Drug therapy: patient compliance

Consequences of the discontinuation of antihypertensive treatment in successfully treated patients

Hypertension is probably the most important public health problem in developed countries. Over the last 40 years, an increasing number of hypertensive patients have been treated with various antihypertensive drugs. If the blood pressure (BP) is controlled, the discontinuation of the antihypertensive drug may result either in a relapse of the disease or in the maintenance of normal BP for a long time. In this study, we discuss the available data regarding the consequences of antihypertensive drug withdrawal in successfully treated patients and we suggest guidelines for the application in clinical practice.

Patient knowledge of immunotherapy before and after an educational intervention: a comparison of 2 methods

BACKGROUND

Immunotherapy is an invaluable therapy for allergic asthma, allergic rhinitis, and hymenoptera hypersensitivity. It is, however, not without risks.

OBJECTIVES

To examine patient knowledge regarding immunotherapy and to determine the most effective educational method to improve their knowledge by answering the following questions: Before educational intervention, what is the current knowledge level regarding allergy vaccinations of patients receiving immunotherapy? What effect does an educational encounter have on that level of knowledge? Which educational intervention--a one-on-one session vs a handout--if either, increases patient knowledge more?

METHODS

An original, self-administered patient questionnaire was distributed to all patients receiving immunotherapy. Patients were randomly assigned to a control group, an intervention group that received an educational handout monthly for 2 months, or an intervention group that had a one-on-one educational session with a physician or nurse practitioner. After 3 months, all patients completed an identical follow-up questionnaire. Pretest and posttest scores were compared for each group and among the different groups to determine which method was more effective. Repeated-measures analysis of variance was used to determine the effect of instruction type on differences in pretest and posttest scores.

RESULTS

All 3 groups significantly improved their mean overall questionnaire scores (P < .001). The amount of change was greater in the intervention groups than in the control group, but it did not reach statistical significance (P = .59).

CONCLUSIONS

Baseline immunotherapy knowledge of allergy vaccination patients was better than expected, and further educational interventions did not significantly improve this knowledge.

Coming full circle in pharmacovigilance: communicating safety information to patients through patient package inserts

Optimal drug therapy requires that the patient should be informed adequately, unequivocally and in timely fashion. Patient package inserts (PPIs) have an important facilitating role to play in this respect. Patients' confidence in the benefit of a drug treatment and their fear of its side effects are strong determinants of their adherence to that treatment. Yet, the European PPI format does not allow a discussion of the treatment's benefits, which results in an unbalanced focus on side effects. This serious shortcoming may significantly interfere with a patient's compliance. In addition, prescribers are often unaware of the content of the PPI of the products they are prescribing. To rectify this situation, the development is proposed of annotated PPIs providing the scientific background to the PPI message. In conclusion, European PPIs need to be improved. The patient should be informed of the expected benefit of a drug treatment, its likelihood and the expected time course of the effect, and not only of side effects and interactions, which constitutes the present focus. Moreover, prescribers need to be informed about the content of the PPIs for the medicines they prescribe.

Refractory Inflammatory Bowel Disease

Therapeutic options for refractory colonic inflammation in patients with ulcerative colitis or Crohn's disease have recently been expanded with the introduction of biologic therapies. Intravenous corticosteroids and cyclosporine A remain the standard therapies for severe ulcerative colitis. Monoclonal antibodies directed at tumor necrosis factor-a have proven to be exceptionally efficacious in patients with severe or refractory Crohn's disease. Immunomodulatory therapy with azathioprine, 6-mercaptopurine, or methotrexate has demonstrated efficacy for maintenance of remission in patients with refractory ulcerative colitis or Crohn's disease. The use of experimental biologic agents may be considered for those patients who fail to respond to or remain dependent on corticosteroids. Surgical intervention still remains for patients with severe colitis who fail to respond to medical therapy or develop life-threatening complications such as perforation or toxic megacolon.

Empowering Providers to Meet Patient Information Needs

Recent studies on the effectiveness of patient information tools and methods confirm that what patients want and what they get are sometimes widely at odds. As the paternalistic notion of “compliance” is evolving into the patient-centred concept of “adherence,” new data and guidelines may help us to address our patients' wants and needs for medication information. This in turn supports patients in their own health and medication management.

Knowledge and expectations of patients receiving aeroallergen immunotherapy

BACKGROUND

Patients receiving aeroallergen immunotherapy frequently have poor knowledge and unfounded expectations of various important aspects of their treatment.

OBJECTIVE

To evaluate patients' knowledge about the content, benefit, and risk related to the aeroallergen immunotherapy that they were receiving.

METHODS

A self-administered questionnaire was distributed to all patients older than 16 years who had undergone aeroallergen immunotherapy for allergic rhinitis at 3 university-affiliated allergy clinics.

RESULTS

A total of 132 patients (77 males and 57 females; mean +/- SD age, 30 +/- 13 years) participated in the study. The mean +/- SD duration of treatment was 30 +/- 60 months. Complete recovery of their allergies was expected by 39% of the patients. One fifth of the study group did not know when improvement should be expected, and 18% anticipated improvement to occur within days or weeks from the initiation of treatment. Only 32% were aware that immunotherapy might have some potential risk or adverse effects, and 24.2% failed to identify at least one of the allergens they were receiving. Patients who were interviewed during their first 6 months of aeroallergen immunotherapy had more knowledge about it than those who had been undergoing long-term treatment.

CONCLUSIONS

There is a grave lack of knowledge and numerous misconceptions among substantial numbers of patients receiving aeroallergen immunotherapy. More educational effort is needed to increase patients' knowledge about immunotherapy before and during aeroallergen immunotherapy to improve their compliance and the success and safety of this therapeutic modality.

Achieving low target pressures with today's glaucoma medications

In the 21st century there are more highly effective medical management options for glaucoma than there were in the 1980s and 1990s. In deciding among them, the clinician's challenge is to select what is clinically relevant from the large amounts of available data. In evaluating different drugs the clinician must consider not only the mean intraocular pressure (IOP) of a trial population, but also the percentage of patients achieving clinically relevant low IOPs. The consistency of IOP control throughout the day and night is also critical. Other factors such as safety, tolerability, and cost-effectiveness must also be kept in mind, with an awareness (both in human and monetary terms) of the cost of treatment failure. This overview concludes that newer medical regimens for IOP lowering address efficacy and safety issues more successfully than older ones.

Efficacy and safety of azithromycin as monotherapy or combined with metronidazole compared with two standard multidrug regimens for the treatment of acute pelvic inflammatory disease

The objective of the study was to compare the efficacy of azithromycin, alone or with metronidazole, versus two standard multidrug regimens for the treatment of acute pelvic inflammatory disease (PID). Patients with PID were treated with once-daily intravenous (i.v.) azithromycin 500 mg for 1 day or 2 days followed by once-daily azithromycin 250 mg orally for a total of 7 days, alone or with three-times-daily metronidazole 400 mg or 500 mg i.v. then orally for a total of 12-14 days. The comparators were either metronidazole + doxycycline + cefoxitin + probenecid or doxycycline + amoxycillin/clavulanate given at standard recommended doses for up to 21 days. In total, 309 patients were treated for PID. The diagnosis was confirmed laparoscopically in 74.8% of patients. Rates of clinical success for azithromycin, alone (97.1%) or with metronidazole (98.1%), were comparable to those for the comparator regimens (94.6%). Eradication rates for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma hominis and anaerobes were also comparable for each of the treatment groups. Both azithromycin regimens were well tolerated. In conclusion, azithromycin, alone or with metronidazole, provides a shorter, simpler treatment option for the successful management of acute PID.

Attitudinal classification of patients receiving antibiotic treatment for mild respiratory tract infections

The aim of this study was to determine patients' perceptions of antibiotic therapy and the doctor's skill in the management of ambulatory respiratory tract infections. Standardized face-to-face interviews were used with more than 3000 randomized patients or parents from four European countries. Attitudinal dimensions relating to their doctor identified four patient types: Involved (30%), Deferent (23%), Ignored (13%) and Critical (17%). Involved and Deferent patients were the most satisfied by the information received from their doctor (43%/39% compared with 17%/16% for Ignored/Critical, respectively, P < 0.01). They also scored more highly on the accurate use of antibiotics, with 80%/80% vs. 38%/62%, respectively (P < 0.01), understanding dosing intervals and 77%/77% vs. 36%/60% (P < 0.01), understanding the course length. Involved and Deferent patients showed better compliant behaviour, with 91% of both groups vs. 86% of the Ignored and Critical claiming to have taken every dose (P < 0.001) and 92%/87% vs. 84%/85% claiming to have finished the course (P < 0.001 for Involved only). Involved and Deferent patients were less prone to save part of a course of antibiotics than the Ignored and Critical (46%/41% vs. 20%/31%, P < 0.001), and they perceived the antibiotics prescribed to be more effective (36%/31% vs. 21%/15%, P < 0.001). By analysing patient perceptions, this study identifies an important mirror effect, whereby a more sympathetic attitude from the doctor should increase the patient's involvement in disease management, for a more appropriate use of antibiotics in common infections.

Noncompliance with Treatment of Neurologic Disease

Noncompliance is a major problem in the treatment of a number of neurologic disorders. Because many neurologic disorders are chronic and many treatments are prophylactic rather than symptomatic, noncompliance is of particular concern. The fact that many neurologic disorders also affect cognition, motivation, and mood adds to this problem. Decreasing the number of times per day the patient is supposed to take the medication is the single most effective way of improving compliance. Making the patient an active participant in treatment planning, as well as through patient education, use of a pillbox, and frequent visits may all help improve compliance.

Long term efficacy and safety of atorvastatin in the treatment of severe type III and combined dyslipidaemia

BACKGROUND

Fibric acid derivatives and HMG-CoA reductase inhibitors are effective in combination for treating patients with familial dysbetalipoproteinaemia and severe combined dyslipidaemia, but combination therapy affects compliance and increases the risk of side effects.

AIM

To evaluate the efficacy and safety of monotherapy with atorvastatin, an HMG-CoA reductase inhibitor with superior efficacy in lowering low density lipoprotein cholesterol and triglyceride concentrations, in patients with dysbetalipoproteinaemia and severe combined dyslipidaemia.

METHODS

Atorvastatin was tested as single drug treatment in 36 patients with familial dysbetalipoproteinaemia and 23 patients with severe combined dyslipidaemia.

RESULTS

After 40 weeks of 40 mg atorvastatin treatment decreases in total cholesterol, triglycerides, and apolipoprotein B of 40%, 43%, and 41%, respectively, were observed in the combined dyslipidaemia group, and of 46%, 40%, and 43% in the dysbetalipoproteinaemic patients. Target concentrations of total cholesterol (< 5 mmol/l) were reached by 63% of the patients, and target concentrations of triglycerides (< 3.0 mmol/l) by 66%. Treatment with atorvastatin was well tolerated and no serious side effects were reported.

CONCLUSIONS

Atorvastatin is very effective as monotherapy in the treatment of familial dysbetalipoproteinaemia and severe combined dyslipidaemia.

Therapeutic drug monitoring of indinavir and nelfinavir to assess adherence to therapy in human immunodeficiency virus-infected children

INTRODUCTION

Adherence to highly active antiretroviral therapy is required to obtain an optimal long term virologic response rate of HIV-1-infected children. Plasma concentrations of protease inhibitors (PIs) outside the limits of the reference values indicate nonadherence to antiretroviral therapy in adults. We studied during a 2-year follow-up period routinely taken plasma protease inhibitor concentrations to assess adherence to antiretroviral therapy in HIV-1-infected children.

METHODS

In 40 children (ages 3 months to 18 years) blood samples were taken at regular outpatient visits every 12 weeks after the start of highly active antiretroviral therapy and analyzed for plasma concentrations of indinavir or nelfinavir by high performance liquid chromatography and for plasma HIV-1 RNA load. The percentage of samples fulfilling the criteria for adherence was assessed for each child by three methods. For each sample a concentration ratio was calculated by dividing the concentration in that sample by the time-adjusted population value. According to Method 1 concentration ratios below or above concentration ratio limits (CORALs) of population data obtained in adults were highly indicative of nonadherence. Because many children have high PI levels, Method 2 evaluated plasma samples of PIs with only the lower CORAL. According to Method 3 only children with plasma samples below the limit of quantification (0.04 mg/l) were considered noncompliant. Differences in adherence rate between virologic responders and virologic nonresponders and between adherence rates and the two protease inhibitors were analyzed. The cumulative incidence of HIV-1 RNA levels >500 copies/ml in children was calculated.

RESULTS

Thirty-one children started treatment with indinavir, and nine children started treatment with nelfinavir. The median adherence rates for indinavir as determined by methods 1, 2 and 3 were 54% [interquartile range (IQR), 25 to 69%], 67% (IQR 50 to 92%) and 80% (IQR 63 to 100%), respectively. For nelfinavir median adherence rates of 60% (IQR 39 to 75%), 100% (IQR 67 to 100%) and 100% (IQR 100 to 100%) were observed. Adherence rates calculated with Method 2 were significantly higher in virologic responders ( = 0.04). Adherence rates calculated with Methods 2 and 3 were significantly lower in children using indinavir compared with those using nelfinavir ( = 0.02 and = 0.02, respectively).

CONCLUSION

Calculation of adherence rates using the lower limit of CORALs of indinavir or nelfinavir in children may be a useful measurement for the assessment of nonadherence to antiretroviral therapy in children.

Factors affecting compliance with allergen immunotherapy at a military medical center

BACKGROUND

Allergen immunotherapy (AIT) is a safe and effective treatment for certain allergic disorders; however, noncompliance with therapy is common. We evaluated the compliance rates among groups receiving AIT at a military medical center and identified factors affecting compliance.

METHODS

The charts of the 381 actively enrolled patients in our AIT program were evaluated for patient compliance. Noncompliant patients were contacted to determine the reason for stopping therapy. Patients were then grouped by diagnosis, age, sex, military status, and schedule of AIT and evaluated for differences.

RESULTS

The overall compliance rate was 77.4%. The most common reasons for noncompliance included inconvenience, precluding medical condition, and adverse systemic reaction. There were no differences in compliance rates by diagnosis or sex. Noncompliant patients were younger than compliant patients, 35.4 years versus 42.4 years (P = 0.001); however, when patients were divided into three age categories (<18, 18 to 45, and >45 years), the youngest and oldest groups were more compliant (P < 0.001). Active-duty members were less compliant than retirees and family members, 65.7% versus 83.1% and 81.4%, respectively (P = 0.004). Patients receiving a conventional schedule of AIT were more compliant than those on a rush schedule, 80.0% versus 48.4% (P < 0.001).

CONCLUSIONS

Factors found to affect patient compliance with an AIT regimen at our military medical center include age, military status, and schedule of AIT. The most common reasons for noncompliance included inconvenience, precluding medical conditions, and adverse systemic reactions. Clinicians need to be aware of the factors limiting patient compliance with AIT in an attempt to maximize treatment effectiveness.

Medication management ability assessment: results from a performance-based measure in older outpatients with schizophrenia

Patients with schizophrenia who adhere to physicians' recommended use of medications are less likely to relapse than those who do not. Self-report measures of adherence have been criticized on a number of grounds. Here we describe a performance-based measure of medication management, the Medication Management Ability Assessment (MMAA), which represents a modification of the Medication Management Test used in individuals with HIV infection. Subjects were 104 patients older than 45 years with diagnoses of schizophrenia or schizoaffective disorder, and 33 normal comparison subjects (NCs). Subjects participated in a role-play task (MMAA) that simulated a prescribed medication regimen similar in complexity to one that an older person is likely to be exposed to. The total number of pills over that prescribed, total number of pills under that prescribed, and total number of correct responses were calculated. Self-report and prescription record data on adherence as well as data on measures of psychopathology, global cognitive status, and other clinical measures were also gathered. MMAA role-plays required 15 minutes, and its 1-week test-retest reliability was excellent (intraclass correlation coefficient, 0.96). Patients committed significantly more errors in medication management compared with NCs. Significantly more patients were classified as being nonadherent (i.e., taking +/-5%, 10%, 15%, or 20% of prescribed pills) compared with NCs. Patients with more severe cognitive deficits performed worse on the MMAA. MMAA performance was significantly related to prescription refill records, performance-based measures of everyday functioning, and self-reported quality of life. The MMAA is a useful instrument for observing ability to manage medications in patients with schizophrenia. The measure was related to severity of cognitive impairment, suggesting that adherence may improve with psychotropic and psychosocial interventions that target these deficits.

Telmisartan: a review of its use in hypertension

Telmisartan is an angiotensin II receptor antagonist that is highly selective for type 1 angiotensin II receptors. It was significantly more effective than placebo in large (n >100), double-blind, randomised, multicentre clinical trials in patients with mild to moderate hypertension. Telmisartan 20 to 160 mg once daily produced mean reductions in supine trough systolic blood pressure and diastolic blood pressure of up to 15.5 and 10.5 mm Hg, respectively. Maximum blood pressure reduction occurred with a dosage of 40 to 80 mg/day. Telmisartan 40 to 120 mg/day was as effective as amlodipine 5 to 10 mg/day or atenolol 50 to 100 mg/day in dose-titration studies. Telmisartan 20 to 160 mg/day was generally similar in efficacy to enalapril 5 to 20 mg/day or lisinopril 10 to 40 mg/day in both titration-to-response and other studies. Hydrochlorothiazide was coadministered in most of the titration-to-response studies if patients remained hypertensive. Telmisartan 80 mg/day was more effective than submaximal dosages of losartan (50 mg/day) or valsartan (80 mg/day) and was as effective as a fixed-dose combination of losartan 50 mg plus hydrochlorothiazide 12.5 mg over the last 6 hours of the dosage interval and the whole 24-hour postdose interval. In patients with severe hypertension, telmisartan 80 to 160 mg/day was as effective as enalapril 20 to 40 mg/day (both agents could be titrated and combined sequentially with hydrochlorothiazide 25 mg and amlodipine 5 mg). The addition of hydrochlorothiazide to telmisartan was more effective than each agent alone at lowering blood pressure in patients with hypertension. Telmisartan was well tolerated in patients with mild to moderate hypertension and was significantly less likely to cause persistent, dry cough than lisinopril.

CONCLUSION

Telmisartan is an effective antihypertensive agent with a tolerability profile similar to that of placebo. Comparative data have shown telmisartan to be as effective as other major classes of antihypertensive agents at lowering blood pressure. Compared with lisinopril, telmisartan is associated with a significantly lower incidence of dry, persistent cough. Therefore, telmisartan is a useful therapeutic option in the management of patients with hypertension.

Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management

PURPOSE

To evaluate oncology outpatients' level of adherence to their analgesic regimen during a 5-week period.

PATIENTS AND METHODS

A random sample of 65 adult oncology outpatients with a Karnofsky performance status score of >or= 50, an average pain intensity score of >or= 2.5, and radiographic evidence of bone metastasis were recruited for this longitudinal study from seven outpatient settings. On a daily basis, patients rated their level of pain intensity and recorded pain medication intake. Adherence rates for opioid analgesics prescribed on an around-the-clock (ATC) and on an as-needed (PRN) basis were calculated on a weekly basis.

RESULTS

Overall adherence rates for ATC opioid analgesics ranged from 84.5% to 90.8% and, for PRN analgesics, from 22.2% to 26.6%. No significant differences over time were found in either of these adherence rates.

CONCLUSION

One factor that seems to contribute to ineffective cancer pain management is poor adherence to the analgesic regimen.

Therapeutic compliance methodologies in HIV-infection treatment: A comparative study

Compliance with HIV treatment has been studied extensively. Following the introduction of tritherapy, its importance and implications have changed. Antiretroviral treatments entail taking up to 20 pills a day at set hours, for which there are often numerous undesirable and even toxic side effects. These therapeutic constraints lead to what is labeled greater or lesser compliance. Certain factors such as side effects, modes of contamination, and trust in physicians appear to be more closely linked to noncompliance than others. A recurring problem is how to assess this compliance. There are two types of measures that serve this purpose: direct (biological) or indirect (interviews, questionnaires). It is often very difficult to know how authors actually proceed in assessing their patients' compliance. To determine this, we analyzed 27 of the 310 studies published between 1990 and 2000 on therapeutic compliance in HIV-infected patients. These 27 studies were not chosen because they are a statistically representative sample of the related literature, but because they account quite well for the different types of methods used to measure compliance with HIV treatment. Our analysis shows that compliance measures are quite diverse and can be either a combination of direct and indirect measures, or consist of one or more direct measures or only indirect measures. These three methodological orientations are discussed first. The limits and biases of self- and hetero-compliance assessment, so often neglected, are studied next. Finally, problems related to the temporal facet of compliance behavior are analyzed, namely definition of the concept, need for a more precise theoretical elaboration, and the place of health psychology in relation to the medical sciences.

Refractory Inflammatory Bowel Disease

Therapeutic options for refractory colonic inflammation in patients with ulcerative colitis or Crohn's disease have recently been augmented by the introduction of biologic therapies. Intravenous corticosteroids and cyclosporin A remain the standard therapies for severe ulcerative colitis. Monoclonal antibodies directed at tumor necrosis factor alfa (TNF-alpha) have proven to be most efficacious in patients with severe or refractory Crohn's disease. Immunomodulatory therapy with azathioprine, 6-mercaptopurine, or methotrexate has demonstrated efficacy for maintenance of remission in patients with refractory ulcerative colitis or Crohn's disease. The use of experimental biologic agents may be considered for those patients who fail to respond to or remain dependent on corticosteroids. Surgical intervention is indicated for patients with severe colitis who fail to respond to medical therapy or develop life-threatening complications such as perforation or toxic megacolon.

Tuberculosis in North Carolina: trends across two decades, 1980-1999

In North Carolina, we analyzed cumulative data for tuberculosis (TB) from 1980 through 1999 to determine trends in incidence, population subgroups at risk, and implications for health policy- makers. The overall incidence rates declined significantly over the study period (p = 0.0001). This decline correlates strongly with an increase in TB patients receiving directly observed therapy. Males have approximately twice the risk for disease, and persons >65 years of age are at the highest risk. For every Caucasian with TB, six blacks, six Hispanics, and eight Asians have the disease. TB incidence rates are declining in all other population subgroups but increasing in foreign-born and Hispanic persons.

Inclusion of older women in randomized clinical trials: factors associated with taking study medication in the fracture intervention trial

OBJECTIVES

The purpose of this study is to describe the early study medication discontinuation (SMD) experience during the first year of follow-up in a randomized clinical trial in older women and to determine the associations between various baseline characteristics and risk of SMD. DESIGH, SETTING, AND PARTICIPANTS: The authors studied 6,459 postmenopausal women aged 55 to 80 from 11 clinical settings during their first year of participation in the Fracture Intervention Trial (FIT). This trial was designed to test the efficacy of alendronate (Fosamax) on fracture prevention among women with low bone mass.

RESULTS

Study medication discontinuation was greatest in the first month post-randomization (2.2%) and declined thereafter. Cumulative rates of study medication discontinuation were 4.8% (n = 311) at 3 months and 11.1% (n = 717) at 12 months. SMD was not associated with age, marital status, alcohol consumption, regular exercise, past estrogen replacement therapy use, bone mineral density, or personal or maternal fracture history. After adjusting for covariates and markers of comorbidity, the strongest predictor of SMD was fair-to-poor self-rated health (relative risk (RR) 2.10; 95% confidence interval (CI) 1.47, 2.99). Having four or more depressive symptoms was also a significant predictor and had a risk associated with SMD (RR vs none 1.34; 95% CI 1.05, 1.71) similar to that seen for individuals with good self-rated health (RR 1.49; 95% CI 1.16, 1.91).

CONCLUSIONS

Results from this cohort emphasize that clinical trials in older women with multiple concomitant conditions can achieve high levels of adherence. Thought should be given to measuring self-rated health and depressive symptoms before randomization to help identify individuals to be targeted for special assistance programs that focus on encouraging adherence.

Weight gain associated with psychotropic drugs

Weight gain is a common adverse effect of psychotropic drugs. Clinically significant weight gain puts the patient at risk for coronary heart disease, hypertension, Type II diabetes, dyslipidaemia and cancer, and can lead to non-compliance, with the probability of relapse and subsequent (re)hospitalization. This review focuses on specific drug classes such as antipsychotics, antidepressants, mood stabilizers and anxiolytics that have a propensity to induce clinically significant weight gain. Patients should be informed of potential drug-induced weight gain and instructed in the importance of weight management techniques (e.g., proper nutrition, physical exercise, behaviour modification). Individual patient-risk profiles should also be assessed. To ensure adherence to treatment, a proactive physician-patient relationship is essential. Patient compliance and quality-of-life issues are addressed. For appropriate medication selection, the clinician should consider the weight gain potential of various psychotropic agents.

Percentage of Adherence Correlates with the Risk of Protease Inhibitor (PI) Treatment Failure in HIV-Infected Patients

Objectives

To determine the effect of adherence on the rate of protease inhibitor (PI) treatment failure among human immunodeficiency virus (HIV)-infected patients.

Methods

A prospective study of a cohort of 282 patients who initiated PI therapy from March 1996 to December 1997. Adherence was quantified as the percentage of prescribed doses reportedly taken and treatment failure was defined as HIV RNA levels above 200 copies/ml after 1 year on therapy.

Results

Overall, 190 patients (67%) missed prescribed doses. However, mean percentage of doses taken was 91% (range, 21–100%). Demographic, virological and immunological characteristics could not predict adherence outcomes. The causes of non-adherence included intolerance or side effects (35%), complexity of treatment (23%), or recurrence in active drug abuse (17%), whereas abandonment owing to HIV-related disease was uncommon (6%). A degree of adherence above 90% correlated significantly with viral suppression [relative risk (RR) 1.69; 95% confidence interval (CI) 1.1–2.56; P<0.01]. In a multivariate analysis, a lower degree of adherence (RR, 0.96; P=0.006), a higher HIV viral load (RR, 2.03; P=0.0001), prior antiretroviral therapy (RR, 2.5; P=0.01), and use of saquinavir-hard gel capsules (saquinavir-HGC) (RR, 1.77; P=0.03) were strongly associated with treatment failure.

Conclusion

The percentage of adherence and initial HIV viral load are the most important determinants of virological response to PI therapy and non-adherence is related to treatment-related factors in the majority of cases.

Double-blind, randomized, multicentre comparison of the effects of amlodipine and perindopril on 24 h therapeutic coverage and beyond in patients with mild to moderate hypertension. General Physicians Investigators' Group

OBJECTIVE

To compare the therapeutic coverage and safety of amlodipine and perindopril in patients with mild to moderate hypertension (diastolic blood pressure > or = 90 mmHg and < or = 109 mmHg).

DESIGN

A double-blind, randomized, parallel-group, multicentre study.

METHODS

Following a 2-week placebo wash-out period, the patients were randomly allocated to treatment with either amlodipine at 5-10 mg once a day or perindopril at 4-8 mg once a day, for 60 days. Trough: peak ratios were calculated by two different methods (global and individualized approaches) from 24 h ambulatory blood pressure recordings made after the placebo period and after the active treatment period. Residual lowering of blood pressure after single-blind, single-dose omission was also investigated with further 24 h ambulatory blood pressure monitoring. Safety assessments were made throughout the study.

RESULTS

The placebo-adjusted, global, diastolic blood pressure trough: peak ratio was 0.80 in the amlodipine group (n = 47) and 0.81 in the perindopril group (n = 49) in an intent-to-treat analysis. The corresponding global systolic blood pressure trough: peak ratio was 0.83 for amlodipine and 0.68 for perindopril. Individual trough: peak ratios were non-normally distributed. Mean (+/- SD) individual trough: peak ratios (intent-to-treat analysis) for diatolic blood pressure were 0.50 +/- 0.69 for amlodipine (median 0.42) and 0.15 +/- 3.27 for perindopril (median 0.33). In the per protocol analysis, the corresponding values were 0.50 +/- 0.72 (median 0.34) for amlodipine and 0.01 +/- 3.90 for perindopril (median 0.21). Both treatments produced comparable decreases in clinic systolic and diastolic blood pressure between days 0 and 60. Forty-eight hours after the last dose, both systolic and diastolic blood pressure were lower in amlodipine-treated patients than perindopril-treated patients. Amlodipine and perindopril were generally well tolerated. The most frequently reported adverse event was leg oedema in amlodipine-treated patients (19.1%), and coughing in perindopril-treated patients (14.3%).

CONCLUSIONS

These results showed no statistically significant difference in trough: peak ratios between amlodipine and perindopril. However, the ambulatory blood pressure trough: peak ratios showed very large variations. Determination of trough: peak ratios by the conventional approach or by an individual approach can yield disparate values. After omitting one dose, a condition imitating noncompliance, blood pressure was more effectively controlled with amlodipine than with perindopril.

Issues of non-compliance in mental health

This paper explores and questions the ideas and notions in respect of non-compliant behaviours. Traditionally, research into this area has focused on identifying individual characteristics from within the adult branch of nursing and within the confines of the medical model of compliance. Little research has investigated the phenomena of non-compliance within the specialty of mental health. It may be suggested that identifying characteristics in this setting is futile. There are many factors determining a client's compliance behaviours. These include gender, social class, race and socio-economic status. Those suffering from mental ill health are often the most vulnerable in society and it may be argued that as such are often coerced into accepting treatment with those who refuse frequently being labelled as non-conformist. The ability of the client to refuse treatment should be based upon informed consent, but is often dependent upon the social prejudice of the health care professional, their misuse of power to bring about compliance behaviours and their inability to act as an effective advocate. Finally, by eliciting information, shared negotiation, planning and improved communication health professionals may improve compliance behaviours based upon the client's needs and wishes.

Compliance with timolol treatment in glaucoma

PURPOSE

To assess levels of compliance in elderly patients on timolol eyedrops for glaucoma.

METHODS

A postal questionnaire was sent from the general practitioner to 86 patients over 55 years of age on repeat prescriptions for timolol eyedrops. The questionnaire asked details about the duration of treatment, family history, the level of understanding of the disease and the importance of treatment, other regular medication, side-effects attributed to the drops and how often patients omitted their drops. A search of practice and local hospital dispensing data was carried out to assess how frequently monthly repeat prescriptions for timolol eyedrops were dispensed over a 12 month period. This allowed a total volume to be calculated for each patient.

RESULTS

Twenty-four per cent of patients admitted to omitting eyedrops either occasionally or frequently. Fifty-one per cent were found to have had insufficient drops dispensed to comply with treatment as prescribed. In non-complaint patients the mean period without drops was 85 days of the year, with a maximum of 165 days.

CONCLUSION

Compliance with treatment is poor and patients underestimate their level of defaulting when questioned.

Drug compliance in therapeutic trials: a review

Because poor compliance introduces a major risk of bias in the interpretation of the results of a therapeutic trial, it is an important element to consider. At the planning stage, factors known to be associated with poor compliance should be recognized. The different methods of evaluating compliance, either clinical or biological, should be reviewed and the best strategy selected. During the therapeutic trial, the objective is to maintain an appropriate level of compliance. Patients, investigators, and sponsors have different options and responsibilities. The analysis should incorporate compliance as a specific variable in order to help test the robustness of the data. Compliance constitutes by itself a specific outcome measure. Compliance should be an integral part of study reports and publications, but it is frequently not discussed.

The interaction of patient perception of overmedication with drug compliance and side effects

OBJECTIVE

Little is known about the significance of patient-perceived overmedication. We sought to determine its prevalence and relation to medication compliance, adverse drug reactions, health-related quality of life (HRQOL), and burden of illness.

DESIGN

Analysis of self-reported questionnaire data. PATIENTS/PARTICIPANT: There were 1,648 participants in a longitudinal study of male veterans.

INTERVENTION

Participants listed each of their medications with indication, missed doses, adverse reactions, and whether their amount of medication was "too much, the right amount, or too little." The survey included questions about medication adherence, "problems with medications," common symptoms, and screening questions for a number of chronic conditions. We assessed HRQOL with the Multiple Outcomes Study 36-Item Short Form Health Study (SF-36).

MEASUREMENTS AND MAIN RESULTS

Of the 1,256 respondents, 1,007 (80%) had taken medication within 4 weeks. Forty (4%) thought they were taking too much. They reported a 1.6-fold increase in prescription medications, a 5-8 fold increase in adverse effects, a 1.5-2 fold decrease in compliance, an increase in each of seven measured symptoms, and a decrease in six of eight SF-36 domains (p < .05 for all comparisons), the exceptions being the mental health and role-emotional scales. There was also a slight increase in the report of any chronic illness (95% vs 86%, p > .05).

CONCLUSIONS

Patient perception of overmedication correlates with self-report of decreased compliance, adverse drug reactions, decreased HRQOL, and an increase in symptomatology that is compatible with unrecognized side effects of medication. Such patients warrant careful evaluation.

Relational control patterns in physician-patient clinical encounters: continuing the conversation

The purpose of this study is to continue the application of the relational communication approach for describing physician-patient control patterns and provide initial exploration into the implication of these control behaviors on patient satisfaction and compliance. Videotaped family medicine clinical visits were analyzed with Rogers and Farace's (1975) Relational Communication Control Coding Scheme. In addition, telephone surveys were conducted with patients 2 to 3 weeks after the clinical visit to assess levels of patient satisfaction and compliance. Transactional results indicated physicians manifested more control submission, whereas patients engaged in greater control dominance. The resulting outcomes of control behaviors showed an increase in patient compliance when physicians exhibited less control assertiveness and patients showed less control submission. An increase in patient satisfaction was found when physicians showed less control dominance.

Treating tuberculosis: the essential role of social work

The resurgence of tuberculosis gives cause for alarm. Compliance with an effective medication regimen leads to cure; yet, many patients fail to comply. This paper discusses factors affecting compliance and the essential role of social work, from an ecological perspective, when intervening to increase compliance. The authors relate comments made by patients at the only hospital originally and still serving as a TB sanatorium in relation to literature on compliance. Changes at the hospital include the development of a social work department which uses the ecological perspective in working with patients whose histories include non-compliance, as well as alcoholism, homelessness, loneliness, joblessness, and AIDS. The content of interviews with patients reveal and identify problems for future research.

Age differences in information-seeking among cancer patients

Studies examining patient populations have found that information-seeking decreases with age. However, researchers usually define information-seeking as involving only the medical establishment, while they neglect other sources of information. The present study examined the use of two types of information sources, non-medical establishment (newspaper, television, and friends) and medical establishment (doctors and nurses), among seventy-five cancer patients aged eighteen to eighty-one years. Patients responded to questionnaires asking about information-seeking, desire for more cancer information, self-perception of their knowledge about cancer, and actual knowledge of facts about cancer. For the medical establishment source, information-seeking decreased with age; however, no age differences existed for seeking non-medical establishment information. In individuals with high levels of desire for information, older adults reported more information-seeking from non-medical sources than did younger adults.

Trends in alpha-blocker treatment of patients with benign prostatic hyperplasia and hypertension: dosing regimens and cost comparisons

Dosing regimen is an important determinant of both drug cost and patient compliance. This retrospective analysis evaluated dosing regimens and drug acquisition costs for 101 patients identified from medical records in a large metropolitan hospital as having hypertension and/or benign prostatic hyperplasia and receiving alpha-blocker therapy with either doxazosin or terazosin. Although once-daily administration is generally recommended for both drugs, 25 (38%) of 66 patients receiving terazosin were treated twice daily compared with 6 (17%) of 35 patients treated twice daily with doxazosin. This difference was statistically significant. The average (mean +/- SD) daily treatment cost per patient for all individuals receiving terazosin during the period of the record review was $1.68 +/- 0.60. For patients treated with doxazosin, the average was $0.96 +/- 0.65-a highly statistically significant result. If all 66 patients receiving terazosin had been converted to doxazosin at the beginning of the study, annual savings would have been $17,345.00. These results demonstrate the importance of reviewing actual dosing regimens. The fact that doxazosin could be administered to a significantly higher percentage of patients once daily rather than twice daily substantially decreased its cost relative to terazosin. A once-daily treatment regimen may also enhance patient compliance, thereby improving the chances of therapeutic success.

Do patients get the best deal when antibiotics are prescribed out of hours?

OBJECTIVE

To investigate patients' compliance in obtaining follow on prescriptions after being prescribed a "starter pack" by the accident and emergency (A&E) department, and to assess the cost of the starter pack system.

METHODS

During a study period of two months, out of hours prescriptions of antibiotic starter packs in A&E were monitored prospectively to determine how many patients returned to the hospital pharmacy or to their general practitioner (GP) for the remainder of the prescribed course. Current costs of out of hours antibiotic prescriptions were calculated, as were the costs of providing a full course of antibiotics on the patient's first visit to the A&E department.

RESULTS

During the study period, 571 antibiotic items were prescribed as starter packs (three days' supply) to 437 patients. Of these, 232 (53%) chose to return to the hospital and 175 (40%) to their GP for the follow on prescription to complete their course. In 29 cases (7%) the information was not recorded and those patients were excluded from analysis. Only 50% of patients electing to obtain the follow on prescription from their GP did so compared with 83.7% of those electing to return to the hospital pharmacy. Failure to obtain the follow on prescription was termed "late primary non-compliance". There was an estimated annual saving to the hospital of Pounds 3131 if the patients were given the full course of antibiotics at their primary attendance at A&E.

CONCLUSIONS

Patients prescribed antibiotics out of hours should be dispensed full courses. This would eliminate late primary non-compliance at no extra cost to the health authority.

Efficacy and safety of two dosing regimens of buspirone in the treatment of outpatients with persistent anxiety

This randomized, double-masked, comparative study evaluated the efficacy and safety of buspirone 30 mg/d, administered twice a day (BID) or three times a day (TID), in patients with generalized anxiety disorder (GAD), commonly called persistent anxiety. Patients who participated had GAD according to criteria of the Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Revised, modified to include patients for whom the symptom duration was at least 4 weeks and scored > or = 18 on the Hamilton Rating Scale for Anxiety (HAM-A). After a 7-day placebo lead-in phase, patients who continued to qualify were randomized to receive buspirone, titrated from 15 mg/d (5 mg TID) to 30 mg/d, as either a BID or TID regimen, for 8 weeks. Of the 137 patients who began the study, 120 patients were included in the data evaluation. Both buspirone BID and TID treatment groups demonstrated significant reductions in mean HAM-A total scores and improvement on Clinical Global Impression measures, with no significant differences detected between the two treatment groups for either measure at any time point. The overall incidence of adverse events was similar for both treatment groups, except for a significantly greater incidence of amblyopia in patients receiving buspirone 15 mg BID. In summary, there was no appreciable difference in efficacy or safety between buspirone 15 mg BID or 10 mg TID in patients with persistent anxiety.

Factors influencing compliance with antiepileptic drug regimes

Failure to comply with drug regimes is prevalent amongst patients with epilepsy and the consequence of this is often an increased risk of further seizures. This paper describes the level of, and influences upon, non-compliance with antiepileptic drug (AED) treatment. A postal questionnaire was sent to an unselected, community-based population of patients with epilepsy. This instrument included questions about patients' AED treatment, any related side-effects, and AED-taking behaviour. Univariate analysis showed that factors associated with compliance were patient age, how important patients felt it was to take drugs as prescribed, whether patients reported feelings of stigma, whether on mono- or polytherapy, whether they were experiencing any side-effects because of AEDs, whether patients had a regular arrangement to see their GP about epilepsy and how easy they found their GP to talk to. Multivariate analysis showed that the strongest predictors of non-compliance were feeling it was not very or not at all important to take AEDs as prescribed, being a teenager, being aged under 60 and being on monotherapy. Further implementation of educational programmes for people with epilepsy would help to improve levels of compliance thereby reducing the risk of unnecessary seizures.

The effect on 24 h blood pressure control of an angiotensin converting enzyme inhibitor (perindopril) administered in the morning or at night

OBJECTIVE

To determine the clinic and ambulatory blood pressure when the same dose of perindopril (4 mg) is administered in the morning (0900 h), or at night (2100 h), in particular, to determine whether the early morning blood pressure rise, the duration of effect and the pattern of response differed.

METHODS

Twenty male patients with diastolic blood pressure 95-110 mmHg when seated and 24 h mean ambulatory diastolic blood pressure > 85 mmHg after 4 weeks' placebo were allocated randomly to be administered 4 mg perindopril at 0900 h or at 2100 h. Clinic blood pressure (with the patient seated and erect) was measured 2 and 4 weeks after the therapy had been started and ambulatory blood pressure monitoring with a SpaceLabs device was performed for 26 h during week 4. The patients then crossed over to the other time of dosage and the measurements were repeated. The study was conducted from a hospital clinic.

RESULTS

The clinic analysis concerned all 20 patients but the ambulatory analysis concerned 18 patients because the ambulatory blood pressure monitor data sets were inadequate for two patients. Compliance was high (97 +/- 3%), with a suggestion that it was better with the 0900 h dose. Clinic blood pressure (with the patient seated and erect) was lower under both regimes and the blood pressure with night-time administration of perindopril tended to be lower than that with daytime administration (P = 0.05-0.10). Twenty-four-hour mean, daytime and night-time means were lower with both doses than they were with placebo and did not differ. Both regimes reduced the early morning peak blood pressure rise and the effect tended to be greater with the 2100 h dose (P = 0.05-0.10). The 0900 h dose had an effect that persisted for > 24 h but the effect of the 2100 h dose had dissipated 18 h after the dose. There was no excessive night-time fall in blood pressure with the 2100 h dose. The trough : peak ratio with the 0900 h dose was 0.86 for systolic and 0.70 for diastolic blood pressure.

CONCLUSION

The early morning blood pressure rise is reduced more when 4 mg perindopril is administered at 2100 h. However, the 2100 h dose regime does not reduce blood pressure over 24 h whereas 24 h control is achieved with the 0900 h dose. In clinical practice the 2100 h dose would have been titrated to the next dose range in more patients. This study indicates that the response profile obtained with an angiotensin converting enzyme inhibitor cannot be transformed from one dose time to another automatically and that chronobiology has important effects on a drug's action.

Compliance with pharmacological treatment in outpatients from a Brazilian cardiology referral center

To evaluate the degree of compliance with pharmacological therapy, and to identify predictors of non-compliance in outpatients from a cardiology referral center in São Paulo, Brazil, we studied 485 outpatients 230 (47.4 percent) males and 255 (52.6 percent) females, through an interview guided by a questionnaire during medical consultation. The ages ranged between 17 and 86 (mean 54, standard deviation 15) years. Heart disease and socioeconomic factors (residence, means of transport, educational level and professional status) were studied. In addition, we examined the drugs prescribed including: difficulties in taking them; the source of supply, and the patient's knowledge of the drugs. Assessment of compliance was based on the patients' response. The patients' answers were compared with the prescription and progress notes. Errors were recorded if the patient reported using one or more nonprescribed medicines. Compliance with therapy was recorded if the patient said the prescription was taken correctly without interruption and without error. The variables with significant differences in univariate analysis were further analyzed by multivariate log-linear regression analysis. Noncompliance occurred in 286 (59 percent) of the patients, and was predicted by the reported difficulty in taking medication (P < 0.001), and by the lack of knowledge of medication names (P < 0.001). Thus, noncompliance with medical therapy was common. The main predictors of non-compliance were the reported difficulty in taking medication and inability to identify medicines' names.

Directly observed therapy for tuberculosis: the Harlem Hospital experience, 1993

OBJECTIVES

A directly observed therapy program was established at Harlem Hospital, New York, NY, in 1993 to promote high tuberculosis treatment completion rates.

METHODS

The Harlem program used an on-site surrogate family model. Treatment completion rate, visit adherence rate, human immuno-deficiency virus seroprevalence, and time to sputum culture conversion were assessed.

RESULTS

Out of 145 enrolled patients with suspected and confirmed tuberculosis, 95 (92 confirmed and 3 suspected) continued treatment. The visit adherence rate was 91.1 +/- 7.9%, with one patient (1%) lost to follow-up.

CONCLUSION

High rates of treatment completion and visit adherence were achieved because of unique program characteristics. Thus, directly observed therapy is advocated as a means of ensuring treatment completion.