1. Medication Adherence Erin Rank, PharmD Candidate The Ohio State University College of Pharmacy May 23, 2007

2. Quote for the Day “Drugs don’t work in patients who don’t take them.” - C. Everett Koop, M.D.

3. Questions for you…… What are some things that may make you not want to take your medications? What are the benefits of your medications? How do you remember to take your medications?

4. Objectives Definition WHOs Three Pillars Facts and Stats Importance of medication adherence Predictors of poor adherence Barriers to adherence Tips to improve adherence

5. What is medication adherence? The extent to which a patient follows a medication regimen as prescribed by their doctor Patient-centered Mutual understanding between patient and doctor Replaced “compliance” No perfect term

6. What is medication adherence? Influenced by many different factors:  Patient  Practices of physician/healthcare team  Insurance/health system  Patient’s social support and environment

7. What’s the bottom line? You can only get the full benefit of your medication if you follow your prescribed treatment plan

8. A few notes about medications Can take weeks to months to work Skipping “a dose or two” CAN be a problem Many side effects subside after awhile If one med doesn’t work, there are many others to try Herbal products CAN interact

9. World Health Organization’s Three Pillars of Adherence Three Pillars:  Patient information  Motivation  Behavioral skills *Motivation most important as it is key in long- term behavior changes

10. Adherence Facts Higher adherence rate in acute vs. chronic conditions Chronic diseases hit a low point after 6 months 50% of patients on ADs won’t be taking them after 3 months Adherence decreases as # of meds increases

11. Adherence Facts Adherence is hard to measure clinically Means different things to different people Rate of adherence can range from 0 to over 100% Rates reported ~ 40-75% for chronic diseases

12. Adherence Facts Omitted or delayed doses most common “White-coat” adherence Increased dose frequency  poor adherence

13. Adherence to medication determined by dosing frequency Osterberg, L., Blaschke, T. Adherence to medication. N Engl J Med 2005;353:487-497. Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther 2001;23:1296-1310.

14. What adherence patterns are typical in chronic disease? 1/6- Take few or no doses, but give good impression 1/6- Have nearly perfect adherence 1/6- Drug holidays each month or more 1/6- Drug holidays 3-4 times each year 1/6- Miss an occasional dose 1/6- Take almost all doses but have some timing issues

15. Why do we care? Poor adherence associated with increased death, worsening of disease, and increased costs to patient and health care system

16. Factors that contribute to poor adherence Treatment of disease without symptoms Complex treatment plan Cost Poor relationship with doctor Missed appointments Cognitive/psychological problems Poor understanding of disease

17. Factors that contribute to poor adherence Poor follow-up by physician Lack of patient “buy-in” Concern about taking drugs Limited social support Substance abuse Physical problems Anger about the illness Side effects

18. Factors that contribute to poor adherence COST SIDE EFFECTS

19. Cost concerns Generics Ask your pharmacist Talk with your physician to increase awareness Assistance for some medications that insurance plan doesn’t cover

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21. Side effect management Common undesirable effects:  Nausea  Weight gain  Sexual dysfunction  Drowsiness  Sleep changes  Dry mouth  Blurred vision

22. Side effect management Common undesirable effects:  Constipation  Dizziness  Anxiety Talk with your health care team—many ways to deal with these issues!

23. Why do patients report poor adherence? Biggest problem—forgetfulness Drugs don’t fit in lifestyle Chose to miss doses Incomplete information Don’t know

24. Barriers on the provider side Complex regimens Discuss benefits/side effects Cost issues Consideration of drug and lifestyle needs Relationship with patient

25. Barriers on the Health System side Formularies Co-payments/cost-share Provider access

26. Osterberg, L., Blaschke, T. Adherence to medication. N Engl J Med 2005;353:487-497. Wilson J, Axelsen K, Tang S. Medicaid prescription drug access restrictions: exploring the effect on patient persistence with hypertension medications. Am J Manag Care 2005;11:SP27-SP34. Zyczynski TM, Coyne KS. Hypertension and current issues in compliance and patient outcomes. Curr Hypertens Rep 2000;2:510-514.

27. Interventions to improve adherence Four main targets:  Patient education  Increased provider access  Improved communication between health care team and patient  Alterations in dosing schedules

28. What can you do? Communication is key! -Talk to your doctor/health care team -Know your insurance plan -Pick the plan that is right for you -Ask about generics and cheaper alternatives

29. What can you do? Use reminders:  Sticky notes  Beeping alarms  Timers  Pill box (count out doses in advance)

30. What can you do? Support system  friends, family, health- care team Make your regimen fit your lifestyle Plan ahead for refills/travel/weekends Write it down!  Journal, planner  Write down when a dose is missed and why  What works and what doesn’t

31. Remember……… There is a drug and/or regimen that can work for you!

32. Questions? Thanks!

33. References Osterberg, L., Blaschke, T. Adherence to medication. N Engl J Med 2005;353:487-497. Aruffo, S., Grey, S. Think you have a compliance problem? Think again. The Case Manager 2005;16:43-46. Vlasnik, J.J., Aliotta, S.L., DeLor, B. Evidence-based assesment and intervention strategies to increase adherence to prescribed medication plans. The Case Manager 2005;16:55-59. Vlasnik, J.J., Aliotta, S.L., DeLor, B. Medication adherence: factors influencing compliance with prescribed medication plans. The Case Manager 2005;16:47-51. About.com: http://aids.about.com/cs/adherence/tp/tenadherence.htm; Accessed May 4, 2007. ©2007 About, Inc., A part of The New York Times Company.http://aids.about.com/cs/adherence/tp/tenadherence.htmThe New York Times Company Wilson J, Axelsen K, Tang S. Medicaid prescription drug access restrictions: exploring the effect on patient persistence with hypertension medications. Am J Manag Care 2005;11:SP27-SP34. Zyczynski TM, Coyne KS. Hypertension and current issues in compliance and patient outcomes. Curr Hypertens Rep 2000;2:510-514. Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther 2001;23:1296-1310.