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There has been a large disconnect between how compliant providers believe their patients are and those patients’ actual level of compliance.1,2 Studies have shown that 50% of patients do not adhere to their medication regimen more than 75% of the time.3 It is difficult for patients on lifelong medication regimens to remain completely compliant, given barriers to adherence such as medication costs, confusing dosing requirements, and a basic lack of understanding of the importance of the medications in question. Along with encouraging patients to maintain their medication regimens, there are several other things providers can do to aid them in achieving compliance.
TO THE POINT
By making drop regimens easier and educating patients on the consequences of noncompliance, optometrists can help improve medical management of glaucoma.
TIPS AND TRICKS
Remembering to take a medication every day can be overwhelming, especially when patients face a daunting array of glaucoma medications. Having patients explain why they are experiencing compliance issues can help both the patient and the doctor to find better solutions to this problem. If the patient has difficulty keeping the drops straight, color-coding may help keep them organized. If forgetfulness is an issue, it may be helpful to involve a family member. It can also be helpful to incorporate drops into an already established routine. For example, if a patient takes systemic medications, he or she can place the bottles next to the pill box and administer them all at the same time. Linking drops with other hygiene routines such as brushing the teeth or taking a nightly shower can serve the same purpose.
Many patients struggle with adherence due to a misperception that the drops must be administered only at a particular time each day. For instance, one of my patients works the third shift, and he believed he could not take the drops as indicated because he was at work when he was supposed to use them. It is far more important, however, to administer the drops at the same time every day than to do so at a particular time. Stressing the importance of consistency rather than a specific time can greatly aid in increasing compliance. For example, if 5:00 pm is a more convenient time for a patient to use his prostaglandin analogue than right at bedtime, that is fine as long as he remains consistent with that time. Have patients choose a time that will be convenient, preferably as part of an already established routine, and compliance generally improves.
PRESERVATIVE-FREE COMBINATION DROPs
A common barrier to compliance is the sheer number of drops a patient must administer each day. This issue is exacerbated when the regimen is further complicated by the requirements for each medication, such as different administration schedules (once, twice, three times daily) and the time the patient must wait between drops. If a patient struggles with just one drop each day, then additional drops and requirements will not help matters. Further, adding a second medication often decreases compliance with the first medication,4 and the problem worsens with every added medication.
Compliance issues for medications that must be administered two or more times a day are even worse.5 I have prescribed combination medications in my practice for some time, and I have found that patient compliance improved significantly with the use of commercially available branded combination medications such as brimonidine tartrate 0.2%/timolol maleate 0.5% ophthalmic solution (Combigan, Allergan), dorzolamide HCl 2%/timolol maleate 0.5% ophthalmic solution (Cosopt PF, Akorn), and brinzolamide 1%/brimonidine tartrate 0.2% ophthalmic suspension (Simbrinza, Alcon). In fact, in 2015, the largest growth in the glaucoma market was in combination drops.
Recently, another approach is the use of branded compounded medications. Simple Drops (Imprimis Pharmaceuticals) is a line of compounded combination glaucoma medciations, available in six formulations. The delivery vehicle used by the manufacturer, a poloxamer 407 base, ensures increased residence time and bioavailability and acts as a surfactant for the combination formulations.6 Patients receive the medications they need while reducing their number of drops. Typically, costs are reduced, and call-backs to practices from pharmacies, patients, and insurance companies are also significantly reduced, if not eliminated altogether.
In my experience, the use of these compounded drops has improved regimen clarity for patients, family members, doctors, and staff. Most of our experience has been with the Simple Drops combinations that are not available in any branded formulation, such as the timolol/brimonidine/dorzolamide combination (Tim-Brim-Dor).
With these combination drops, patient satisfaction and quality of life have been significantly improved. Additionally, concerns about toxicity due to preservatives are eliminated with these preservative-free formulations. The only adverse reaction attributed to these combinations we have seen is a transient burning sensation reported by some patients, which dissipates after a few seconds to minutes. Overall, we have seen a significant increase in compliance—especially in patients who were previously taking the individual components separately—and, as a result, better intraocular pressure control and patient satisfaction.
Perhaps the most common reason people forget their drops is that they do not view them to be as important as systemic pills. Therefore, it is critical to educate patients on the vital role these medications play in maintaining their ocular health and vision. They need to understand what happens if drops are missed: how their disease will progress, and what the irreparable consequences will be for their vision if they do not comply with their medication regimen.
A patient is no different from any other consumer. Many people will happily pay $5.00 for a cup of gourmet coffee every morning because they enjoy starting their mornings with that expensive shot of caffeine. Give patients a value for their medications. They will be more likely to adhere to their regimen if providers ensure that they understand the value of their medication, what it is doing for them, and why that particular medication was prescribed for them.
To educate my patients on the choices I make with their medications, I have created a nonbranded form that explains the differences in the consistency of inactive ingredients between generic formulations and those of equivalent branded drugs or branded compounded drugs. That assurance of consistency shows my patients that they are taking medications that will remain stable and perform as expected with long-term use.
Once patients understand the value of their medications, compliance often increases—as does their willingness to pay for the medications. They find ways to remember on their own because it then becomes important to them.
1. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497.
2. Friedman DS, Quigley HA, Gelb L, et al. Using pharmacy claims data to study adherence to glaucoma medications: methodology and findings of the Glaucoma Adherence and Persistency Study (GAPS). Invest Ophthalmol Vis Sci. 2007;48(11):5052-5057.
3. Okeke CO, Quigley HA, Jampel HD, et al. Adherence with topical glaucoma medication monitored electronically: the Travatan Dosing Aid Study. Ophthalmology. 2009;116(2):191-199.
4. Robin AL, Covert D. Does adjunctive glaucoma therapy affect adherence to the initial primary therapy? Ophthalmology. 2005;112(5):863-868.
5. Olthoff CMG, Schouten JSAG, van de Borne BW, Webers CA. Noncompliance with ocular hypotensive treatment in patients with glaucoma or ocular hypertension an evidence-based review. Ophthalmology. 2005;112(6):953-961.
6. Cholkar K, Patel SP, Vadlapudi AD, Mitra AK. Novel strategies for anterior segment ocular drug delivery. J Ocul Pharmacol Ther. 2013;29(2):106-123.
I. Paul Singh, MD
• ophthalmologist, The Eye Centers of Racine & Kenosha, Wisc.
• financial disclosure: speaker/consultant: Aerie, Alcon, Allergan, Bausch + Lomb, Ellex, Glaukos, Imprimis, Ivantis, Novabay, Shire, Sun, Zeiss