This document discusses medication adherence. It defines medication adherence and explains that it is one of the most important factors in determining therapeutic outcomes, especially for chronic illnesses. The document outlines different types of medication non-adherence, including primary and secondary (both intentional and unintentional) non-adherence. It also discusses various methods for measuring and improving medication adherence.

1. MEDICATION ADHERENCE
AMEENA KADAR K A
FIRST SEM M PHARM
PHARMACY PRACTICE
SANJO COLLEGE OF PHARMACEUTICAL STUDIES

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3. MEDICATION ADHERENCE
 It is defined as the extent to which a patient’s medication-taking behavior
coincides with the intention of the health advice.
 Medication adherence is one of the most important factors that determine
therapeutic outcomes, especially in patients suffering from chronic illnesses.
 Whatever the efficacy of a drug, it cannot act unless the patient takes it.
 Adherence to treatment is the key link between treatment and outcome in
medical care.
 The word compliance and adherence are not synonym; Compliance
suggests that patient is passively following the doctor’s order without any
established professional relationship.
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Why Don’t Patients Take Their Medicine?

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When is Adherence Important?
There are many situations in clinical practice where adherence is extremely
important for better therapeutic outcomes. These include:
a. Replacement therapy. For example, thyroxine and insulin are essential for
maintaining the body’s metabolism and must be used regularly as prescribed.
b. Maintenance of pharmacological effect. For example, anti-hypertensive and
oral hypoglycemic agents. Control of blood pressure throughout the day and
maintaining blood sugar levels within the normal range are necessary to
obtain optimal treatment benefit.
c. Maintenance of serum drug concentrations to control a particular
disorder. For example, anti-convulsants. Sub-therapeutic levels of anti-
convulsants may increase the risk of convulsions in an epileptic patient.

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d. Some diseases of public health importance where non-adherence is a
major obstacle to achieving control. For example, tuberculosis, human
immunodeficiency virus and related opportunistic infections, hepatic infections,
preventive strategies such as immunization programs.
e. In chronic diseases such as diabetes and hypertension, where adherence is
important to prevent short-and long-term complications such as diabetes.

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Why
patients have
difficultywith
treatment?

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TYPES OF MEDICATION NON-ADHERENCE
 Normally patients tend to miss the medication dose due to various reasons is
termed as Medication non-adherence.
Medication
non-adherence
Primary non-
adherence
Secondary
non-adherence
Intentional
non-adherence
Unintentional
non-adherence

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 Primary non-adherence to medication: If a patient fails to get his/her
prescription dispensed.
 Secondary non-adherence to medication:
i. Intentional non-adherence to medication:
 If patient willfully deviate the instructions given by the physician.
 For example, the patient may take less than the prescribed dose with
an assumption that the prescribed dose is high or may take more
than the prescribed dose expecting quicker recovery from the
disease.
 Intelligent non-adherence: It was first coined by Weintraub. If a person
willfully stops medication due to some adverse effects such as nausea,
vomiting or gastric irritation etc., by cessation of the medication, if the
condition improves then it is called as intelligent non-adherence.

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Unintentional non-adherence to medication:
 When the patient has misunderstood or forgotten the doctor’s directions,
or fails to adhere to the prescribed dosage regimen due to cognitive
problems such as memory loss or confusion.
 For example, patients may cease to take antibiotics after two days or anti-
tubercular drugs after two months if they forget that the doctor had advised
them that a full treatment course should be completed. In both situations,
there is a chance of treatment failure and an increased risk of drug-resistant
organisms emerging.

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 Medication non-adherence is also classified based on the extent of medication
use by the patient as:
1. Adherent: When a person takes his/her medication more than 80%
of the prescribed doses.
2. Partially adherent: The medication between 70-80% of the
prescribed doses.
3. Non-adherent: Person takes the medication less than 70% of the
prescribed doses.
 Consequences of Medication non-adherence
 Poorer health outcomes
 Increased utilization of health care resources
 High health care expenditures
 Decreased Quality of life.

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1. Direct – objective
 Measure blood or urine levels of drugs – gives indication of short-term adherence,
unless the drug has a long half-life
 Measure blood levels of marker – add marker to medicines and measure levels in
the body. The ethical issue of the safety of the given marker is a matter of
concern. For example, low-dose phenobarbitone gives both quantitative and
qualitative data over the preceding few weeks with little intra and inter individual
variation.
2. Indirect – objective
 Pill count – count the tablets remaining in the container. Vulnerable to
overestimates of adherence.
 Prescription refill – accurate data monitoring system required.
 Electronic medication containers – opening and closure times of container
recorded on a microprocessor in the lid of the container.

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3. Health outcome measures – assessing therapeutic efficacy, for
example, blood pressure control, asthma severity, survival,
hospitalization, etc.
 Clinic attendance – opportunity to counsel patients. Clinic non-attenders are
more likely to be non-adherent.
 Appointment making
 Appointment keeping
 Preventive visits
4. Indirect – subjective (methods of questionable reliability)
 Patient interview – asking patients if they have adhered to the prescribed
regimens
 Diary keeping

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FORMULA TO CALCULATE MEDICATION ADHERENCE
% Adherence =
Total no. of actual doses the patient has consumed since last appointment
Χ 100
Total no. of calculated doses to be consumed

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IMPROVING
MEDICATION
ADHERENCE

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 A large number of interventions to improve patient adherence have been
studied.
 Most of these have been patient-oriented and educational.
 The interventional strategies can be provider-targeted or patient-focused.
 Provider-targeted interventions include the education of healthcare workers
including the treating physician, community pharmacists and nurses.
 Patient targeted interventions include various educational strategies with oral or
written instructions, or audiovisual materials.
 Education can be imparted to patients individually or with their family members
or in patient groups.
 Interventions which target the behavior of patients are also useful.
 These include medication diaries, verbal agreement with patients, tailoring the
regimen to suit the patients’ convenience and reminders by mail or telephone.

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 Patient education strategies that can help improve medication
adherence
1. Present the most important instructions first.
2. Reinforce a few simple, clearly stated instructions with easy-to-read, written
instructions.
3. Tailor medication regimen to the patient’s daily schedule and lifestyle.
4. Involve the family to assist and encourage adherence.
5. Stress the importance of adherence at follow-up and recognize the patient’s
effort to comply.
6. Schedule follow-up visits according to the patient’s previous adherence
record.
7. Select medications which can be given once daily and with the least potential
to cause side effects.

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8. Patients should not only be informed of possible side effects, but also what to do
if the side effects occur; for example, stop the medicine, contact the doctor, take a
simple remedy or persevere with treatment.
9. Restrict information to four key points.
10. Use simple language, short sentences and specific instructions.
11. Check for recall.
 Simplification of the regimen : This refers to the rationalization of a patient’s
regimen to one that can be realistically managed, that is, a compromise between
the ideal and one that can be achieved.
 This can in most situations be done without adversely affecting the patient’s
treatment outcome.
 For example, this may involve decreasing the number of medications being
taken, reducing the frequency of dosing or synchronizing the dose times of
various medicines in the regimen.

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 Strategies to improve the pharmacist–patient relationship
 Be friendly and approachable
 Improve communication skills
 Take into account the spiritual and psychological needs of the patient
 Improve patient education
 Encourage patients to discuss their main concerns without interruption or
premature closing
 Elicit patient perception of the illness and associated feelings and
expectations
 Learn methods of active listening and empathy
 Give clear explanations
 Check the patient’s understanding
 Negotiate a treatment plan

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 Check the patient’s attention to medication adherence
 Simplify the therapeutic regimen
 Be aware of the patient’s wishes
 Involve the patient in treatment decisions
 Improve home support
 Monitor beneficial effects
 Monitor side effects
 Provide long-term support to the patient and continuity of care
 Speak the same language
 Shorten the pharmacy waiting time

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REFERENCES
 Community Pharmacy Practice by Ramesh Adepu. Page No.61-65.
 A Textbook of Clinical Pharmacy Practice, Essential concepts and skills
by G Parthasarthi, Karin Nyfort Hansen and Milap C Nahata. Second
Edition. Page No.74- 84.

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