Medication Compliance

Aka: Medication Compliance, Medication Adherence, Medication Nonadherence, Medication Noncompliance, Medication Synchronization, Combination Medication

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II. Epidemiology

  1. Chronic medications are not taken as prescribed in up to 50% of cases
  2. New medication prescriptions are not filled in up to a third of cases

III. Approach

  1. Assess Medication Compliance at every visit (analogous to checking Vital Signs at each visit)
    1. Ask about problems taking medications and missed doses
    2. Review medication refill patterns with pharmacy if non-compliance is suspected
  2. Understand barriers to Medication Adherence
    1. Medication Cost
    2. Perceived medication lack of benefit
    3. Social Determinants of Health (poverty, food insecurity, lack of transportation)
  3. New medications should receive focus
    1. Explain why the medication is indicated and for how long
    2. Anticipatory guidance on adverse effects
    3. Select Generic Medications or employ cost cutting methods (e.g. cut larger dose tablet in half)
  4. Employ Shared Decision Making to obtain patient buy-in
    1. Consider cutting or eliminating medications (Deprescribing) with lower efficacy or greater adverse effects
    2. Review medication risk versus benefit
      1. Patients may prefer the risks related to not taking the medication
      2. Patients may prefer alternative, less potent agents that are lower cost or fewer adverse effects
  5. Encourage Medication Compliance through education
    1. Explain benefits of medication
    2. Review correct schedule of medication
    3. Discuss ways to reduce adverse effects
    4. Patient should be able to paraphrase the key education points in their own words
    5. Give an active, updated medication list at each visit (part of after visit summary)
  6. Employ reminder systems to take medications (forgetting accounts for 30% of nonadherence)
    1. Work to simplify regimens (once daily medications, Combination Medications)
    2. Use pill boxes
    3. Time medication delivery with daily activities
    4. Consider alarms or phone applications to issue reminders
    5. Consider mobile applications (e.g. Medisafe, Dosecast)
  7. Bad-Tasting Medications
    1. Some medications may be mixed with sweet thick liquids (e.g. coffee creamer, Chocolate syrup, apple sauce)
      1. Examples inclde Dexamethasone, Tamiflu
    2. Medications typically taste better when chilled (or consider sucking a popsicle before dose)
    3. Consider following medication with a sweet beverage
    4. (2020) presc lett 27(2): 11
  8. Involve pharmacists
    1. Consider pharmacy consultants to review medications with patients
      1. May help to eliminate compliance barriers (e.g. cost, adverse effects)
    2. Patients should share their medication lists with their pharmacists
      1. Allows for screening for Drug Interactions and duplicate Medication Classes
    3. Perform Medication Synchronization
      1. Work with the pharmacist to synchronize refill dates
        1. Coordinate all medications to be filled on the same date (with 90 day supply)
      2. Will require some medications with a smaller number of pills dispensed
        1. Patient may need to pay extra to resynchronize refills
  9. Involve others
    1. Involve family members to assist with Medication Compliance
  10. Combination Medications
    1. Combination agents may simplify medication regimens and in the case of Generic Drugs, further drop cost
      1. Reasonable strategy when medication doses are stable and Generic Medication use
      2. Many of the HIV Treatment regimens combine multiple agents
    2. Combination Medication disadvantages
      1. Unable to modify the combination drug components in different ratios
      2. Cause of adverse effects less clear when a combination agent was recently started
      3. Cost may be considerably higher than taking individual pills (combinations may extend a patent)
    3. References
      1. (2020) Presc Lett 27(7):40

IV. Associated Conditions: Disorders commonly complicated by Medication Nonadherence

  1. Cardiovascular conditions
    1. Hypertension
    2. Hyperlipidemia
    3. Coronary Artery Disease
    4. Congestive Heart Failure
  2. Endocrine conditions
    1. Diabetes Mellitus (e.g. Diabetic Ketoacidosis)
  3. Gynecology
    1. Oral Contraceptives
  4. Infectious Disease
    1. Antibiotic noncompliance overall is common (missed doses, stopping course early)
    2. HIV Infection (Antiretroviral therapy)
  5. Lung conditions
    1. Asthma
    2. COPD
  6. Neurologic conditions
    1. Migraine Headache
    2. Seizure Disorder
  7. Psychiatric conditions
    1. Major Depression
    2. Anxiety Disorder
    3. Bipolar Disorder
    4. Schizophrenia

V. References

  1. (2023) Presc Lett 30(6): 33
  2. (2014) Presc Lett 21(10): 59
  3. (2013) Presc Lett 20(12): 68-9

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