Enhancing patient compliance in the elderly. Role of packaging aids and monitoring

Improper intake of medication by elders--insights on contributing factors: a review of the literature

Elders represent 6.4% of the world's populations, and 60% of them take medication. In one of six hospital admissions of elders, failures in medication intake are involved. Most of these admissions (88%) could be prevented if elders at risk can be identified (Beijer & Blaey, 2002). This review was conducted to identify and gain insight into which factors influence medication intake in elders. The factors are grouped into six categories: physiological factors, cognitive factors, polypharmacy and medication frequency, patient consent to the treatment and motivation for taking the medication, demographic variables, and family caregivers and social support. In order to identify elders at risk in an early stage, it is recommended that a risk-assessment instrument be developed.

Patient-reported behavior and problems in using glaucoma medications

OBJECTIVE

The objectives of the current study were to describe the different types of problems patients receiving adjunctive therapy reported having when taking their glaucoma medications and to examine the relationship between patient-reported problems in taking their glaucoma medications and patient adherence.

DESIGN

Cross-sectional survey.

PARTICIPANTS

A survey was distributed to glaucoma patients in 4 geographically distinct ophthalmology practices. We excluded patients using only 1 glaucoma medication. The survey was completed by 324 patients.

METHODS

For each patient, average percent adherence to his or her glaucoma medication regimen was calculated. Logistic regression was used to examine how patient characteristics and problems in using glaucoma medications were related to reported adherence.

MAIN OUTCOME MEASURE

Whether patients were less than 100% adherent in the previous week.

RESULTS

We found that 60% of patients reported 1 or more problems with taking their glaucoma medications. Fourteen percent of patients reported being less than 100% adherent to their glaucoma regimen medications during the previous week. Patients who had difficulty remembering to take their glaucoma medications and those who reported that they had other problems or concerns with their glaucoma medications were significantly less likely to be 100% adherent.

CONCLUSIONS

Patient adherence to a glaucoma medication regimen could be improved among patients receiving adjunctive therapy. Ophthalmologists and their clinical colleagues should make sure to discuss the problems and concerns that patients may have in taking their glaucoma medications in an effort to improve adherence.

5-HT(3)-receptor antagonists in the management of nausea and vomiting in cancer and cancer treatment

The 5-HT(3)-receptor antagonists, considered as 'gold standard' therapy for cancer patients, are generally perceived to have similar efficacy and safety profiles, andmost antiemetic guidelines do not distinguish between agents. However, important pharmacological differences exist between agents, which may translate into potential benefits for some patients. In particular, 5-HT(3)-receptor antagonists vary in the nature of their receptor antagonism and plasma half-lives, possibly leading to differences in duration of action. Agents with a longer duration of action provide antiemetic protection throughout the acute emetic period (24 h) with a single daily dose, whereas shorter-acting agents, e.g. ondansetron, may require multiple dosing for full efficacy. Differences also exist between agents in their hepatic metabolism and cardiovascular safety, which may present particular problems for elderly patients who often receive additional medications for comorbid conditions, increasing the risk of drug-drug interaction. Recent antiemetic guidelines from the National Comprehensive Cancer Network recommend preferential use of palonosetron for moderately emetogenic chemotherapy; however, this agent is newly approved and key clinical questions remain unanswered by clinical trial data. Selection of an appropriate 5-HT(3)-receptor antagonist should be based on proven efficacy and safety, as well as on the individual characteristics of the patient.

Medication non-adherence in the elderly: how big is the problem?

Adherence to medication is one of the most intriguing and complex behaviours demonstrated by patients. Non-adherence to a therapeutic regimen may result in negative outcomes for patients and may be compounded in populations with multiple morbidities which require multiple drug therapy. Such a population is exemplified by the elderly. However, non-adherence may not be more prevalent in older patients and there is no consensus in the literature that age is a predictor of poor adherence. Indeed, older patients may deliberately choose not to adhere to medication (intentional non-adherence) to avoid adverse effects. Furthermore, many of the studies on adherence lack commonality in terms of how adherence is measured, the definition of an 'older' patient and the range of disease states which have been examined. Adherence may also be affected by access to medications which may be restricted by the use of formularies or insurance programmes. However, non-adherence may represent a greater risk in older people resulting in poor disease control which may be compounded with multiple morbidity and polypharmacy. A range of strategies have been implemented to try and improve adherence in this patient population. The use of forgiving drugs (those which have a prescribed dosage interval that is 50% or less the duration of drug action) may facilitate occasional lapses in drug-taking. Drug holidays (deliberate, supervised non-adherence for a fixed period of time) have been used in Parkinson's disease to reduce adverse effects. Once-daily scheduling of drug administration may offer a pragmatic approach to optimising drug therapy in some patients; this may be supplemented through the use of compliance aids. What is increasingly apparent, however, is that the role of the patient (irrespective of age) is critical in decision-making about medication, together with communication between patients and healthcare professionals. This has been articulated through the concept of concordance which has been described as a therapeutic alliance between the patient and healthcare professional. In addition, interventions employed to improve adherence must be multifaceted, and together with practical approaches (reducing unnecessary drugs and simplifying dosage regimens), the patient perspective must be considered. Good adherence should be seen as a means of achieving a satisfactory therapeutic result and not as an end in itself.

Compliance with inhaled insulin treatment using the AERx iDMS Insulin Diabetes Management System

OBJECTIVE

The AERx Insulin Diabetes Management System [AERx iDMS, jointly developed by Novo Nordisk (Bagsvaerd, Denmark) and Aradigm Corp. (Hayward, CA)] provides insulin by pulmonary administration. This investigation was designed as a pilot trial to demonstrate the ability of patients to use the electronic device to deliver mealtime inhaled insulin doses and explore the impact on compliance.

METHODS

AERx iDMS was evaluated in a substudy of a 12-week, multicenter open trial by adult patients with type 2 diabetes previously on any insulin regimen. The device was used for dosing fast-acting human insulin immediately before main meals, in combination with bedtime NPH insulin. The AERx iDMS device recorded the date and time of each insulin inhalation, insulin units used, and inhalation technique during aerosol delivery. Compliance was defined as the percentage of prescribed doses taken during the treatment period, dose timing, and the efficiency of dosing technique.

RESULTS

Insulin dosing for 49 patients (age 59.1 +/- 7.7 years) using AERx iDMS was monitored for 78.9 +/- 10 days (range, 41-94 days) with 226 +/- 35 doses (range, 122-272 doses). Patients inhaled on average 2.9 +/- 0.3 doses of insulin daily, taking an average of 11.8 +/- 5.6 units per dose. Compliance with the prescribed regimen was 94.3 +/- 9.1% (range, 45-100%). Overall, 4.2 +/- 9.5% of prescribed doses were omitted. Hemoglobin A1c decreased 0.77 +/- 0.96% from baseline to the end of the study. Inhalation technique was excellent, with 97% of patients experiencing fewer than five inadequate doses.

CONCLUSIONS

Excellent compliance with AERx iDMS dosing, timing, and inhalation technique showed that the device was well accepted by patients. The electronic monitoring feature could be used as an educational tool to help patients and clinicians manage insulin dosing.

Medication non-adherence among older adults: a review of strategies and interventions for improvement

Medication non-adherence among older adults is a prevalent and costly problem; approximately one half have problems following their prescribed medication regimen, and more than 10% of hospital admissions are the result of medication non-adherence. In this literature review, medication non-adherence is defined and described among adults age 50 and older. Factors associated with medication non-adherence are presented, interventions to improve medication non-adherence are discussed, and methods for assessing medication non-adherence are reviewed. In addition, nursing assessment and intervention to improve medication non-adherence are described.

Treatment implications for radiation-induced nausea and vomiting in specific patient groups

Radiation-induced nausea and vomiting (RINV) affect the management and quality of life of cancer patients. Current guidelines for RINV prevention recommend prophylaxis with a 5-hydroxytryptamine (5-HT(3))-receptor antagonist for patients receiving moderately or highly emetogenic radiotherapy regimens. Randomised trials have compared such antagonists with conventional antiemetics, and have demonstrated their efficacy and safety. Special consideration is needed for antiemetic treatment in certain patient groups, particularly the elderly and those with renal or hepatic impairment. Radiation oncologists should be aware of the effect on antiemetic treatment of factors such as comorbid conditions (particularly cardiovascular disease), polypharmacy and drug-drug interactions, and choose the agent with the lowest potential for additional complications. The most appropriate antiemetic treatment to improve patient compliance and quality of life should ideally combine proven efficacy with uncomplicated administration and convenient dosing regimens.

A systematic review of adherence with medications for diabetes

OBJECTIVE

The purpose of this study was to determine the extent to which patients omit doses of medications prescribed for diabetes.

RESEARCH DESIGN AND METHODS

A literature search (1966-2003) was performed to identify reports with quantitative data on adherence with oral hypoglycemic agents (OHAs) and insulin and correlations between adherence rates and glycemic control. Adequate documentation of adherence was found in 15 retrospective studies of OHA prescription refill rates, 5 prospective electronic monitoring OHA studies, and 3 retrospective insulin studies.

RESULTS

Retrospective analyses showed that adherence to OHA therapy ranged from 36 to 93% in patients remaining on treatment for 6-24 months. Prospective electronic monitoring studies documented that patients took 67-85% of OHA doses as prescribed. Electronic monitoring identified poor compliers for interventions that improved adherence (61-79%; P < 0.05). Young patients filled prescriptions for one-third of prescribed insulin doses. Insulin adherence among patients with type 2 diabetes was 62-64%.

CONCLUSIONS

This review confirms that many patients for whom diabetes medication was prescribed were poor compliers with treatment, including both OHAs and insulin. However, electronic monitoring systems were useful in improving adherence for individual patients. Similar electronic monitoring systems for insulin administration could help healthcare providers determine patients needing additional support.

The impact of reducing dose frequency on health outcomes

BACKGROUND

Dosing schedules may be one important factor determining whether patients take their prescribed medication. Schedules may influence whether a patient stays on the prescribed therapy and, if so, the degree to which the regimen is followed. Both factors are important determinants of health outcomes and health care costs.

OBJECTIVE

The goal of this study was to investigate the impact of reducing dose frequency on health outcomes and health care costs.

METHODS

Articles from peer-reviewed journals were identified from the medical literature databases MEDLINE, International Pharmaceutical Abstracts, and HealthSTAR for the years 1985 through 2002. The search included all references that reported on the impact of a change of dose frequency on chronic disease. Search terms used were combinations of dose frequency, dose schedule, and dosing and efficacy, safety, clinical effectiveness, preferences, adherence, compliance, persistence, health-related quality of life, patient satisfaction, resource use, and costs.

RESULTS

Reducing the number of daily doses through extended-release formulations or newer drugs has frequently been shown to provide the patient with better symptom control in a number of disease states. Overall improvements were seen in adherence, patient quality of life, patient satisfaction, and costs. However, results of some studies indicate that not all patients, medications, or diseases may be candidates for reduced dosing due to the potential effects on symptom control, incidence of adverse events, and overcompensation for missed doses.

CONCLUSION

Where feasible, reducing dose frequency may offer benefits for the patient in terms of health outcomes and for the health care budget holder in terms of costs.

Pharmacological factors influencing anticancer drug selection in the elderly

Persons over the age of 65 years are the fastest growing segment of the US population. In the next 30 years this segment will represent more than 20% of the population. Fifty percent of all cancers occur in this age group and therefore the total cancer burden is expected to rise. Data are becoming available that will better guide the use of chemotherapy in the older patient population. Studies are presented discussing pharmacokinetic data on a number of chemotherapeutic agents with an emphasis on those that have entered clinical practice over the past few years. Many of these agents seem to have a beneficial therapeutic index, particularly in regard to older patients. Aging can affect the pharmacokinetics of chemotherapy in a number of ways. Absorption is only modified minimally by age. The greater concern with the use of oral drugs is patient compliance. Volume of distribution is affected by changes in body composition, anaemia and decreased plasma albumin concentration. There are many drugs in which renal excretion plays an important role. Decline in glomerular filtration is a consistent phenomenon with aging. Drug metabolism is primarily affected by changes in the P450 system and coadministration of drugs which also interact with this important enzyme system. The selection of chemotherapy in the elderly is frequently determined by degree of comorbidity and the patients' functional status. These factors are critical and can often determine response and toxicity. This article discusses the changes that occur with antimetabolites, camptothecins, anthracyclines, taxanes, platinum compounds, epipodophyllotoxins and vinca alkaloids. There has also been an increasing trend toward the use of oral chemotherapy. Factors that must be considered in selecting chemotherapeutic agents include limitations of saturability of absorption, patient compliance and the pharmacokinetic and pharmacodynamic changes that occur in older patients. Interpatient variability and age-related changes in drug metabolism are discussed. Careful attention to the physiological changes with age and dose adjustments necessary for end-organ dysfunction (renal, hepatic) are needed to ensure the safe administration of chemotherapy. In this article specific diseases are discussed (breast, colon, ovarian and non-small lung cancers) with recommendations for drug selection in adjuvant chemotherapy and the treatment of metastatic disease. Future studies will need to incorporate these various factors to properly evaluate chemotherapy in older patients. Research and educational initiatives targeted to this population will need to be a priority.

Medication compliance feedback and monitoring in a clinical trial: predictors and outcomes

OBJECTIVE

The objective of this study was to demonstrate the utility of continuous monitoring and enhancement of medication compliance during a long-term clinical trial, predictors of compliance, and relationships to drinking outcomes.

METHODS

Alcohol-dependent patients enrolled in a multicenter VA cooperative study were randomly assigned to once-daily naltrexone (NTX) for 3 or 12 months (short-term or long-term NTX) or placebo for 12 months of treatment. All medications were dispensed in bottles with medication event monitoring (MEMS, AARDEX, Union City, CA) caps with a microprocessor that recorded openings as presumptive doses. Patients were trained to develop personal cues as dosing reminders. Monthly feedback sessions included review of compliance data and cues.

RESULTS

There were no significant differences among short-term NTX, long-term NTX, and placebo (209 each) groups in measures of compliance. Overall compliance rates were 71% +/- 31% of doses for the first 13 weeks and 43% +/- 33% of doses over 52 weeks. Some doses were taken during 83% +/- 27% of the first 13 weeks. Higher medication compliance predicted fewer drinks per drinking day (P = .02) throughout follow-up and a lower percentage of drinking days (P = .002 during the first 13 weeks) with no significant effect for treatment group.

CONCLUSIONS

The feedback and monitoring programs were important features to demonstrate that lack of treatment effect was not a result of poor compliance. Medication compliance data supported the internal validity of the trial by demonstrating that good compliers had better outcomes, irrespective of treatment with NTX or placebo. The MEMS feedback methodology is feasible for use in multicenter trials.

Risk factors and predictors of compliance in depression

Naturalistic studies show that the average length of antidepressant treatment is less than 6 months and that discontinuations are high, especially in primary care depressed patients. Factors leading to treatment discontinuation are multiple and poorly understood. Discontinuations are most frequent during the first month of therapy, and the prevalent reasons vary during the course of therapy. Approximately 25% of patients do not inform their physician about stopping their antidepressant medication. Recent research provides new information that may serve as a guideline for improving compliance. The physician-patient relationship, including the amount of time the physician takes to explain the expected duration of treatment and possible adverse effects, is a key factor. The physician's attitude about the medication is also important. Strategies should be adapted to the stage of treatment, as common reasons for discontinuation change as treatment progresses.

Pharmacology of antineoplastic agents in older cancer patients

Persons over the age of 65 years are the fastest growing segment of the United States population. In the next 30 years it will comprise over 20% of the population. Fifty percent of all cancers occur in this age group and therefore there will be an expected rise in the total cancer burden. Data is becoming available which will better guide the use of chemotherapy in the older patient population. Studies will be presented discussing pharmacokinetic data on a number of chemotherapeutic agents with an emphasis on those which have entered practice over the past few years. Many of these agents seem to have a beneficial therapeutic index, particularly in regard to older patients. There has also been an increasing trend toward the use of oral chemotherapy. Factors that must be considered in choosing chemotherapy include limitations of saturability of absorption, patient compliance and the pharmacokinetic and pharmacodynamic changes which occur in older patients. Interpatient variability and age related changes in drug metabolism are discussed. Careful attention to the physiologic changes with age, and dose adjustments necessary for end organ dysfunction (renal, hepatic) are needed to ensure the safe administration of chemotherapy.

Interventions to improve medication compliance in older patients living in the community: a systematic review of the literature

Noncompliance affects all age groups, but older patients have specific barriers against effective medication use and can be more vulnerable to the incorrect use of medication. Some age-related barriers are vision loss and cognitive impairment. In people aged 60 years or older, noncompliance with medication regimens varies from 26-59%. In this article we review randomised controlled trials (RCTs) on interventions aimed to improve compliance with medication regimens in older patients living in the community. It is known from other reviews that multifaceted interventions, a combination of interventions, are more often effective than single-focus interventions, probably because these address a wider range of barriers. Also, an individual approach with specifically tailored interventions is effective at improving compliance. In this review the following two hypotheses are evaluated: i) multifaceted interventions improve compliance more successfully than single interventions; and ii) interventions that are tailored to patients improve compliance more successfully than generalised interventions. A systematic literature search in four databases produced 14 suitable RCTs with 23 interventions that we categorised as single or multifaceted, and generalised or tailored. Differences in medication compliance between the intervention group and the control group were in less than half of the comparisons in favour of the intervention group. Telephone-linked reminder systems achieved the most striking effect, looking at differences between the intervention and control group, and deserve further attention. Overall, multifaceted interventions and tailored interventions seemed to result more often in differences in compliance rates in older adults in favour of the intervention group compared with a control group than single and generalised interventions.

Adherence to angiotensin-converting enzyme inhibitor therapy for heart failure

This study examined adherence to angiotensin-converting enzyme inhibitor therapy among 171 heart failure clinic patients. Adherence was monitored over a 3-month period with an electronic event monitor housed in a medication bottle cap, which recorded the date and time the cap was opened and closed. The average percentage of days that the prescribed number of doses (regimen adherence) was taken over the observation period was 84%. Seventy-one percent of patients showed 85%-100% adherence with their daily regimen; 19% exhibited less than 70% adherence. The overall high rates of adherence to angiotensin-converting enzyme inhibitor therapy observed among heart failure clinic patients is consistent with research that shows improved outcomes for patients managed in heart failure clinics. Electronic medication monitoring can be useful in identifying a substantial fraction of patients who are poorly adherent so that interventions to improve adherence can be targeted toward them. Additional research is needed to develop and test adherence-enhancing interventions.

Telithromycin is as effective as amoxicillin/clavulanate in acute exacerbations of chronic bronchitis

This randomized, double-blind study evaluated the efficacy and safety of a short, 5-day course of telithromycin, a new ketolide antibacterial, compared with a standard 10-day course of amoxicillin/clavulanate, in the treatment of acute exacerbations of chronic bronchitis (AECB). The study enrolled 325 adult patients with AECB and a history of chronic obstructive pulmonary disease (COPD). Patients received either telithromycin 800 mg once daily (qd) for 5 days (followed by placebo for 5 days) or amoxicillin/clavulanate 500/125 mg three times daily (tid) for 10 days. Clinical cure rates for telithromycin post-therapy (Days 17-21, test-of-cure) and late post-therapy (Days 31-36) were 86.1 and 78.1%, respectively; 82.1 and 75.0% for amoxicillin/clavulanate. Excellent clinical cure rates were also observed for high-risk patients. Bacteriologic outcome was satisfactory for 69.2% of telithromycin recipients vs 70.0% for amoxicillin/clavulanate recipients. Both treatments were generally well tolerated, although the frequency of drug-related adverse events was almost two-fold higher for amoxicillin/clavulanate (25.0 vs. 13.1%). Thus, a 5-day course of telithromycin 800 mg qd is an effective and well-tolerated alternative to a standard 10-day course of amoxicillin/clavulanate 500/125 mg tid for first-line empiric treatment of AECB in adults with COPD.

The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence

OBJECTIVES

To provide an updated review of the literature on the extent of and risk factors for inappropriate prescribing in the elderly.

METHODS

A comprehensive review of the most recent publications in English assessing inappropriate prescriptions for elderly patients in the United States using the 1997 version of the Beers explicit criteria. The reviewed articles were obtained via an electronic search of the MEDLINE database for articles published between 1997 and 2001 and a manual search through major journals for articles referenced in those located through MEDLINE. Search terms were Beers, explicit criteria, inappropriate drug use, prescribing, prescriptions, medication use, elderly, and health outcomes.

RESULTS

Using the updated explicit criteria, a total of 11 empirical studies were identified, all of which were conducted using observational surveys or claims databases. The reported prevalence of elderly patients using at least one inappropriately prescribed drug ranged from a high of 40% for a population of nursing home patients to 21.3% for community-dwelling patients over age 65. Propoxyphene, amitriptyline, long-acting benzodiazepines (e.g., chlordiazepoxide, diazepam, flurazepam), and dipyridamole are among the most commonly occurring inappropriate prescriptions. With a few exceptions, the most significant patient-related predictors of inappropriate prescribing include polypharmacy, poor health status, and female sex. Other potential risk factors include prescribing location, ethnicity, age, and referral status. Limited evidence was found of increased health care utilization and poorer quality of life resulting from inappropriate drug use in the elderly in Medicare health maintenance organization and emergency department settings.

CONCLUSION

The prevalence of inappropriate prescribing remains alarmingly high for the elderly in general and for nursing home residents in particular. This review identified some attributes of the elderly groups most vulnerable to inappropriate prescribing. Future research should document more evidence regarding the adverse impact of inappropriate prescribing on total health care costs and patient health outcomes.

Oral bioavailability of desloratadine is unaffected by food

OBJECTIVE

To determine the effect of coadministration of food on the bioavailability of oral desloratadine.

DESIGN

A randomised, open-label, single dose crossover study in which healthy adults received a single, oral dose of desloratadine 7.5mg, 50% greater than the recommended dose of 5mg, under fed or fasted conditions and were then crossed over to receive the other treatment regimen.

PARTICIPANTS

18 healthy volunteers (11 men, 7 women) aged from 18 to 43 (mean 29) years and weighing 54 to 104 (mean 76.4) kg were enrolled and completed this study.

MAIN OUTCOME MEASURES

C(max), AUC(S) and AUC(infinity ).

RESULTS

Maximum mean plasma concentration (C(max)) was 3.53 microg/L in fed compared with 3.30 microg/L in fasted participants. Area under the plasma concentration-time curve from time 0 to time of final quantifiable sample (AUC(S)) mean values were 61.0 microg/L x h in fed and 61.9 microg/L x h in fasted participants. Fed individuals had mean AUC extrapolated to infinity (AUC(infinity )) of 62.5 microg/L x h compared with 63.5 microg/L x h in fasted participants. None of these differences between the fed and fasted state was statistically significant. The most frequently reported adverse event was headache. There were no statistically significant changes in ECG parameters.

CONCLUSION

The results of this study indicate that food has no effect on the oral bioavailability of a single oral dose of desloratadine 7.5mg.

Pharmacokinetic considerations of oral chemotherapy in elderly patients with cancer

Persons over the age of 65 years are the fastest growing segment of the US population. In the next 30 years they will comprise over 20% of the population. Fifty per cent of all cancers occur in this age group and therefore there will be an expected rise in the total cancer burden. There has been an increasing trend over the past 20 years toward the use of oral chemotherapy. This change has been encouraged by the need to decrease the costs of chemotherapy administration, patient preferences and quality of life issues. Factors that must be considered with oral chemotherapy administration include limitations of saturability of absorption, patient compliance and pharmacokinetic/pharmacodynamic changes which occur in elderly patients. Interpatient variability and drug metabolism, particularly age-related changes in drug metabolism are being studied. The cytochrome P450 system has been intensively studied because of its importance with regard to chemotherapeutic drugs. This article reviews these issues and provides details regarding specific drugs including temozolomide, thalidomide, topotecan, the fluoropyrimidines, etoposide, hydroxycarbamide (hydroxyurea), tamoxifen, and alkylating drugs. Complementary and alternative therapies are also discussed.

Current pharmacotherapeutic strategies for overactive bladder

Overactive bladder (OAB) is a chronic, distressing condition characterised by symptoms of urgency (sudden overwhelming urge to urinate) and frequency (urinating more than eight times daily), with or without urge urinary incontinence (sudden involuntary loss of urine). It affects millions of people of all ages and both sexes world wide, with greater prevalence in women and the elderly. The treatment of OAB is aimed at reducing debilitating symptoms, which have a significant effect on all aspects of an individual's quality of life, including social, domestic, psychological, occupational, physical and sexual functioning. Anticholinergic agents are currently recommended as first-line therapy for OAB. Their use results in significant clinical improvement in patients, although a lack of selectivity for receptors in the bladder may lead to troublesome side effects, including dry mouth, blurred vision, somnolence, dizziness and constipation. Recent research efforts have focused on developing drugs with a reduced propensity for causing these problems. Of the available anticholinergic agents, oxybutynin and tolterodine are the most widely used to treat OAB. Studies directly comparing tolterodine immediate-release (IR) with oxybutynin IR have shown that the two agents have similar efficacy. However, tolterodine IR is significantly better tolerated, particularly with respect to the incidence and severity of dry mouth. An extended-release formulation of tolterodine (4 mg capsules) has recently been developed to allow for once-daily dosing. In addition to greater convenience, tolterodine extended-release has shown enhanced efficacy and tolerability compared with tolterodine IR.

Medication compliance problems in general practice: detection and intervention by pharmacists and doctors

Medication compliance; the role of a portable Medical Summary Card as a compliance aid; and the role of a medical practice-based clinical pharmacist in identifying medication-related problems in a rural general practice setting is evaluated. A clinical pharmacist checked the medications of 50 predominantly aged patients against their medical summary and noted inconsistencies and potential medication problems. From this information the general practitioner (GP) assessed patient compliance with prescribed medications and transcribed the correct medication regimen and medical problems onto a Medical Summary Card for the patient to carry. Forty per cent of the patients were non-compliant. A Medical Summary Card alone was unable to improve compliance. Issues noted by the clinical pharmacist warranted a change in therapy for 8% of patients. Eighteen per cent of patients provided medical information to the clinical pharmacist of which the GP was unaware. Non-compliance with prescribed medications is common. A portable Medical Summary Card may not rectify this problem. Patients' withholding medical information from their medical practitioner is of particular concern.

Naltrexone in the treatment of alcohol dependence

BACKGROUND

Although naltrexone, an opiate-receptor antagonist, has been approved by the Food and Drug Administration for the treatment of alcohol dependence, its efficacy is uncertain.

METHODS

We conducted a multicenter, double-blind, placebo-controlled evaluation of naltrexone as an adjunct to standardized psychosocial treatment. We randomly assigned 627 veterans (almost all men) with chronic, severe alcohol dependence to 12 months of naltrexone (50 mg once daily), 3 months of naltrexone followed by 9 months of placebo, or 12 months of placebo. All patients were offered individual counseling and programs to improve their compliance with study medication and were encouraged to attend Alcoholics Anonymous meetings.

RESULTS

There were 209 patients in each group; all had been sober for at least five days before randomization. At 13 weeks, we found no significant difference in the number of days to relapse between patients in the two naltrexone groups (mean, 72.3 days) and the placebo group (mean, 62.4 days; 95 percent confidence interval for the difference between groups, -3.0 to 22.8). At 52 weeks, there were no significant differences among the three groups in the percentage of days on which drinking occurred and the number of drinks per drinking day.

CONCLUSIONS

Our findings do not support the use of naltrexone for the treatment of men with chronic, severe alcohol dependence.

Tablet-breaking ability of older persons with type 2 diabetes mellitus

PURPOSE

The purpose of this study was to assess the ability of older persons with type 2 diabetes to accurately break in half 2 different formulations of micronized glyburide tablets.

METHODS

Thirty persons with type 2 diabetes, over age 70, were recruited from the St Louis University geriatric clinics. Participants were randomly assigned to 2 groups. Group A broke 30 Glynase Prestabs and 30 generic tablets using 2 different manual tablet-breaking methods. Group B broke 15 Glynase Prestabs and 15 generic tablets without instructions. Visual analog scales were used to assess pain and difficulty of tablet breaking.

RESULTS

A higher percentage of successful tablet breaking was reported with Glynase Prestabs (80%) compared with the generic tablets (33%). Mean pain scores for breaking Glynase Prestabs were 0.1 (Group A) and 0.9 (Group B). Higher pain scores were obtained for the generic tablets (2.1 for Group A, 3.2 for Group B). Glynase Prestabs were easier to break in both groups, and the resultant half tablets showed less variance from the expected theoretical weight (50% of whole parent tablet weight).

CONCLUSIONS

Older adults broke Glynase Prestabs more accurately and with less difficulty than generic micronized glyburide tablets. This variation in ease of tablet breaking and accuracy between different tablet formulations affect bioavailability and patient compliance.

Cue-dose training with monetary reinforcement: pilot study of an antiretroviral adherence intervention

OBJECTIVE

To assess the feasibility and efficacy of two interventions for improving adherence to antiretroviral therapy regimens in HIV-infected subjects compared with a control intervention.

DESIGN

Randomized, controlled, pilot study.

SETTING

Department of Veterans Affairs HIV clinic and community-based HIV clinical trials site.

PARTICIPANTS

Fifty-five HIV-infected subjects on stable antiretroviral therapy regimens. Subjects were predominantly male (89%) and African American (69%), and had histories of heroin or cocaine use (80%).

INTERVENTIONS

Four weekly sessions of either nondirective inquiries about adherence (control group, C), cue-dose training, which consisted of the use of personalized cues for remembering particular dose times, and feedback about medication taking using Medication Event Monitoring System (MEMS) pill bottle caps, which record time of bottle opening (CD group), or cue-dose training combined with cash reinforcement for correctly timed bottle opening (CD+CR).

MEASUREMENTS

Opening of the pill bottle within 2 hours before or after a predetermined time was measured by MEMS.

RESULTS

Adherence to the medication as documented by MEMS was significantly enhanced during the 4-week training period in the CD+CR group, but not in the CD group, compared with the control group. Improvement was also seen in adherence to antiretroviral drugs that were not the object of training and reinforcement. Eight weeks after training and reinforcement were discontinued, adherence in the cash-reinforced group returned to near-baseline levels.

CONCLUSIONS

Cue-dose training with cash reinforcement led to transient improvement in adherence to antiretroviral therapy in a population including mostly African Americans and subjects with histories of drug abuse. However, we were not able to detect any sustained improvement beyond the active training period, and questions concerning the timing and duration of such an intervention require further study. Randomized, controlled clinical studies with objective measures of adherence can be conducted in HIV-infected subjects and should be employed for further evaluation of this and other adherence interventions.

Limits of confidence in tracer compounds as a means of measuring patient compliance with medication

Chemical tracers are thought to be a desirable means of measuring patient compliance with medication. However, no compound has emerged as a standard. To explain this observation, the authors explored the mathematics of simulated tracers with half-lives 5 to 140 days over a month of daily dosing. To model assay variability, they added random "noise" to calculated tracer serum levels. They then fitted those altered levels to the dosing pattern most likely to have produced them, given known kinetics of the tracers. The large number of possible dosing patterns over a month (268,435,456) magnified uncertainty in interpreting noise-altered levels. At best, with an assay variability of 5%, compliance could be estimated only within 4 to 8 doses per month. The tracer with a half-life of 30 days performed best. Pairing tracers did not improve uncertainty. The authors found that even a model neglecting many real-world variables suggests a limited role for tracers in measuring compliance.

Randomized, double-blind study of short-course (5 day) grepafloxacin versus 10 day clarithromycin in patients with acute bacterial exacerbations of chronic bronchitis

The efficacy and safety of grepafloxacin were compared with clarithromycin in a randomized, double-blind, multicentre clinical trial of 805 patients with acute bacterial exacerbations of chronic bronchitis (ABECB). Patients were randomized to receive grepafloxacin 400 mg od for either 5 (n = 273) or 10 days (n = 268) or clarithromycin 250 mg bd for 10 days (n = 261). Patients were assessed pre-treatment, 3-5 days during treatment, 1-3 days post-treatment and at follow-up (21-28 days post-treatment). The clinical success rates for the evaluable patients were 91% in the 5 day grepafloxacin group, 95% in the 10 day grepafloxacin group and 86% in the clarithromycin group. At follow-up, respective rates were 72%, 81% and 73%. A total of 513 pathogens were isolated from the pre-treatment sputum specimens of 400 (49%) patients. The primary pathogens were Haemophilus influenzae (36% of isolates), Haemophilus parainfluenzae (27%), Moraxella catarrhalis (12%), Streptococcus pneumoniae (11%) and Staphylococcus aureus (3%). Pathogens were eradicated or presumed eradicated at post-treatment in 85%, 91% and 58% of evaluable patients treated with grepafloxacin for 5 days, grepafloxacin 10 days and clarithromycin 10 days, respectively. The eradication rates in both grepafloxacin groups were significantly greater than the clarithromycin group (P<0.001). All treatments were well tolerated and incidence of drug-related adverse events in each group was comparable. This study demonstrates that both a 5 and a 10 day regimen of grepafloxacin 400 mg od are as clinically and bacteriologically effective as in the treatment of ABECB clarithromycin 250 mg bd. for 10 days.

Effectiveness of short-course therapy (5 days) with grepafloxacin in the treatment of acute bacterial exacerbations of chronic bronchitis

Three hundred eighty-nine patients were enrolled in a double-masked, multicenter, randomized clinical trial comparing the clinical and bacteriologic efficacies and safety of a 5-day course (n = 195) versus a 10-day course (n = 194) of grepafloxacin 400 mg once daily in the treatment of acute bacterial exacerbations of chronic bronchitis (ABECB). Patients in the 5-day treatment group received placebo on days 6 through 10. Bacteriologic assessments were based on cultures of sputum specimens obtained before and, when possible, during and after treatment. Organisms were isolated from the pretreatment sputum specimens of 332 of 388 (86%) patients, the primary pathogens being Haemophilus parainfluenzae, Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Staphylococcus aureus (29%, 19%, 4%, 5%, and 5% of isolates, respectively). Among isolates tested for beta-lactamase production, results were positive in 25% of H influenzae isolates and 90% of M catarrhalis isolates. Forty-two percent of S pneumoniae isolates demonstrated reduced susceptibility (intermediate or high-level resistance) to penicillin. A satisfactory clinical outcome (cure or improvement) was achieved in 83% (128 of 155) and 81% (122 of 150) of clinically evaluable patients treated with grepafloxacin for 5 or 10 days, respectively. Pathogens were eradicated or presumed eradicated in 77% (106 of 138) and 80% (98 of 123) of bacteriologically evaluable patients treated with grepafloxacin for 5 or 10 days, respectively. The 2 treatment groups were equivalent with respect to both clinical and bacteriologic efficacy, and no statistically significant differences in the incidence of drug-related adverse events were seen between the 2 groups. Substantial symptom relief was evident with both treatment regimens by the first during-treatment measurement, which occurred between days 3 through 5. These results indicate that treatment with 400 mg grepafloxacin once daily for 5 days is as well tolerated and effective as treatment for 10 days in patients with ABECB. The lower cost compared with a 10-day regimen and the increased likelihood that patients will complete the entire shorter, once-daily regimen make the 5-day grepafloxacin regimen a useful therapeutic option in the treatment of ABECB.