, physical ability to administer all the required doses and cost, especially in older patients with a number of health problems.

Ophthalmologists must be aware of the burden posed by a patient’s multiple medical regimens, as well as the attendant financial costs and potential side effects. These factors continue to stimulate the need for combined medications, such as prostaglandins/beta blockers, which, if approved, would both save costs and increase convenience.

Poor persistency is problematic

Compliance issues are not unique to glaucoma or to the United States. According to a large study of prescription drug data for diabetes, high cholesterol, glaucoma and bladder incontinence, the prescription renewal rate at approximately 6 months is less than 50% for all four chronic conditions (Figure 1).^1-4

Time to discontinuation
of various therapies in the United States
Figure 1 [graph]

Figure 1. Failure to comply with chronic medical regimens is a problem faced by clinicians in all medical specialties. Unlike other conditions, ensuring compliance in glaucoma is made more difficult by the lack of obvious symptoms.

(Figures courtesy of Richard A. Lewis, MD.)

Poor persistency is a global public health problem. Multiple studies have shown that more than 50% of patients with ocular hypertension and primary open-angle glaucoma discontinue prescribed medication within 1 year.^5,6 Although some patients restart therapy at a later date, lengthy gaps in therapy often occur.

Obstacles to compliance include both lack of education, which can be addressed by the clinician, and physical impediments, often related to age or concomitant conditions. Clinicians must work with patients to ensure a thorough understanding of their disease and the risks associated with failure to follow a specific regimen on a consistent basis. Another concern is the cost of drug therapy; clinicians must weigh efficacy vs. cost in developing a treatment regimen, but also remember that a patient may stop treatment altogether if the more effective medication is too expensive for the patient.

Age and conditions such as arthritis also impact treatment. Previous research has found that difficulty in directing the bottle when applying drops occurred in at least 36% of patients. Other difficulties include squeezing the bottle, identifying the bottle, poor visibility of the dropper tip, blinking, prodding the eye with the dropper tip and shaky hands (Figure 2).⁷ Clinicians may need to consult with a general physician to determine steps to overcome these concerns.

Reasons for noncompliance:
administration difficulty
Figure 2 [graph]

Figure 2. When determining a glaucoma medical regimen, clinicians should consider the areas of greatest difficulty for patients.

Can compliance be accurately assessed?

Although combination drugs would be a great tool in helping increase compliance, the best advice is for ophthalmologists to develop a relationship with their glaucoma patients to provide information about the disease and the need for compliance.

— Richard A. Lewis, MD

Accurately assessing compliance among glaucoma patients remains a challenge. Research has repeatedly shown the following: physicians are unable to distinguish the compliant patient with any degree of certainty, physicians assume a much higher rate of compliance than what is actually occurring and patients are not always truthful about their compliance.⁸

In a landmark study, Michael A. Kass, MD, and colleagues instructed patients on how to use their medications and then subsequently interviewed both physicians and patients. Although physicians assumed that 80% of their patients were taking the medications as prescribed, only 26% of patients were actually taking the medications at the correct dosage level.⁹

When assessing compliance, IOP measurements can be misleading for several reasons: high IOP can be a predictor of noncompliance or indicate a nonresponse to treatment, compliance rates often increase before an office visit and IOP measurements may not reflect fluctuations when medications were omitted.

Strategies for increasing compliance

Although combination drugs would be a good tool in helping increase compliance, the best advice is for ophthalmologists to develop a relationship with their glaucoma patients to provide information about the disease and the need for compliance.

In addition, clinicians should share ideas for improving compliance (Table).¹⁰ For example, a study conducted in New Zealand found that placing sterile black tape around the bottle tip made the tip easier for patients to visualize, which aided in ocular therapy.¹¹ Patients were less likely to touch the eye with the dropper and less likely to require multiple drops compared to a standard dropper.

Table. Strategies to improve compliance

Providing instructions and patient education materials
Simplifying the medication regimen
Counseling about the regimen
Offering support group sessions
Sending reminders manually or electronically
Cuing medications to daily events
Acknowledging a patient’s adherence efforts
Self-monitoring with regular physician review and reinforcement
Involving family members and significant others

An effort is also being made to develop a new compliance monitor for Travatan (travoprost, Alcon), whereby ophthalmologists can use their computer to see how patients manage their treatment regimens. This device would provide quality instruction time with patients on drop administration, drug application intervals, missed doses and the overall correlation with disease progression. When this compliance monitor becomes available, ophthalmologists will have more accurate information on individual patients.

References
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