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Glaucoma Therapy: The Pharmacist’s Role in Compliance
Glaucoma Therapy: The Pharmacist's Role in Compliance By Paul O'Dea
I
t is sad but true that the efficacy of a drug · means nothing if a patient is unwilling to take it. Although estimates vary, the majority of studies indicate that one-quarter to one-half . of glaucoma patients do not take medications according to instructions. 1A substantial number of defaulting patients claim th.at they never had any intention of following the physician's instructions. And it is generally agreed that at least 3% to 7% of prescription orders are never even dispensed. 1 The problem of compliance with glaucoma therapy has always been acknowledged. However, it is only since the methods used to measure compliance have become more accurate that the seriousness of the problem has been revealed. An editorial in the May 1986 issue of the American Journal ofOphthalmology called noncompliance "a leading cause of glaucoma blindness." 2 The obvious question is, "What can the pharmacist do to ensure that none of his patients become victims of 'blindness by default'?" Noncompliance. refers to any one of four ways that a patient may default in taking medication: Failure to take medication, including missed doses, inadequate doses, and stopping therapy prematurely;
Taking medication at incorrect time intervals; Ill Taking too much medication; II ·Taking medication for the wrong purpose. Noncompliance in glaucoma patients is generally associated with the first two of these. II
·Factors Associated with Noncompliance
A
s might be expected, published studies are often contradictory regarding the factors associated with noncompliance. The majority of studies agree that the following factors are related to noncompliance: II Complexity of therapeutic regimen. The greater the number of medications and the greater the total number of daily doses, the greater will be the rate of default. 1'3 s Incidence of side effects. The rate of noncompliance increases as the number and severity of drug-related side effects increases.1'3 Ill Duration of therapy. As the length of the required treatment period increases, the probability of noncompliance also increases. 1'3 • Physician-patient relationship. Noncompliance can be correlated with an impersonal manner and lack of warmth on the part of the physician. 1'4
Glaucoma - the Compliance -Picture Paul O'Dea is staffpharmacist; Jules Stein Eye Institute, University of California, Los Angeles· Medical Center, Los Angeles, CA. Received January 198&; ac{!epted ·M areh 1988. 38
M.
any attempts have been made to create a profile of a typical defaulter. Unfortunately, this has proved to be an impossible task. Noncompliance does not correlate with age, sex: income, numberof dependents, level
American Pharmacy, Vol. NS28, No. 9 September 1988/582
of education, occupation, maritaf status, race, e~hnic background, socioeconomic status, diagnosis, or severity of disease. 4 -6 The only assumption that can be safely made is that compliance can never be assumed. Every patient is a potential defaulter. Those who are totally ~nreliable in one situation may be completely reliable in another. Glaucoma can be viewed as a textbook example of a disease most likely to foster · noncompliance. It is asymptomatic, causing no pain or immediate disability. It is a chronic disease that requires lifelong adherence to a daily therapeutic regimen. The consequences of improper compliance are not immediate. And even patients who are always compliant see no subjective improvement in their condition. At times, the treatment may appear to be far worse than the disease. Pilocarpine, untii -recentiy tlie most commonly prescribed glaucoma medication, was generally administered four times a day. It frequently caused ocular side effects such as brow aches, buming and stinging on administration, fluctuating vision, and poor vision in dimly lit areas. Since factors such as complexity of therapeutic regimen and incidence of side effects have repeatedly been linked to noncompliance, it is reasonable to place some of the responsibility for noncompliance on the drug itself. In 1978, the first beta blocker received approval for topical ophthalmic use in this country. Currently, besides timolol, there are two other beta blockers - betaxolol, and levobunolol- approved for glaucoma therapy in the United States. Their efficacy, simplified dosage regimen (once or twice daily), and low incidence of ocular side effects have made beta blockers the most commonly prescribed ocular hypotensive drugs in the United States today. However, a substantial number of glaucoma patients require additive therapy to keep their intraocular pressures at acceptable levels. Pilocarpine and other, newer drugs such as propine (a prodrug of epinephrine), which have fewer side effects and are effective at lower concentrations than the parent drug, are frequently used concomitantly with beta blockers.
Review of Recent Study Results
I
n the past, researchers were forced to. rely on methods such as physician estimates or patient interviews to determine compliance rates in glaucoma patients. Since both physi-
cians and patients are known to overestimate compliance, the results of these studies may be open to question. Studies done in the past several years have used an unobtrusive eyedrop medication monitor that electronically records the date and time of each administration. Patients are unaware of the monitor because the electronic components are concealed in an inner container of the bottle.
~ '
'Glaucoma can be viewed as a textbook example ( of a disease most likely to foster noncompliance. It is asymptomatic, chronic, and even patients who are always compliant see no improvement in their condition.' One recent study of patients on pilocarpine assessed the correlation between actual compliance, as measured with medication monitors, and other methods commonly used to determine compliance. These methods included intraocular pressure, pupillary diameter, pupillary reactivity to light, the patient's report of compliance, the patient's written log of administration, the weight of eyedrops utilized, and the physician's prediction of compliance. The results of the study indicated that there was no correlation between either intraocular pressure or pupillary diameter and compliance as measured by the monitors. Other factors, such as physician's predictions, correlated only moderately with compliance as measured by the monitors. The authors concluded that "none of these measures taken by itself or combined in any manner adequately distinguished patients with lower rates of compliance from those with higher rates of compliance." It appears that at present the eyedrop monitor is the only reliable method for detecting patients who default. 7 The results of another recent study supported this conclusion. Patients on pilocarpine reported taking 97% of the prescribed doses. Medication monitors revealed that the patients had actually administered only 76% of the prescribed doses. The authors noted that "patients may be poor observers of their own behavior or they may fear a reprimand if they tell their physicians the truth." 8
American Pharmacy, Vol. NS28, No. 9 September 1988/583
39
This same study revealed that the morning dose of medication was administered with greater regularity than any of the other doses, perhaps because patients were able to tie that ·administration to other morning activities. Many patients defaulted by spacing their administrations improperly. Only 30% of the subjects had a mean interval of 12 hours or more between the night and morning doses. Finally, the study subjects were significantly more compliant in the 24 hours preceding their return appointments than they were during the entire observation period. Some physicians may inadvertently be reinforcing noncompliance by telling patients who have been compliant only for the previous day that they are doing well. The advantages of beta blockers over pilocarpine led researchers to theorize that compliance with beta blockers would be better than compliance with pilocarpine treatment. A recently published study indicated that, as measured by medication monitors, patients administered 83% of their prescribed doses of beta blocker.9 The results suggest that although compliance is influenced by drug regimen, defaulting is not eliminated by pre.scribing a more convenient medication with fewer ocular side effects.
-v, ~....
'Carelessness and lack of
_
understanding are beyond · the power of any drug to address. It is at this point that the human element must be added to the equation. And it i·s at this point that the pharmacist can begin to make a difference.'
When asked, patients themselves give various reasons for noncompliance. Among the most frequent responses are forgetfulness, inconvenience, carelessness, and misunderstanding directions. 3·10 Drugs with fewer side effects and less frequent administration schedules may make some difference to those who are forgetful or inconvenienced. However,carelessness a:gd lack of understanding are beyond the power of any drug to address, regardless ofhow efficacious it is. It is at this point that the human element must be added to the equation. And it is at this point that the pharmacist can begin to make a difference. 40
Pharmacists can often identify probable noncompliers simply by reviewing prescription renewal records. A patient whose prescription order calls for twice daily administration in both eyes who has used only two 10-ml bottles of medication in the past 6 months is almost certainly a noncomplier. Predicting medication usage is difficult at best. Ten to twelve 10-ml bottles of medication might be a reasonable estimated average yearly usage for full compliance with twice daily therapy in both eyes. This figure has not been substantiated and should be used only as a general guideline when reviewing patients' prescription order renewal records.
Improving Compliance: The Pharmacist's Role lthough some findings h~ve been contradictory, most researchers agree that the following elements do increase compliance: • Written instructions; 4-6 • Patient education· 1·3·4·6 • More complete labeling of medications; 3·6 • Increased supervision and counseling; 4·6·11 • Integration of treatment with daily routines; 1·3·4·6 • Medication calendars; 6 • Reduction of medication-induced side effects;3·4·6 • Simplification of medical regimens; 1·3·6·10 • Improved patient-physician relationship.1,3,11 Some of these factors, such as simplification of medical regimen, are controlled by the physician. However, pharmacists are in an ideal position to make use of many of them. The following paragraphs highlight these areas and offer suggestions that will enable pharmacists to make a positive impact on the compliance rates of their glaucoma patients.
A
Patient Education Studies have shown that within minutes of consultation patients forget one-third to onehalf of what they are told - particularly instructions and advice. The amount forgotten seems to increase with the gravity of the situation. 1 In one study some patients said that they had been told about their disease during their first appointment, but had not been able to remember the information. The reasons given included shock, tiredness, deafness, and preoccupation. 10 This same study indicated that many patients were anxious
American Pharmacy, Vol. NS28, No. 9 September 1988/584
1
about their condition and wanted information but did not feel they should bother the physicians at the clinic. The pharmacist has the opportunity to provide information to the patient in a setting that is less stressful and more conducive to learning and retention. The first step is to tell patients that you are going to explain the treatment regimen in clear, easy-to-understand terms and in logical sequence. Although it may seem too simplistic, the place to start is with the name of the disease. Studies have indicated that patients who know they have glaucoma are better compliers than those who don't know the name of their condition. 10 Next, try to give the patient a basic understanding of the disease and its treatment. The more patients understand about glaucoma, the more likely they are to understand the reasons for the directions they have been given. Each patient must first understand that the damage from glaucoma occurs when intraocular pressure is not constantly controlled and that the best way to control it is to space the drops properly. Once a person understands this, it is more likely that he or she will understand why twice daily means 12 hours apart, not just twice a day. Patients on regimens that call for two different drops should also be told that if the two are applied less than 5 to 10 minutes apart, the second drop will wash out some of the first and negate some of its effectiveness. 4 Some patients may be unable to tell whether or not their drops were actually instilled. As a result they may instill too many drops or none at all. One excellent way to avoid this problem is to have patients keep their medication in the refrigerator. Since the conjunctival mucosa is sensitive to temperature change, the drop will then be easily felt.
Overlabeling Make sure that your overlabeling is large enough for the patient to read and that he or she understands it. Remember the axiom that says, ''Any order that can be misunderstood will be misunderstood." Never assume that a patient who doesn't ask questions understands the directions. Many people are simply too embarrassed to ask. If possible, read the typed instructions to the patient when the prescription order is first dispensed. If any of the patient's family members are present, they should also have a clear understanding of all instructions.
'The more patients understand about glaucoma, the more likely they are to understand the reasons for the directions they have been given.' Discussion of Side Effects Most of the side effects of glaucoma medications are predictable. This doesn't make them any less annoying for the patient who experiences them. However, it is helpful to educate patients about the potential side effects of a medication and discuss methods of coping with them. This is an ideal way to establish a positive relationship with the patient as well as build his or her confidence. It is also important to help patients distinguish between those side effects that should be reported to the physician and those that must just be accepted. Many patients on pilocarpine therapy experience brow ache, visual blurring, and poor dark adaptation. Patients taking epinephrine or dipivefrin may experience injection (dilation of blood vessels) and burning or stinging upon instill ation. While these are certainly bothersome to the patient, they are in the "to be expected" category and need not be reported. Glaucoma medications do have other more serious side effects that patients should report immediately to their physicians. Tachycardia, arrhythmia, and hypertension have been reported with epinephrine. Severe cardiovascular and respiratory reactions such as arrhythmia, syncope, cerebral vascular incident, cerebral ischemia, congestive heart failure, palpitation, bronchospasm, and respiratory failure have been reported with the use of beta blockers. For glaucoma patients administering medications with potential systemic side effects, the pharmacist should instruct the patient to occlude the punctum for 5 minutes immediately after the instillation of the drops. This is done by pressing the forefinger against the inside corner of the eye to prevent the medication from entering the tear duct. Another slightly less effective technique is to keep the eyelid closed for 5 minutes immediately after drop instillation. Studies have shown that these techniques markedly decrease systemic absorption and increase the medication level in the eye itself. 12
American Pharmacy, Vol. NS28, No. 9 September 1988/585
41
Finally, do not assume that a patient who has mentioned potentially serious side effects to the pharmacist has also told the prescribing physician. Many people feel much more comfortable with the pharmacist than with a physician and are more willing to confide. Patients should be urged to discuss all potentially serious side effects with their physicians.
'Patients cannot be coerced, frightened, threatened, or cajoled Into compliance. They can, however, be educated, advised, and encouraged. The compliant patient is one who sees himself as an active member of the medication team, not the passive victim of a disease.'
Continuing Support Finally, perhaps the most important way that pharmacists can increase compliance is through developing and maintaining an ongoing relationship with each patient. The pharmacist sees many of his patients on a regular basis, not just when they are renewing their glaucoma prescriptions. Therefore, he is in an excellent position to provide the continual "education, supervision, and reinforcement [that] inspires patients' acceptance of their condition, allowing their emotional responses to be replaced by rational understanding." 4 In the final analysis, patients cannot be coerced, frightened, threatened, or cajoled into compliance. They can, however, be educated, advised, and encouraged. The compliant patient is one who sees himself as an active member of the medication team, not the passive victim of a disease. The pharmacists who make a positive impact on compliance rates are those who are able to instill thi_s sense of responsibility in their patients.®
References As pharmacists are well aware, most people receive medical care and prescriptions from more than one physician. It is possible that one physician may not know what a second, or third, physician is prescribing for the same patient. Patients should be urged to tell their internists or family doctors about the medications their ophthalmologists have prescribed. This is especially important with beta blockers because of the potential for additional side effects if the drug product is also being taken systemically.
Integration of Treatment "Tailoring," or integrating treatment into a patient's daily routine, has proved to be an effective way to salvage noncompliant patients. Pharmacists can be of great help in this area because, as just mentioned, they are usually aware of all of the patient's medications, not just glaucoma medications. Have the patient chart daily routines and habits. It should include everything from getting up in the morning and brushing his teeth to eating meals, reading the paper, watching favorite daily television programs, feeding the dog, and going to bed. Once this chart has been compiled, you can work with the patient to schedule medications around daily activities and habits that will act as prompts to take a specific drug. 42
1. S.I. Davidson and T. Akinbehin, Compliance in Ophthalmology, Trans Ophthalmol Soc U K, 100, 286 (1980). 2. E.M. Van Buskirk, The Compliance Factor, Am J Ophthalmol, 101, 609 (1986). 3. B. Blackwell, Patient Compliance, N Engl J Med, 289, 249 (1973). 4. T.J. Zimmerman and A.H. Zalta, Facilitating Patient Compliance in Glaucoma Therapy, Suru Ophthalmol, 28, 252 (1983). 5. M.A. Kass and B. Becker, Compliance to Ocular Therapy, in Symposium on Ocular Therapy, vol. 9, I.H. Leopold and R.P. Burns, eds., John Wiley & Sons, New York, pp. 119-35. 6. F.S. Ashburn et al., Compliance with Ocular Therapy, Surv Ophthalmol, 24, 237 (1980). 7. M.A. Kass et al., Can Ophthalmologists Correctly Identify Patients Defaulting from Pilocarpine Therapy? Am J Ophthalmol, 101, 524 (1986). 8. M.A. Kass et al., Compliance with Topical Pilocarpine Therapy, Am J Ophthalmol, 101, 515 (1986). 9. M.A. Kass et al., Compliance with Topical Timolol Treatment, Am J Ophthalmol, 103, 188 (1987). 10. J~M. MacKean and A.R. Elkington, Compliance with Treatment of Patients with Chronic Open-angle Glaucoma, Br J Ophthalmol, 67, 46 (1983). 11. R.S. Riffenburgh, Doctor-Patient Relationship in Glaucoma Therapy, Arch Ophthalmol, 75, 204 (1966). 12. T.J. Zimmerman et al., Improving the Therapeutic Index ofTopically Applied Ocular Drugs, Arch Ophthalmol, 12, 551 (1984).
11
American Pharmacy, Vol. NS28, No. 9 September 1988/586
I
t is sad but true that the efficacy of a drug · means nothing if a patient is unwilling to take it. Although estimates vary, the majority of studies indicate that one-quarter to one-half . of glaucoma patients do not take medications according to instructions. 1A substantial number of defaulting patients claim th.at they never had any intention of following the physician's instructions. And it is generally agreed that at least 3% to 7% of prescription orders are never even dispensed. 1 The problem of compliance with glaucoma therapy has always been acknowledged. However, it is only since the methods used to measure compliance have become more accurate that the seriousness of the problem has been revealed. An editorial in the May 1986 issue of the American Journal ofOphthalmology called noncompliance "a leading cause of glaucoma blindness." 2 The obvious question is, "What can the pharmacist do to ensure that none of his patients become victims of 'blindness by default'?" Noncompliance. refers to any one of four ways that a patient may default in taking medication: Failure to take medication, including missed doses, inadequate doses, and stopping therapy prematurely;
Taking medication at incorrect time intervals; Ill Taking too much medication; II ·Taking medication for the wrong purpose. Noncompliance in glaucoma patients is generally associated with the first two of these. II
·Factors Associated with Noncompliance
A
s might be expected, published studies are often contradictory regarding the factors associated with noncompliance. The majority of studies agree that the following factors are related to noncompliance: II Complexity of therapeutic regimen. The greater the number of medications and the greater the total number of daily doses, the greater will be the rate of default. 1'3 s Incidence of side effects. The rate of noncompliance increases as the number and severity of drug-related side effects increases.1'3 Ill Duration of therapy. As the length of the required treatment period increases, the probability of noncompliance also increases. 1'3 • Physician-patient relationship. Noncompliance can be correlated with an impersonal manner and lack of warmth on the part of the physician. 1'4
Glaucoma - the Compliance -Picture Paul O'Dea is staffpharmacist; Jules Stein Eye Institute, University of California, Los Angeles· Medical Center, Los Angeles, CA. Received January 198&; ac{!epted ·M areh 1988. 38
M.
any attempts have been made to create a profile of a typical defaulter. Unfortunately, this has proved to be an impossible task. Noncompliance does not correlate with age, sex: income, numberof dependents, level
American Pharmacy, Vol. NS28, No. 9 September 1988/582
of education, occupation, maritaf status, race, e~hnic background, socioeconomic status, diagnosis, or severity of disease. 4 -6 The only assumption that can be safely made is that compliance can never be assumed. Every patient is a potential defaulter. Those who are totally ~nreliable in one situation may be completely reliable in another. Glaucoma can be viewed as a textbook example of a disease most likely to foster · noncompliance. It is asymptomatic, causing no pain or immediate disability. It is a chronic disease that requires lifelong adherence to a daily therapeutic regimen. The consequences of improper compliance are not immediate. And even patients who are always compliant see no subjective improvement in their condition. At times, the treatment may appear to be far worse than the disease. Pilocarpine, untii -recentiy tlie most commonly prescribed glaucoma medication, was generally administered four times a day. It frequently caused ocular side effects such as brow aches, buming and stinging on administration, fluctuating vision, and poor vision in dimly lit areas. Since factors such as complexity of therapeutic regimen and incidence of side effects have repeatedly been linked to noncompliance, it is reasonable to place some of the responsibility for noncompliance on the drug itself. In 1978, the first beta blocker received approval for topical ophthalmic use in this country. Currently, besides timolol, there are two other beta blockers - betaxolol, and levobunolol- approved for glaucoma therapy in the United States. Their efficacy, simplified dosage regimen (once or twice daily), and low incidence of ocular side effects have made beta blockers the most commonly prescribed ocular hypotensive drugs in the United States today. However, a substantial number of glaucoma patients require additive therapy to keep their intraocular pressures at acceptable levels. Pilocarpine and other, newer drugs such as propine (a prodrug of epinephrine), which have fewer side effects and are effective at lower concentrations than the parent drug, are frequently used concomitantly with beta blockers.
Review of Recent Study Results
I
n the past, researchers were forced to. rely on methods such as physician estimates or patient interviews to determine compliance rates in glaucoma patients. Since both physi-
cians and patients are known to overestimate compliance, the results of these studies may be open to question. Studies done in the past several years have used an unobtrusive eyedrop medication monitor that electronically records the date and time of each administration. Patients are unaware of the monitor because the electronic components are concealed in an inner container of the bottle.
~ '
'Glaucoma can be viewed as a textbook example ( of a disease most likely to foster noncompliance. It is asymptomatic, chronic, and even patients who are always compliant see no improvement in their condition.' One recent study of patients on pilocarpine assessed the correlation between actual compliance, as measured with medication monitors, and other methods commonly used to determine compliance. These methods included intraocular pressure, pupillary diameter, pupillary reactivity to light, the patient's report of compliance, the patient's written log of administration, the weight of eyedrops utilized, and the physician's prediction of compliance. The results of the study indicated that there was no correlation between either intraocular pressure or pupillary diameter and compliance as measured by the monitors. Other factors, such as physician's predictions, correlated only moderately with compliance as measured by the monitors. The authors concluded that "none of these measures taken by itself or combined in any manner adequately distinguished patients with lower rates of compliance from those with higher rates of compliance." It appears that at present the eyedrop monitor is the only reliable method for detecting patients who default. 7 The results of another recent study supported this conclusion. Patients on pilocarpine reported taking 97% of the prescribed doses. Medication monitors revealed that the patients had actually administered only 76% of the prescribed doses. The authors noted that "patients may be poor observers of their own behavior or they may fear a reprimand if they tell their physicians the truth." 8
American Pharmacy, Vol. NS28, No. 9 September 1988/583
39
This same study revealed that the morning dose of medication was administered with greater regularity than any of the other doses, perhaps because patients were able to tie that ·administration to other morning activities. Many patients defaulted by spacing their administrations improperly. Only 30% of the subjects had a mean interval of 12 hours or more between the night and morning doses. Finally, the study subjects were significantly more compliant in the 24 hours preceding their return appointments than they were during the entire observation period. Some physicians may inadvertently be reinforcing noncompliance by telling patients who have been compliant only for the previous day that they are doing well. The advantages of beta blockers over pilocarpine led researchers to theorize that compliance with beta blockers would be better than compliance with pilocarpine treatment. A recently published study indicated that, as measured by medication monitors, patients administered 83% of their prescribed doses of beta blocker.9 The results suggest that although compliance is influenced by drug regimen, defaulting is not eliminated by pre.scribing a more convenient medication with fewer ocular side effects.
-v, ~....
'Carelessness and lack of
_
understanding are beyond · the power of any drug to address. It is at this point that the human element must be added to the equation. And it i·s at this point that the pharmacist can begin to make a difference.'
When asked, patients themselves give various reasons for noncompliance. Among the most frequent responses are forgetfulness, inconvenience, carelessness, and misunderstanding directions. 3·10 Drugs with fewer side effects and less frequent administration schedules may make some difference to those who are forgetful or inconvenienced. However,carelessness a:gd lack of understanding are beyond the power of any drug to address, regardless ofhow efficacious it is. It is at this point that the human element must be added to the equation. And it is at this point that the pharmacist can begin to make a difference. 40
Pharmacists can often identify probable noncompliers simply by reviewing prescription renewal records. A patient whose prescription order calls for twice daily administration in both eyes who has used only two 10-ml bottles of medication in the past 6 months is almost certainly a noncomplier. Predicting medication usage is difficult at best. Ten to twelve 10-ml bottles of medication might be a reasonable estimated average yearly usage for full compliance with twice daily therapy in both eyes. This figure has not been substantiated and should be used only as a general guideline when reviewing patients' prescription order renewal records.
Improving Compliance: The Pharmacist's Role lthough some findings h~ve been contradictory, most researchers agree that the following elements do increase compliance: • Written instructions; 4-6 • Patient education· 1·3·4·6 • More complete labeling of medications; 3·6 • Increased supervision and counseling; 4·6·11 • Integration of treatment with daily routines; 1·3·4·6 • Medication calendars; 6 • Reduction of medication-induced side effects;3·4·6 • Simplification of medical regimens; 1·3·6·10 • Improved patient-physician relationship.1,3,11 Some of these factors, such as simplification of medical regimen, are controlled by the physician. However, pharmacists are in an ideal position to make use of many of them. The following paragraphs highlight these areas and offer suggestions that will enable pharmacists to make a positive impact on the compliance rates of their glaucoma patients.
A
Patient Education Studies have shown that within minutes of consultation patients forget one-third to onehalf of what they are told - particularly instructions and advice. The amount forgotten seems to increase with the gravity of the situation. 1 In one study some patients said that they had been told about their disease during their first appointment, but had not been able to remember the information. The reasons given included shock, tiredness, deafness, and preoccupation. 10 This same study indicated that many patients were anxious
American Pharmacy, Vol. NS28, No. 9 September 1988/584
1
about their condition and wanted information but did not feel they should bother the physicians at the clinic. The pharmacist has the opportunity to provide information to the patient in a setting that is less stressful and more conducive to learning and retention. The first step is to tell patients that you are going to explain the treatment regimen in clear, easy-to-understand terms and in logical sequence. Although it may seem too simplistic, the place to start is with the name of the disease. Studies have indicated that patients who know they have glaucoma are better compliers than those who don't know the name of their condition. 10 Next, try to give the patient a basic understanding of the disease and its treatment. The more patients understand about glaucoma, the more likely they are to understand the reasons for the directions they have been given. Each patient must first understand that the damage from glaucoma occurs when intraocular pressure is not constantly controlled and that the best way to control it is to space the drops properly. Once a person understands this, it is more likely that he or she will understand why twice daily means 12 hours apart, not just twice a day. Patients on regimens that call for two different drops should also be told that if the two are applied less than 5 to 10 minutes apart, the second drop will wash out some of the first and negate some of its effectiveness. 4 Some patients may be unable to tell whether or not their drops were actually instilled. As a result they may instill too many drops or none at all. One excellent way to avoid this problem is to have patients keep their medication in the refrigerator. Since the conjunctival mucosa is sensitive to temperature change, the drop will then be easily felt.
Overlabeling Make sure that your overlabeling is large enough for the patient to read and that he or she understands it. Remember the axiom that says, ''Any order that can be misunderstood will be misunderstood." Never assume that a patient who doesn't ask questions understands the directions. Many people are simply too embarrassed to ask. If possible, read the typed instructions to the patient when the prescription order is first dispensed. If any of the patient's family members are present, they should also have a clear understanding of all instructions.
'The more patients understand about glaucoma, the more likely they are to understand the reasons for the directions they have been given.' Discussion of Side Effects Most of the side effects of glaucoma medications are predictable. This doesn't make them any less annoying for the patient who experiences them. However, it is helpful to educate patients about the potential side effects of a medication and discuss methods of coping with them. This is an ideal way to establish a positive relationship with the patient as well as build his or her confidence. It is also important to help patients distinguish between those side effects that should be reported to the physician and those that must just be accepted. Many patients on pilocarpine therapy experience brow ache, visual blurring, and poor dark adaptation. Patients taking epinephrine or dipivefrin may experience injection (dilation of blood vessels) and burning or stinging upon instill ation. While these are certainly bothersome to the patient, they are in the "to be expected" category and need not be reported. Glaucoma medications do have other more serious side effects that patients should report immediately to their physicians. Tachycardia, arrhythmia, and hypertension have been reported with epinephrine. Severe cardiovascular and respiratory reactions such as arrhythmia, syncope, cerebral vascular incident, cerebral ischemia, congestive heart failure, palpitation, bronchospasm, and respiratory failure have been reported with the use of beta blockers. For glaucoma patients administering medications with potential systemic side effects, the pharmacist should instruct the patient to occlude the punctum for 5 minutes immediately after the instillation of the drops. This is done by pressing the forefinger against the inside corner of the eye to prevent the medication from entering the tear duct. Another slightly less effective technique is to keep the eyelid closed for 5 minutes immediately after drop instillation. Studies have shown that these techniques markedly decrease systemic absorption and increase the medication level in the eye itself. 12
American Pharmacy, Vol. NS28, No. 9 September 1988/585
41
Finally, do not assume that a patient who has mentioned potentially serious side effects to the pharmacist has also told the prescribing physician. Many people feel much more comfortable with the pharmacist than with a physician and are more willing to confide. Patients should be urged to discuss all potentially serious side effects with their physicians.
'Patients cannot be coerced, frightened, threatened, or cajoled Into compliance. They can, however, be educated, advised, and encouraged. The compliant patient is one who sees himself as an active member of the medication team, not the passive victim of a disease.'
Continuing Support Finally, perhaps the most important way that pharmacists can increase compliance is through developing and maintaining an ongoing relationship with each patient. The pharmacist sees many of his patients on a regular basis, not just when they are renewing their glaucoma prescriptions. Therefore, he is in an excellent position to provide the continual "education, supervision, and reinforcement [that] inspires patients' acceptance of their condition, allowing their emotional responses to be replaced by rational understanding." 4 In the final analysis, patients cannot be coerced, frightened, threatened, or cajoled into compliance. They can, however, be educated, advised, and encouraged. The compliant patient is one who sees himself as an active member of the medication team, not the passive victim of a disease. The pharmacists who make a positive impact on compliance rates are those who are able to instill thi_s sense of responsibility in their patients.®
References As pharmacists are well aware, most people receive medical care and prescriptions from more than one physician. It is possible that one physician may not know what a second, or third, physician is prescribing for the same patient. Patients should be urged to tell their internists or family doctors about the medications their ophthalmologists have prescribed. This is especially important with beta blockers because of the potential for additional side effects if the drug product is also being taken systemically.
Integration of Treatment "Tailoring," or integrating treatment into a patient's daily routine, has proved to be an effective way to salvage noncompliant patients. Pharmacists can be of great help in this area because, as just mentioned, they are usually aware of all of the patient's medications, not just glaucoma medications. Have the patient chart daily routines and habits. It should include everything from getting up in the morning and brushing his teeth to eating meals, reading the paper, watching favorite daily television programs, feeding the dog, and going to bed. Once this chart has been compiled, you can work with the patient to schedule medications around daily activities and habits that will act as prompts to take a specific drug. 42
1. S.I. Davidson and T. Akinbehin, Compliance in Ophthalmology, Trans Ophthalmol Soc U K, 100, 286 (1980). 2. E.M. Van Buskirk, The Compliance Factor, Am J Ophthalmol, 101, 609 (1986). 3. B. Blackwell, Patient Compliance, N Engl J Med, 289, 249 (1973). 4. T.J. Zimmerman and A.H. Zalta, Facilitating Patient Compliance in Glaucoma Therapy, Suru Ophthalmol, 28, 252 (1983). 5. M.A. Kass and B. Becker, Compliance to Ocular Therapy, in Symposium on Ocular Therapy, vol. 9, I.H. Leopold and R.P. Burns, eds., John Wiley & Sons, New York, pp. 119-35. 6. F.S. Ashburn et al., Compliance with Ocular Therapy, Surv Ophthalmol, 24, 237 (1980). 7. M.A. Kass et al., Can Ophthalmologists Correctly Identify Patients Defaulting from Pilocarpine Therapy? Am J Ophthalmol, 101, 524 (1986). 8. M.A. Kass et al., Compliance with Topical Pilocarpine Therapy, Am J Ophthalmol, 101, 515 (1986). 9. M.A. Kass et al., Compliance with Topical Timolol Treatment, Am J Ophthalmol, 103, 188 (1987). 10. J~M. MacKean and A.R. Elkington, Compliance with Treatment of Patients with Chronic Open-angle Glaucoma, Br J Ophthalmol, 67, 46 (1983). 11. R.S. Riffenburgh, Doctor-Patient Relationship in Glaucoma Therapy, Arch Ophthalmol, 75, 204 (1966). 12. T.J. Zimmerman et al., Improving the Therapeutic Index ofTopically Applied Ocular Drugs, Arch Ophthalmol, 12, 551 (1984).
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American Pharmacy, Vol. NS28, No. 9 September 1988/586