Drug compliance : The actual medication taken by the patient from the prescribed medication

1. DRUG COMPLIANCE
Dr G Praveena
Final year Post graduate
Dept of Pharmacology

2.  Introduction
 Importance
 Factors contributing to poor compliance
 Factors that are insignificant for compliance
 Measurement of Medication adherence
 Evaluation of drug compliance
 Methods to achieve compliance
 Conclusion

3. INTRODUCTION
 Compliance: Act of obeying an order, rule or
request
 Drug compliance in medical & pharmaceutical
literature
 Major challenge to prescriber
 Individually, it is the percentage of prescribed
doses of medication actually taken up by the
patient over a specified period of time

4.  Compliance, adherence, therapeutic alliance,
concordance
 Involves patient compliance & doctor compliance
 Patient compliance: The extent to which actual
behavior of patient coincides with medical advice
& instructions
- It may be complete/ partial/ erratic/ nil/ over
compliance

5. -There may be non presentation of prescriptions
- 25-50% either fail to follow or do not take it at
all
- 20% patients are over compliant, may take
more drug than prescribed
 Doctor compliance: The extent to which the
behavior of doctor fulfils their professional duty

6. IMPORTANCE
 About 1 in 4 show non-compliance
 As per WHO,
“ Increasing the effectiveness of
adherence interventions may
have a far greater impact on the
health of the population
than any improvement in
specific medical treatments “

7.  Poor adherence/ non compliance :
# Therapeutic failure
# Rejection of best drug
# Increased
-hospital admissions
-economic burden
-morbidity & mortality
 Good adherence : positive health outcome,
surrogate marker for overall healthy behavior

8.  Importance of route of drug administration:
i) confusion regarding oral antibiotics-
- pediatric preparations instilling into eyes &
ears esp. for ear infection.
or
-give suppositories by oral route.
ii) N-acetyl cysteine:
- inhalation used as a mucolytic (cystic fibrosis).
- given orally or IV for replenishing glutathione
stores in liver for paracetamol poisoning.

9.  Importance of timing:
e.g.: tid after meals.
how many patients takes 3 meals a day?
- Only 1 out of 137 patients has taken eighth
hourly
 Drug administration and diurnal variation:
- Glucocorticoids secretion highest in morning :
exogenous steroid replacement in morning – less
HPA. axis suppression.
- Bronchodilators at night.
- Benzodiazepines – morning decrease efficiency.

10. FACTORS CONTRIBUTING TO POOR
COMPLIANCE
Patient related
Physician related
Health system related
Therapy related

11. Patient Related Factors
 Lack of information  Unintentional or
forgetfulness
 Intelligent or wilful
 Illness
 Socio economic
factors
Patient has not understood, so
can not comply
Patient understands , but fails
to carry

12. Physician Related Factors
 Lack of awareness
 Ineffective communication: with patient
 Inadequate communication: between
physicians

13. Health Care Related Factors
 Time constraints
 Lack of care coordination

14. Therapy Related Factors
 Complexity of medication regimens
 Duration of Therapy
 Inconvenience with lifestyle
 Adverse effects

15. Factors that are insignificant for
compliance:
 Age (except at extremes)
 Gender
 Intelligence (except at extreme deficiency)
 Educational level (probably)

16. MEASUREMENT OF MEDICATION
ADHERENCE
 Medication adherence percentage > 80%
 Defined as
No. of pills absent in a given time × 100
No. of pills prescribed for same time
 Limitations: assumes that the absent pills are
taken by the patient
 White coat adherence: Improved medication
taking behavior in the 5 days before or 5 days
after a health care encounter

17. EVALUATION OF DRUG
COMPLIANCE
 Direct Observation
Therapy
 Measurement of
drug & its
metabolites in
plasma
 Proxy evidence
 Patient’s report
 No. of dosages
removed from the
container
Direct Indirect

18. STRATEGIES TO IMPROVE
COMPLIANCE
 Identification of risk factors:
- assuming all patients as potential non
compliers
- Inconsistent or non existent therapy: Non
compliance should always be considered

19. Suggestions for doctors:
 Not to be ignorant, to adapt new advances when they
are sufficiently proved
 Development of plan - On individual basis.
- Involve patient in deciding treatment plan.
- Make simple plan
- Minimum no. of drugs & drug taking occasions
- Adjusted to fit patient’s life style
i) Use fixed dose combinations, sustained release /
injectable depot formulations / long t1/2 drugs
ii) Arrange direct observation of each dose in exceptional
cases
- Provide clear oral & written information adapted to the

20. - Use patient friendly packaging
E.g.: calendar packs;
monitored dose systems
- For illiterate patients, prescribing drugs with distinctive
physical characteristics. Eg: 1red tab, 1 white tab, 1
yellow tab,1 capsule instead of 4 white tablets
- Inconvenience & forgetfulness decreased by timing
doses corresponding to regular activities in patients daily
schedule.
- Do not write bd/tid write timings in am/pm. if possible see
that it combines with normal routine

21. - Interaction should signal the start of an
alliance, not as a closing encounter with
patient
- See the patient regularly & not so infrequently
that the patient feels the doctor has lost
interest
- Enlist the help of family members, carers
- Use computer generated reminders for repeat
prescription

22. Patient Education
 What every patient needs to know:
 An account of the disease, reason for prescribing
 Name of the medicine
 Objective: to treat the disease
to relieve symptoms
 How & when to take medicine
 Whether it matters if a dose is missed & what is to be
done
 For how long the medicine is needed

23.  Instructions about the side effects that do not require
discontinuation of drug,
- adverse effects that require immediate reporting, e.g. :
allergy
 Any interaction with alcohol or other medicines,
including effects on driving
 Involve patient in decision-making process
 Health education- make patient understand benefits of
treatment and importance of compliance without using
complex terms.

24.  Patient is asked to repeat the instructions to check
whether he/she understands correctly.
 Encourage patients to ask questions
 Audio visual aids in waiting room help in visualizing
nature of illness, mode of action of drugs, method of
drug administration, e.g.: insulin-injections, metered
dose inhalers, bisphosphonates etc.. and answering
questions patients may have

25. NATIONAL COUNCIL ON PATIENT
INFORMATION AND EDUCATION
 NCPIE
 name of the medicine ? what is it supposed to do?
 how much of medicine should i take , when should
i take and for how long?
 what foods, beverages other medicines/drugs
should i avoid while taking it?
 what are the possible side effects? what should i
do if they occur?
 what written material is available about the
medicine?

26. CONCLUSION
 Drugs don't work in patients who don't take
them
 Physicians must recognize that poor
medication adherence contributes to sub
optimal clinical benefits
 Sustained, coordinated effort will ensure
optimal medication adherence

27. REFERENCES
 The Pharmacological Basis Of Therapeutics,
Goodman & Gilman, 12th Edition
 Clinical Pharmacology, Bennett Brown,9th Edition
 Advanced Pharmacology, Bikash Medhi
 Pharmacology And Pharmacotherapeutics
Satoskar 23rd Edition
 Principles Of Pharmacology
Sharma 2nd Edition
 Medication Adherence: WHO Cares?, Marie T
Brown, Jennifer K Bussell,
http://www.ncbi.nlm.nih.gov.in

28. THANK YOU