Adherence to Medical Therapy
Chat Highlights
March 19, 2008

On Wednesday, March 19, 2008, Dr. Michael Pro, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Adherence to Medical Therapy".

Moderator: Welcome Dr. Pro. Tonight's topic is “Adherence to Medical Therapy."  This must be one of the most important factors in successful treatment.

Dr. Pro:  Absolutely and it really is quite a problem.  I have a few articles that quote some figures:

Gurwitz et al examined the adherence of Medicaid patients with glaucoma who were older than 65 years and who were newly initiated to a single topical agent for glaucoma. Adherence was measured through a retrospective review of prescription records. The study found that 23% of the patients did not receive a refill of their glaucoma medication within a 12-month period after the initiation of therapy.

[Gurwitz JH, Glynn RJ, Monane M, Everitt DE, Gilden D, Smith N, Avorn J Treatment for glaucoma: adherence by the elderly. Am J Public Health. 1993 May;83(5):711-6.]

In another article, Sleath and co-workers found that 60% of patients reported 1 or more problems with taking their glaucoma medications. Fourteen percent of patients reported being less than 100% adherent to their glaucoma regimen medications during the previous week. Patients who had difficulty remembering to take their glaucoma medications and those who reported that they had other problems or concerns with their glaucoma medications were significantly less likely to be 100% adherent.

[Sleath B, Robin AL, Covert D, Byrd JE, Tudor G, Svarstad B. Patient-reported behavior and problems in using glaucoma medications. Ophthalmology. 2006 Mar;113(3):431-6. Epub 2006 Feb 3.]

P:  What, in your experience, are the major obstacles to compliance?

Dr. Pro:  There is a recent article that discusses this.

Friedman and co-workers addressed factors that were associated with medication non-compliance. They found that:

Doctor-patient communications and health-related beliefs of patients contribute to patient adherence. Patient learning styles that are associated with less concern about the future effects of glaucoma and the risks of not taking medications are associated with lower adherence. Specifically, knowledge about potential vision loss from glaucoma is a critical element that tends to be missed by more passive doctor-dependent patients who tend to be poorly adherent. These findings suggest that educational efforts in the office may improve patient adherence to medical therapies.”

Eight variables were associated independently with a lower medication possession ratio: (1) hearing all of what you know about glaucoma from your doctor (compared with some or nothing); (2) not believing that reduced vision is a risk of not taking medication as recommended; (3) having a problem paying for medications; (4) difficulty while traveling or away from home; (5) not acknowledging stinging and burning; (6) being non-white; (7) receiving samples; and (8) not receiving a phone call visit reminder.

[Friedman DS, Hahn SR, Gelb L, Tan J, Shah SN, Kim EE, Zimmerman TJ, Quigley HA. Doctor-Patient Communication, Health-Related Beliefs, and Adherence in Glaucoma Results from the Glaucoma Adherence and Persistency Study. Ophthalmology. 2008 Mar 3; Epub ahead of print]

Moderator: Dr., what does number (1) in the list above mean?

Dr. Pro:  In other words, if a patient is non-inquisitive and passive, he or she will not research into their disease on their own and will not read about the seriousness of their condition. After all, a patient may see his or her doctor once every 6 months, between those visits he or she may not consider his or her glaucoma at all.

In another study, Taylor et al used qualitative methods to examine the reasons for non-adherence among glaucoma patients. They assembled 2 focus groups and conducted 11 in-depth interviews. They found that forgetfulness was the primary reason for non-adherence among these patients.

They also found that provider–patient communication was very important to the patients. Patients also wanted their providers to give them suggestions on how to make their medication regimens easier.

[Taylor SA, Galbraith SM, Mills RP. Causes of non-compliance with drug regimens in glaucoma patients: a qualitative study. J Ocul Pharmacol Ther. 2002 Oct;18(5):401-9.]

P:  Are patients honest about compliance with drug regimes?

Dr. Pro:  I can't say whether they are honest about the drops; probably not always, but that is not always clear.

P:  Traveling with drops is sometimes difficult, with time changes and having to keep the drop cold. I've had the airlines confiscate the gel that keeps my drops cold. Do you have any suggestions on how to deal with those situations?

Dr. Pro:  First, not all drops need to be kept cold. You should ask your pharmacist in particular which drops must be chilled. All glaucoma drops used in my practice are not kept in the refrigerator before they are opened. They keep at room temperature.

As to time changes, it is probably best to try to switch to the local time to improve compliance. If one is used to taking a drop right before bed and then has to try to remember to take it a 2:00 pm, that's difficult.

P:  Have you heard of a drop called duotrav, used in Scotland? It's a combination of timoptic & travatan. Would a combination drop help with compliance?

Dr. Pro:  Duotrav is not available in the U.S., but there are several other fixed-combination drops available. I think combination drops do improve compliance. Studies have shown that compliance drops off when additional drops are added. The beauty of fixed-combination drops is that they combine two medications into one drop.

P:  This may seem like a dumb question, but are there studies that actually track progression of glaucoma against adherence to treatment?

Dr. Pro:  Great question and I cannot think of a study off the top of my head. I'll report back to the group if I see one.

P:  When instilling drops two times a day, should they be done 12 hours apart?

Dr. Pro:  Yes, in almost all cases this is best. Only when patients really have a hard time remembering with that regimen should the spacing be altered.

Dr. Pro:  There are also devices that can help compliance.

The Travatan Dosing Aid—Flowers and co-workers said:

Participating physicians perceived that problems involving dosing and adherence were reduced after patients used the dosing aid. Physicians indicated that they would recommend continued use of the travoprost dosing aid for 91.3% (73/80) of patients. All 10 participating physicians said that they would recommend the dosing aid to patients in the future. Of the 81 patients, the majority (68.8% [55/80]) indicated that they would like to continue using the travoprost dosing aid. For 67.5% (54/80) of patients, dosing adherence as recorded by the travoprost dosing aid was >70%. The dosing lever (39.7% [31/78]) and the visual alarm (29.5% [23/78]) were the 2 most favored features of the dosing aid reported by all evaluable patients. The majority of patients (58.8% [47/80]) indicated that they were "relieved" or "very relieved" that the doctor was able to monitor when they dosed their medication; few (7.5% [6/80]) were "concerned" or "very concerned.”

[Flowers B, Wand M, Piltz-Seymour J, Berke SJ, Day D, Teague J, Smoot TM, Landry TA, Bergamini MV, Mallick S; Travatan Dosing Aid Study Group. Patients' and physicians' perceptions of the travoprost dosing aid: an open-label, multicenter study of adherence with prostaglandin analogue therapy for open-angle glaucoma or ocular hypertension. Clin Ther. 2006 Nov;28(11):1803-11.]

P:  What exactly is this "dosing aid?"

Dr. Pro:  It is a device that was designed by the Alcon Company specifically for the Travatan bottle. It had a computer chip and a built in alarm. When a drop was dispensed the device recorded it and the time. Then the information could be down-loaded onto a PC at the doctor's office. A printout of the patient's drop use was recorded between visits.

P:  Is there a fee for the dosing aid?

Dr. Pro:  No, but I am not sure if Alcon is producing it or supporting it any more.

P:  I have to massage my left eye as often as I can remember, but my right eye only four times a day. I am finding it hard to get used to this. Do you have any suggestions?

Dr. Pro:  You could try to keep a journal or program alarms into a digital watch or cell phone.

P:  Could you explain the purpose of eye massage? I have not heard of this.

Dr. Pro:  Some doctors have post-trabeculectomy patients massage their eyes to improve aqueous flow into the bleb.

P:  Does the massaging improve the flow? Does it increase or change the size of the bleb?

Dr. Pro:  Some doctors certainly think it improves the bleb. It can absolutely increase the bleb size early after the surgery, but patients should be cautioned that too forceful massage can lead to a low pressure or other problems. I once saw a patient who had caused a bleb leak when she had been told to massage and her fingernail scratched the eye.

P:  When a patient stops massaging, what happens to the flow? Does massaging have long-term effects?

Dr. Pro:  Theoretically the flow could decrease. Decreased flow could lead to bleb failure because scarring could take place. That being said, not all doctors have their patients massage and there is no agreement that it really works in the late post-op period (months and years after surgery).

Moderator: Thank you Dr. Pro. As usual, your answers are most helpful. We'll see you in two weeks to discuss exercise and glaucoma.

Dr. Pro: Thank you, goodnight all.

On April 2, Dr. Pro discussed "Benefits of Exersice" in the Chat room. Click here for highlights of that meeting.

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