Date of publication: May 22, 2014

News & Views

Adherence (Part 6) – Improving adherence through treatment optimization and simplifying regimens

Patients can find it challenging to adhere to complicated treatment regimens. For example, elderly patients who have cognitive or memory impairments may find therapy compliance difficult,[1] and younger patients may struggle to adapt their lifestyle to treatment demands.[2] This article will look at different ways in which treatment strategies can be adjusted in order to reduce regimen complexity and potentially improve adherence.

Simplifying dosing demands

Kripalani et al. analysed 37 randomized controlled trials, across multiple chronic diseases, which described interventions intended to enhance patient adherence to self-administered medications.  The review found that the most effective approaches were behavioural interventions that simplified dosing demands.[3]

A systematic review of 76 studies also showed that simpler, less frequent dosing regimens are associated with better adherence in a variety of diseases.[4] Similarly, a Cochrane Review of hypertensive patients also found that reducing the number of daily doses increases adherence.[5]

However, reducing the frequency of phosphate binder dosing is particularly challenging as pills must be taken at every meal. Despite this it may be possible to:

  1. Reduce the number of phosphate binders that need to be taken at each meal, and
  2. Rationalize the dosing regimens of binder and non-binder medications, for example by equating a “morning” dose to “with breakfast”.

Reminder systems

A randomized clinical trial found that a personalized cell phone reminder system was capable of improving adherence to antiretroviral therapy in 23 HIV patients.[6] Similarly a Cochrane review of interventions to improved adherence to lipid lowing drugs found that the most effective interventions were based on reminder systems.[7]

Dose packaging strategies

A systematic review of the adherence benefits of packaging pills with a calendar and/or pill organisers found that six out of ten trials reported higher adherence. However in only one study did this relate to clinically significant improvement.[8]

Individualized treatment plans

Healthcare professionals can also draft specific treatment plans for patients. A Cochrane review by Gray et al. showed that individualized care planning improved adherence in glaucoma patients.[9] Personal treatment plans may also have greater importance in patients with multiple comorbidities, where each condition has its own treatment regimen. Pharmacists have an increasing role to play in developing these plans, through programs such as Medicare’s Medication Therapy Management.

See also the previous Adherence articles:

March 24th, 2014; Adherence Part 1 – The challenge of non-adherence in hyperphosphatemia

April 11th, 2014; Adherence Part 2 – Is adherence to phosphate binder therapy associated with improved outcomes?

April 24th, 2014; Adherence Part 3 – Why do patients not adhere to therapies?

May 6th, 2014; Adherence Part 4 – Why do patients not adhere to phosphate binders:poor tolerability?

May 16th, 2014; Adherence Part 5 – Why do patients not adhere to phosphate binders:high pill burden?

References

1. Andrade ASA, McGruder HF, Wu AW, et al. A programmable prompting device improves adherence to highly active antiretroviral therapy in HIV-infected subjects with memory impairment. Clin Infect Dis Off Publ Infect Dis Soc Am. 2005;41(6):875-882. doi:10.1086/432877.

2. Horne R, Weinman J, Barber N, Elliott R, Morgan M. Concordance, Adherence and Compliance in Medicine Taking: Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). NCCSDO; 2005. Available at: http://www.nets.nihr.ac.uk/__data/assets/pdf_file/0009/64494/FR-08-1412-076.pdf.

3. Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med. 2007;167(6):540-550. doi:10.1001/archinte.167.6.540.

4. Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2001;23(8):1296-1310.

5. Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database Syst Rev. 2004;(2):CD004804. doi:10.1002/14651858.CD004804.

6. Hardy H, Kumar V, Doros G, et al. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs. 2011;25(3):153-161. doi:10.1089/apc.2010.0006.

7. Schedlbauer A, Davies P, Fahey T. Interventions to improve adherence to lipid lowering medication. Cochrane Database Syst Rev. 2010;(3):CD004371. doi:10.1002/14651858.CD004371.pub3.

8. Zedler BK, Kakad P, Colilla S, Murrelle L, Shah NR. Does packaging with a calendar feature improve adherence to self-administered medication for long-term use? A systematic review. Clin Ther. 2011;33(1):62-73. doi:10.1016/j.clinthera.2011.02.003.

9. Gray TA, Orton LC, Henson D, Harper R, Waterman H. Interventions for improving adherence to ocular hypotensive therapy. Cochrane Database Syst Rev. 2009;(2):CD006132. doi:10.1002/14651858.CD006132.pub2.

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