Patient-reported behavior and problems in using glaucoma medications

Adherence with brimonidine in patients with glaucoma aware and not aware of electronic monitoring

PURPOSE

To assess the impact of open versus masked adherence monitoring on adherence with topical brimonidine using two different dosing schedules.

METHODS

Thirty-seven patients with glaucoma or ocular hypertension were enrolled in a prospective, observational cohort study. Patients were randomly assigned to open or masked adherence monitoring and to brimonidine twice daily (BID) or three times daily (TID). Patients received conventional brimonidine eye drops with attached electronic monitoring devices for 4 weeks with weekly intraocular pressure measurements. Adherence calculations comprised dosing intervals, adherence rate and time covered. Subgroup analysis with anova included the factors masking, regimen, diagnosis and age.

RESULTS

Among 36 individually analysed patients, 12 (33%) had adherence rates above 75%, therein two (5%)>90%. The mean adherence rate in 19 patients aware of adherence measurements was 70 ± 17% for brimonidine BID and 65 ± 14% for TID, not significantly different to the rates of 17 patients not informed about adherence measurements (77 ± 6% BID, 62 ± 9% TID, p = 0.24). On average, patients with brimonidine TID achieved significantly lower adherence rates (64 ± 12%) than patients on BID (73 ± 13%, p = 0.02). Still, patients on TID applied brimonidine more often (TID 1.9 ± 0.3, BID 1.5 ± 0.1 mean applications per day). The median coverage was 70% and showed no statistically significant difference between patients on BID and TID (p = 0.36).

CONCLUSION

The study findings suggest that adherence measurements are not significantly altered by open adherence monitoring, which may simplify future adherence studies. Adherence with brimonidine eye drops was insufficient for most patients. These results demonstrate the necessity to develop new strategies to improve compliance in glaucoma therapy.

Novel drug delivery systems for glaucoma

Reduction of intraocular pressure (IOP) by pharmaceutical or surgical means has long been the standard treatment for glaucoma. A number of excellent drugs are available that are effective in reducing IOP. These drugs are typically applied as eye drops. However, patient adherence can be poor, thus reducing the clinical efficacy of the drugs. Several novel delivery systems designed to address the issue of adherence and to ensure consistent reduction of IOP are currently under development. These delivery systems include contact lenses-releasing glaucoma medications, injectables such as biodegradable micro- and nanoparticles, and surgically implanted systems. These new technologies are aimed at increasing clinical efficacy by offering multiple delivery options and are capable of managing IOP for several months. There is also a desire to have complementary neuroprotective approaches for those who continue to show progression, despite IOP reduction. Many potential neuroprotective agents are not suitable for traditional oral or drop formulations. Their potential is dependent on developing suitable delivery systems that can provide the drugs in a sustained, local manner to the retina and optic nerve. Drug delivery systems have the potential to improve patient adherence, reduce side effects, increase efficacy, and ultimately, preserve sight for glaucoma patients. In this review, we discuss benefits and limitations of the current systems of delivery and application, as well as those on the horizon.

Primary open-angle glaucoma: clinical update

Glaucoma is an optic neuropathy that is usually associated with an elevated intraocular pressure. Primary open-angle glaucoma (POAG) is the most common type of glaucoma and is progressive and bilateral but typically asymmetric in patients. Studies have shown that reducing intraocular pressure reduces the risk of vision loss. In the United States, medical intervention by means of prescription eye drops is the initial line of treatment. Nurses play an important role in educating individuals, particularly older adults, about the importance of routine eye care to earlier diagnose, treat, and adequately manage eye diseases such as POAG.

Objective assessment of compliance and persistence among patients treated for glaucoma and ocular hypertension: a systematic review

PURPOSE

This study summarizes findings from objective assessments of compliance (or adherence) and persistence with ocular hypotensive agents in patients with glaucoma and ocular hypertension.

DESIGN

Systematic literature review.

METHODS

A PubMed and reference list search was conducted across publication years 1970-2010, using these terms and variants: "compliance," the equivalent term "adherence," and "persistence" in patients with these conditions and therapies. Summaries of selected studies were stratified by measurement method (electronic monitor, prescription fills review, medical chart review). Measures of central tendency across studies were calculated for commonly-reported compliance or persistence measures.

RESULTS

Fifty-eight articles met all inclusion/exclusion criteria: measurement of compliance-electronic monitoring (seven studies reported in 14 articles), measurement of compliance/ persistence-prescription records (36 studies in 38 articles), and measurement of persistence- medical chart review (six studies in six articles). From electronic monitoring, most therapy-experienced patients took medication consistently, but ≥20% met criteria for poor compliance. From prescription records, only 56% (range 37%-92%) of the days in the first therapy year could be dosed with the medication supply dispensed over this period. At 12 months from therapy start, only 31% (range 10%-68%) of new therapy users had not discontinued, and 40% (range 14%-67%) had not discontinued or changed the initial therapy. From medical chart review, only 67% (range 62%-78%) of patients remained persistent 12 months after starting therapy.

CONCLUSIONS

Evidence provided by this review suggests that poor compliance and persistence has been and remains a common problem for many glaucoma patients, and is especially problematic for patients new to therapy. The direction of empirical research should shift toward a greater emphasis on understanding of root causes and identification and testing of solutions for this problem.

Paired-eye comparison of medical therapies for glaucoma

Objective

To evaluate efficacy and patient preference retrospectively among intraocular pressure (IOP)-lowering prostamide and prostaglandin medications in a real-world clinical setting.

Methods

Chart review of patients with uncontrolled glaucoma or ocular hypertension seen at a private practice clinic (n = 55) who received bimatoprost 0.03% once daily in one eye and either travoprost 0.004% or latanoprost 0.005% once daily in the fellow eye. IOP was evaluated at the initial visit and at a follow-up visit scheduled 4–6 weeks later. At the follow-up visit, each patient discussed the clinical results with their physician, chose which medication they preferred to continue using, and were queried regarding the reason for their choice. This paired-eye comparison method is used routinely in clinical practice to assess clinical response and involve patients in decisions regarding treatment. Change in mean IOP from baseline and patient medication choice were the outcome measures.

Results

Bimatoprost-treated eyes (n = 52) had a mean IOP reduction of 2.7 mmHg and travoprost-treated eyes (n = 47) had an average decrease of 1.7 mmHg (P = 0.230). Bimatoprost significantly reduced mean IOP (from 19.8 mmHg at baseline to 17.1 mmHg at follow-up, P < 0.0001), as did travoprost (from 19.4 mmHg at baseline to 17.7 mmHg at follow-up, P = 0.009). Latanoprost-treated eyes were excluded from the efficacy analysis due to small sample size (n = 5). For continued therapy, patients chose bimatoprost over travoprost by a factor of 2.4 to 1. Of the 15 patients who gave a reason for their choice, 80% said their decision was based primarily on IOP change.

Conclusions

Bimatoprost and travoprost were efficacious in reducing IOP among patients with uncontrolled glaucoma and ocular hypertension. Patients preferred bimatoprost over travoprost when trialed in fellow eyes.

Preliminary survey of educational support for patients prescribed ocular hypotensive therapy

PURPOSE

to establish the impact of educational support on patients' knowledge of glaucoma and adherence, in preparation for an intervention study.

METHODS

structured observation encapsulated the educational support provided during clinical consultations and patient interviews captured the depth of glaucoma knowledge, problems associated with glaucoma therapy, and adherence issues.

RESULTS

one hundred and thirty-eight patients completed the study. Education was didactic in nature, limited for many patients and inconsistent across clinics. Patients showed generally poor knowledge of glaucoma with a median score of 6 (range 0-16). A significant association was found between educational support and knowledge for newly prescribed patients (Kendall's tau=0.30, P=0.003), but no association was found for follow-up patients (Kendall's tau=0.11, P=0.174). Only five (6%) patients admitted to a doctor that they did not adhere to their drop regimen, yet 75 (94%) reported at interview that they missed drops.

CONCLUSIONS

although important, knowledge alone may not sufficiently improve adherence: a patient-centred approach based on ongoing support according to need may provide a more effective solution for this patient group.

Morphometric changes in the rat optic nerve following short-term intermittent elevations in intraocular pressure

PURPOSE

Intraocular pressure (IOP) fluctuations may occur in patients with glaucoma, but how these fluctuations affect axonal populations in the optic nerve and other structures in the eye has been difficult to assess. This study developed a rat model to evaluate the effect of intermittent controlled elevations in IOP on the morphology of the rat optic nerve.

METHODS

IOP was transiently elevated for 1 hour on each of 6 days a week over 6 weeks with an adjustable vascular loop around the right topically anesthetized eye of Sprague-Dawley rats. IOP was measured by pneumatonometer before, immediately after, and at the end of 1 hour of treatment with ligature. Globes and optic nerve segments were prepared for histology and morphometry.

RESULTS

Mean baseline IOP of 14.9 ± 1.8 mm Hg increased to 35.3 ± 2.6 mm Hg (P < 0.001) during 1-hour treatments and returned to 15.0 ± 2.2 mm Hg (P = 0.84) 1 hour after completion. The contralateral untreated eyes had a mean IOP of 14.2 ± 1.9 mm Hg at baseline and 14.6 ± 1.9 mm Hg at the end of treatment. Nerve fiber layer thinning (22%-25%) corresponded with a decrease (7%-10%) in soma number in the ganglion cell layer. Optic nerves displayed axonal degeneration with a modest axon loss of 6% and increased expression of glial acidic fibrillary protein in astrocytes.

CONCLUSIONS

Controlled daily 1-hour IOP elevations can be performed with an adjustable vascular loop in rats. After only 6 weeks, intermittent elevations in IOP produce changes in optic nerve consistent with early degeneration reported in chronic models of glaucoma.

Comparison of ocular hypotensive actions of fixed combinations of brimonidine/timolol and dorzolamide/timolol

OBJECTIVE

To compare brimonidine/timolol fixed combination (BrTFC; Combigan *) with dorzolamide/timolol fixed combination (DTFC; Cosopt dagger) in terms of ability to lower intraocular pressure (IOP) in primary open-angle glaucoma (POAG).

METHODS

This was a prospective, randomized, double-masked, crossover study. After 6 weeks of therapy with timolol maleate 0.5% twice daily, patients were randomized to BrTFC twice daily or DTFC twice daily for 6 weeks, before being crossed over to the other treatment arm for a further 6 weeks. At all follow-up visits, IOP was measured at 09.00 (pre-instillation) 12.00 and 16.00. The primary outcome measure was change in mean diurnal IOP from baseline at 6 weeks. The secondary outcome was percentage of patients with IOP <18 mmHg at 6 weeks. Data were analyzed from all patients who completed the study.

RESULTS

Twenty-five patients were randomized and 20 completed the study. Mean diurnal IOP (mean +/- standard deviation [SD]) was 20.28 +/- 2.03 mmHg at timolol-treated baseline. After 6 weeks, mean diurnal IOP was 16.28 +/- 2.07 mmHg following BrTFC and 17.23 +/- 2.29 mmHg following DTFC (difference: 0.95 mmHg, 95% CI 0.10-1.80, p = 0.03). Mean IOP at 09.00 was 20.95 +/- 2.31 mmHg at baseline. This was reduced to 15.85 +/- 2.56 mmHg following BrTFC and 17.55 +/- 2.67 mmHg following DTFC (difference: 1.70, 95% CI 0.80-2.60, p = 0.001). For the 12.00 and 16.00 timepoints, the mean changes from baseline in the two arms were comparable. Percentages of patients achieving a target IOP of <18 mmHg were 85% following BrTFC and 60% following DTFC (p = NS [not significant]). No treatment-related adverse events were reported with either therapy. Key limitations include the small size of the study population and the 6-week duration of treatment periods, which prevents drawing conclusions regarding long-term therapy.

CONCLUSION

Reductions from baseline in mean diurnal IOP and morning IOP were greater with BrTFC than with DTFC.

Monitoring adherence rates in glaucoma patients using the Travatan Dosing Aid. A 6-month study comparing patients on travoprost 0.004% and patients on travoprost 0.004%/timolol 0.5% fixed combination

OBJECTIVE

To assess adherence in glaucoma patients using the Travatan Dosing Aid (TDA); to record differences in adherence by age, sex, therapy, systemic therapies, years from diagnosis, type of therapy and intraocular pressure (IOP).

RESEARCH DESIGN AND METHODS

Sixth-month cohort study; fifty-six Caucasian, primary open-angle glaucoma patients on travoprost (T) or travoprost/timolol fixed combination (TTFC) monotherapy were submitted to four visits: at baseline and months 1, 3 and 6 (M1, M3, M6). Adherence was recorded with TDA and classified as 'high' if greater than 90%. Self-reported and physician-presumed adherence data were collected. Kruskall-Wallis and Fisher's exact tests were applied.

RESULTS

Thirty-two patients (54.2%) were treated with T. Age, sex, level of schooling, presence of systemic comorbidities, duration of current therapy and IOP were similar between T and TTFC. Seventeen subjects (30.3%) recorded high adherence at every visit, 13 (23.2%) at two visits, 26 (46.4%) otherwise. Adherence was maintained over time with a slight decrease from month 1 to month 6 without statistical differences within and between groups. Adherence was statistically influenced by age (p = 0.007) and duration of therapy (p = 0.004).

CONCLUSION

The typical nonadherent patient is elderly. TDA records indicate that only a minority of patients are really adherent: predictive models to screen for poor adherence are needed.

Predictors of additional intraocular pressure reduction in patients changed to latanoprost/timolol fixed combination

Background

Given the growing number of ocular hypotensive medications available, it is important to be able to predict a positive response to therapy. The purpose of the present study was to identify predictors of an additional 10% intraocular pressure (IOP) reduction after 12 weeks of treatment with latanoprost/timolol fixed combination (FC) in patients requiring a change in their previous ocular hypotensive medication.

Methods

This multicenter, open-label, prospective, phase IIIb study included subjects ≥18 years of age with open-angle glaucoma (OAG) or ocular hypertension (OHT). Eligible subjects had baseline IOP ≥21 mmHg and insufficient response to current beta-blocker monotherapy. The primary efficacy analysis (logistic regression) identified predictors of a positive response after 12 weeks of latanoprost/timolol FC.

Results

The intent-to-treat (ITT) population included 383 subjects treated with ≥1 drop of FC and having ≥1 follow-up IOP assessment. Mean IOP was 22.19 ± 2.16 mmHg at baseline and was reduced by 5.42 ± 2.71 mmHg at study end. In all, 325 (84.9%) subjects had a positive response to latanoprost/timolol FC; the response rate was similar across groups: OAG (n = 208; 82.7%); OHT (n = 161; 87.6%); OAG+OHT (n = 14; 85.7%). Higher baseline IOP (odds ratio: 1.284; 95% confidence interval [CI]: 1.101, 1.497; p = 0.0014) and absence of adverse events (odds ratio: 0.318; 95% CI: 0.161, 0.629; p = 0.0010) were significant predictors of positive response. Age, gender, ethnic origin, diagnosis, family history of OAG/OHT, corneal thickness, and concomitant systemic beta-blocker were not significant predictors of a positive response in the ITT analysis. The FC was well tolerated. The most common adverse events were related to the eye and were consistent with known adverse events associated with latanoprost and timolol.

Conclusions

These results support the use of latanoprost/timolol FC in patients whose IOP is insufficiently controlled on beta-blocker monotherapy. Patients with higher baseline IOP levels and who do not experience adverse events while on therapy are most likely to achieve a positive response to latanoprost/timolol FC.

Trial Registration

Study registration number: NCT00230763

An exploratory study of factors influencing glaucoma treatment adherence

PURPOSE

To understand the factors that influence glaucoma treatment adherence with medication taking, prescription refills, and appointment keeping to develop an intervention for a specific population.

PATIENTS AND METHODS

In-depth interviews were conducted with 80 individuals diagnosed with open-angle glaucoma, glaucoma suspect, or ocular hypertension. Additional eligibility requirements were that all participants were: between the ages of 18 to 80; white or African American; spoke and understood English; and were taking daily doses of topical glaucoma treatments for at least the past year. Cross-tabulations and chi2 tests were conducted to compare adherent and nonadherent individuals, classified as such based on self-report and medical chart/pharmacy data.

RESULTS

Compared with adherent participants, nonadherent participants were less likely to: believe their eye doctors spent sufficient time with them; ask their eye doctor if they had any questions; know of benefits to taking their glaucoma medication regularly; and have someone help them take their glaucoma medications or drive them to eye appointments. Conversely, compared with adherent individuals, nonadherent participants were more likely to have difficulty remembering to take their medications and to believe their glaucoma would affect their eye sight in the future.

CONCLUSIONS

Nonadherent glaucoma patients struggle with a variety of issues related to consistent use of glaucoma medicine and routine eye care. Interventions are needed to address these modifiable factors related to glaucoma treatment adherence.

Scoring and psychometric properties of the Eye-Drop Satisfaction Questionnaire (EDSQ), an instrument to assess satisfaction and compliance with glaucoma treatment

BACKGROUND

The objective of this study was to ascertain the scoring and assess the psychometric properties of the Eye-Drop Satisfaction Questionnaire (EDSQ), a 43-item Patient-Reported Outcome instrument developed to assess patients' satisfaction and compliance with glaucoma treatment.

METHODS

The EDSQ was administered during an observational, retrospective study to 184 French patients treated for glaucoma. The hypothesized structure, including six dimensions (patient-clinician relationship; patient experience; patient-treatment interaction; apprehension; patient knowledge; travel), was tested by assessing the internal consistency reliability (Cronbach's alpha) and construct-related validity (item convergent and discriminant validity). As unsatisfactory results were demonstrated, another structure was defined using a principal component analysis (PCA) combined with content of items. Psychometric properties of this new structure were assessed. Scores were compared between low, moderate and high compliance profile groups defined using data collected with the Travalert electronic device.

RESULTS

Analyses were performed with the 169 patients who completed at least half of the EDSQ items. The hypothesized structure showed a Cronbach's alpha lower than 0.70 for four dimensions out of six and an overall poor construct-related validity (range of item-scale correlations: 0.00-0.68). The new structure obtained with the PCA included six dimensions: concern about treatment (five items); concern about disease (two items); satisfaction with patient-clinician relationship (five items); positive beliefs (three items); treatment convenience (three items); and self-declared compliance (three items). A score ranging from 0 to 100 was calculated for each dimension, with higher scores indicating more of the attribute referred to in the dimension. Internal consistency reliability was good (Cronbach's alpha greater than 0.70 for five dimensions). The structure offered good construct-related validity (range of item-scale correlations: 0.36-0.82). Ceiling effects of 21% and 49%, were observed for the satisfaction with patient-clinician relationship and self-declared compliance scores. Patients in low compliance profile group reported the lowest score for the satisfaction with patient-clinician relationship, positive beliefs, treatment convenience and self-declared compliance dimensions, and the highest score for the concern about treatment dimension.

CONCLUSIONS

The scoring of the EDSQ was developed and the questionnaire proved to have satisfactory psychometric properties. EDSQ scores showed a promising relationship to compliance profiles. The EDSQ could be used in future studies.

A comprehensive perspective on patient adherence to topical glaucoma therapy

TOPIC

Risk factors for poor adherence or nonadherence to topical glaucoma medication regimens.

CLINICAL RELEVANCE

Poor adherence to glaucoma medication regimens may be associated with subsequent visual loss and irreversible optic nerve damage.

METHODS

A literature search was performed using the words "glaucoma AND adherence AND risk" and "glaucoma AND compliance AND risk," limited to those studies in English and focused on care in the United States. Publications from well-regarded journals in this field were reviewed, and a focused summary of the literature is presented.

RESULTS

There are a myriad of adherence barriers inherent to the glaucoma patient population. Although most of these obstacles are common in the elderly (e.g., reduced cognition, musculoskeletal problems, and transportation difficulties), older age has not been shown to be a consistent risk factor for poor adherence to glaucoma medication regimens. Other expected barriers, such as medication cost, limited health insurance, disease severity, and role of complicated dosing regimens, have varied effects based on the patient population studied and the definition of adherence. Poor medication adherence also is associated with decreased adherence to follow-up medical visit schedules. A systematic taxonomy of adherence barriers has been formulated. In addition, subanalyses from the Glaucoma Adherence and Persistency Study identified 8 variables that affect adherence to glaucoma medication regimens as well as several characteristics that support the importance of and associations between doctor-patient communications.

CONCLUSIONS

Recent studies have provided valuable insights into the many factors that increase the risk(s) for poor adherence in patients prescribed glaucoma medications. Four major types of barriers to effective patient adherence (medication regimen, patient factors, provider factors, and situational or environmental factors) have been identified. Addressing these specific barriers will require a tailored, patient-centered approach.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Noncompliance with drug therapy of glaucoma: a review about intervening factors

Glaucoma is defined as an optic neuropathy, characterized for loss of visual field and injury of the optic nerve, being considered as the second cause of blindness in the world, which could be prevented by the use of antiglaucoma eyedrops. The lack of adhesion of the patient to the drug treatment can culminate with loss of the vision. The objective was to revise possible literature data regarding intervening factors for noncompliance and explain estimated rates of noncompliance. A systematic review about the subject was carried out in the period of January to June of 2006. Articles had been searched in two data bases, in the National Library of Medicine (PUBMED) and in the Literature Latin American and Caribbean Health Sciences (LILACS) using the following keywords: glaucoma, compliance of the patient, noncompliance of the patient, treatment and eyedrops. In PUBMED, 199 articles were collected, written in English and French languages. No article was found in LILACS. Considering the inclusion and exclusion criteria, 27 articles were selected, with 25 originals and two reviews. Twelve possible intervening factors for noncompliance were raised, as well as estimates for rates of noncompliance. The noncompliance rates varied from 4.6% up to 59%. Two factors, forgetfulness and inadequate between-doses interval, had been associated to noncompliance of the drug therapy. The factors race, adverse effects, treatment cost, number of instilled doses, coexisting illnesses and number of eyedrops used, had resulted contradictory, being impossible to affirm that they have contributed for noncompliance. Age, sex, educational level and loss of visual field, had not been associated with noncompliance. The glaucoma patients tended to disregard the drug treatment. The wide variation in noncompliance rates could be an influence from the authors' difficulty to define the noncompliance and the variety of methodologies used to estimate it. More studies are necessary for a better evaluation of these 12 raised factors.

Daily costs of prostaglandin analogues as monotherapy or in fixed combinations with timolol, in Denmark, Finland, Germany and Sweden

BACKGROUND

To compare the daily costs of 3 prostaglandin analogues (bimatoprost, latanoprost, travoprost), alone, and associated with timolol in 4 European countries (Denmark, Finland, Germany, and Sweden).

METHODS

Six glaucoma products were sampled by buying 5 bottles from 1 suburban pharmacy in each of the 4 countries. Drops were weighed by a single operator at 1 site according to standardized procedures. Residual drops were then counted. Unit bottle costs were estimated from tariff lists. Eye-drop weights were entered into a nested analysis of variance comprising drug, instillation day, country, the interaction, and a sample factor nested within the country factor. Effectiveness was represented by treatment failure rates estimated from a meta-analysis and a general practitioner survey.

RESULTS

Every drug bottle contained sufficient drops to treat 1 patient for 28/31 days. Drop-size heterogeneity between countries was observed for bimatoprost and bimatoprost/timolol. Mean travoprost and travoprost/timolol drop-sizes were the smallest, and drop-counts per bottle were the lowest for latanoprost, or latanoprost/timolol. In all 4 countries annual costs were least for travoprost and travoprost/timolol.

CONCLUSIONS

On taking into account drug costs and effectiveness, travoprost and travoprost/timolol were cheaper and more effective than latanoprost and latanoprost/timolol and were cheaper than bimatoprost and bimatoprost/timolol.

Self-reported prevalence and factors associated with nonadherence with glaucoma medications in veteran outpatients

OBJECTIVE

The purpose of the current study was to determine the self-reported prevalence of and factors associated with nonadherence with glaucoma medications in veteran outpatients.

METHODS

This survey study was conducted at a Veterans Affairs (VA) clinic. A survey was administered to patients with glaucoma. We calculated the percentage of self-reported adherence with glaucoma medications in each patient. Logistic regression was used to assess whether patient characteristics and difficulties with using glaucoma medications were related to patients' reporting that they were <100% adherent with their glaucoma medications in the previous week.

RESULTS

The survey was completed by 141 patients (men, 91.5%; mean [SD] age, 70.22 [11.60] years [range, 37-93 years]; black race, 45.4%; white race, 44.0%; "other" or data unavailable, 10.6%). Nonwhite patients were significantly less adherent in the previous week than were white patients (27.0% vs 11.3%; P < 0.05). A total of 67.4% patients reported > or =1 difficulty in using their glaucoma medications. The 3 most commonly reported difficulties were "drops fall on cheek" (29.1%), "too many drops come out" (20.6%), and "hard to read print" (17.0%). A total of 19.1% of patients self-reported using <100% of their glaucoma medications in the previous week. The number of difficulties reported was significantly associated with reporting being <100% adherent in the previous week (P<0.05).

CONCLUSION

In this small sample of VA patients with glaucoma, adherence to glaucoma medications could be improved, especially among those who reported difficulties using their medications and those who were nonwhite.

Personality traits, depression, and objectively measured adherence to once-daily prostaglandin analog medication in glaucoma

PURPOSE

To investigate the influence of personality traits, depression, and training on objectively measured adherence to once-daily prostaglandin analog medication.

METHODS

Adherence was measured with the Travalert Dosing Aid on 58 consecutive, regularly followed-up glaucoma patients already on self-administered travoprost. Before the 3-month data-collection period all patients received training on use of the device. Psychologic characteristics were measured using the State-Trait Anxiety Inventory, Eysenck Personality Questionnaire, and Beck Hopeless Scale and Depression Inventory. An adherent day was defined as travoprost instillation at 9 PM +/-2 hours.

RESULTS

Adherence was 77% for the total period. Social desirability was higher than normal (U test, P<0.0001). Seven patients (12.1%) showed mild-to-moderate depression, which was not significantly associated with decreased adherence (Kruskal-Wallis test, P=0.071). Severity of glaucoma, number of ocular and systemic medications, satisfaction with the recording device, and socio-economic characteristics had no influence on adherence.

CONCLUSIONS

Objectively measured adherence to once-daily prostaglandin analog medication was good, and not influenced by treatment characteristics or patient factors including mild-to-moderate depression. The elevated social desirability suggests that self-reported adherence is not a reliable measure of adherence in glaucoma.

Adherence and persistence with glaucoma therapy

Adherence and persistence with chronic therapies is crucial to prevent disease progression, such as in glaucoma. Patients report high rates of adherence, which are not supported by pharmacy claims analysis. This article reviews the literature regarding methods to assess adherence and persistence and the patient behaviors that pose challenges to proper treatment. Rates for persistence are generally below 50% at 1 year. Differentiating efficacy of eyedrops from lack of adherence presently confounds ophthalmic treatment. Additionally, as intraocular pressure (IOP) can appear controlled by short-term adherence, the physician can be fooled into believing the patient's glaucoma is well-controlled. Likewise, when progressive worsening is noted despite good IOP control, it can be problematic whether the patient's target pressure needs to be lowered or adherence needs to be improved. White-coat adherence is common, in which patient adherence rises sharply 1 week before the appointment with the physician, then declines rapidly following the appointment. White-coat adherence may make it difficult to assess IOP control over the longer term; cycling behavior with medication use is well-documented. Adherence and persistence rates differ by class of drug, with higher rates associated with prostaglandin use. We review findings from The Glaucoma Adherence and Persistency Study that identified behaviors associated with poor adherence. Greater physician awareness of adherence and persistence issues is necessary in order to help the patient become more adherent.

Patient-reported barriers to glaucoma medication access, use, and adherence in southern India

The objectives of the study were to (a) describe the different types of problems that patients in southern India reported having when taking their glaucoma medications and (b) examine the relationship between patient reported-problems in taking their glaucoma medications and the self-reported patient adherence. A survey was conducted by clinical staff on 243 glaucoma patients who were on at least one glaucoma medication in an eye clinic in southern India. We found that 42% of patients reported one or more problems in using their glaucoma medications. Approximately 6% of patients reported being less than 100% adherent in the past week. Unmarried patients and patients who reported difficulty squeezing the bottle and difficulty opening the bottle were significantly more likely to report nonadherence.

Will improvement of knowledge lead to improvement of compliance with glaucoma medication?

PURPOSE

To identify specific items on knowledge and need for information that could be used to improve compliance with glaucoma medication.

METHODS

Forty-four randomly selected ophthalmologists assigned 166 consecutive glaucoma patients to complete a questionnaire. The questionnaire was developed systematically based on focus group interviews, consultation of experts and a pilot test. Items included knowledge about glaucoma and its treatment, need for information and compliance with therapy.

RESULTS

No statistically significant correlation was found between the total level of knowledge and compliance. Concerning knowledge of glaucoma, one out of 19 items had a statistically significant negative correlation with compliance. Concerning knowledge of glaucoma treatment, one out of 18 items had a statistically significant positive correlation with compliance. Regarding total need for information, no statistically significant correlation with compliance was found. Three out of 22 items had a statistically significant positive correlation with compliance.

CONCLUSION

Given the number of related items, their direction and limited strength of correlation and the difficulty of hypothesizing a causal relation for some items, it is unlikely that further improving knowledge will greatly improve compliance with glaucoma medication. Interventions focused on attitude and discipline may be of more benefit in improving compliance with therapy.

Prevalence and determinants of non-adherence to topical hypotensive treatment in Dutch glaucoma patients

BACKGROUND

To assess the prevalence and determinants of non-adherence to topical hypotensive treatment in glaucoma patients in order to support interventions targeting enhancement of patient adherence.

METHODS

One-hundred and sixty-six glaucoma patients, recruited by nationwide multi-stage sampling, filled in an extensive and carefully developed questionnaire covering various theoretically relevant determinants of patient adherence which were categorized as psychosocial aspects, barriers and skills.

RESULTS

Prevalence of self-reported non-adherence was 27.3%. Younger patients (<55 years of age) had a higher risk of being non-adherent. Forgetfulness, unavailability of eye drops and difficulties with holding the bottle above the eye when applying the eye drops were the most cited reasons for non-adherence. Fifty percent of the patients indicated that they required more information on the correct administration of eye drops. There was no association between non-adherence and sex, level of education, type of insurance, duration of disease or family history of glaucoma.

CONCLUSIONS

Non-adherence to topical glaucoma medication is fairly common. Aids that minimize forgetfulness and delivery systems facilitating the delivery of medications to the eye could be considered to enhance patient adherence before advancing to other therapies with additional risks and costs.

Intraocular pressure-lowering efficacy of brinzolamide 1%/timolol 0.5% fixed combination compared with brinzolamide 1% and timolol 0.5%

PURPOSE

To compare the safety and intraocular pressure (IOP)-lowering efficacy of brinzolamide 1%/timolol 0.5% fixed combination with brinzolamide 1% or timolol 0.5% alone in patients with open-angle glaucoma (OAG) or ocular hypertension (OHT).

DESIGN

Randomized, double-masked, parallel group, multicenter study.

PARTICIPANTS

Five hundred twenty-three patients were randomized to the study treatments.

METHODS

Patients with OAG or OHT were recruited to the study. Qualifying eyes had IOPs of 24 to 36 mmHg at 8 am and 21 to 36 mmHg at 10 am on 2 eligibility visits after an appropriate washout period from previous treatment. Patients were assigned randomly to either brinzolamide 1%/timolol 0.5%, brinzolamide 1% (Azopt; Alcon Laboratories, Fort Worth, TX), or timolol 0.5%, dosed twice daily and were followed up while receiving therapy for 6 months. At selected sites, additional IOP measurements were performed at 12 pm, 4 pm, and 8 pm during the 2 eligibility visits, at month 3, and at month 6.

MAIN OUTCOME MEASURE

Mean IOP.

RESULTS

Brinzolamide 1%/timolol 0.5% produced statistically significant and clinically relevant reductions from baseline ranging from 8.0 to 8.7 mmHg, which were statistically and clinically superior to that of either brinzolamide 1% (5.1-5.6 mmHg) or timolol 0.5% (5.7-6.9 mmHg). No safety concerns were identified based on an assessment of ocular and cardiovascular parameters and a review of adverse events.

CONCLUSIONS

Brinzolamide 1%/timolol 05% is superior in IOP-lowering efficacy to either brinzolamide 1% or timolol 0.5%.

Development of the conceptual framework for the Eye-Drop Satisfaction Questionnaire (EDSQ) in glaucoma using a qualitative study

Background

Compliance is a major issue in glaucoma care. It is usually poor in glaucomatous patients, and may ultimately result in an acceleration of the disease progression and a risk of blindness. Reasons for this poor compliance are complex and multifactorial, amongst which patient satisfaction can be counted. The objective of this study was to develop a questionnaire to assess patient satisfaction and compliance with eye-drop treatment.

Methods

A qualitative study was carried out to develop the questionnaire. An interview guide was developed based on a literature review. Structured interviews of fifteen French and English patients with primary open-angle glaucoma or intraocular hypertension were conducted by trained interviewers of the native language of the interviewees. General concepts and subconcepts were identified from the transcripts. The questionnaire was developed using the patient verbatim, and submitted to six patients (French and English) for cognitive debriefing. Following patients' comments, items were modified and restructured, and a pilot questionnaire was designed.

Results

Analysis of data from the interviews with patients and clinicians resulted in the elicitation of concepts related to patient satisfaction and compliance with glaucomatous treatment. These were further refined and used to generate a test questionnaire, which consisted of 46 items grouped into 6 domains: patient characteristics, treatment characteristics, patient-clinician relationship, patient experience with the disease and the treatment, interaction between the patient and the treatment, and patient knowledge of the disease and the treatment.

Conclusion

The Eye-Drop Satisfaction Questionnaire (EDSQ) conceptual framework and items were developed simultaneously in French and in English. This questionnaire could be used to evaluate patient satisfaction and compliance with eye-drop treatment and would facilitate the identification of patients at risk of being non-compliant prior to clinical trials or innovative device tests. A psychometric study is under way to validate the questionnaire.

Ocular Comfort of Combination Glaucoma Therapies: Brimonidine 0.2%/Timolol 0.5% Compared with Dorzolamide 2%/Timolol 0.5%

PURPOSE

Successful management of glaucoma and ocular hypertension requires patient compliance with the therapeutic regimen. Because ocular discomfort affects compliance, we compared the comfort of brimonidine 0.2%/timolol 0.5% and dorzolamide 2%/timolol 0.5%.

METHODS

In this single-centre, randomized, double-masked, internally controlled/paired-eye study, 30 subjects without a significant ocular surface disease received brimonidine 0.2%/timolol 0.5% in 1 eye and dorzolamide 2%/timolol 0.5% in the fellow eye. They evaluated discomfort at 30-40 s and 5 min postinstillation.

RESULTS

At 30-40 s, brimonidine 0.2%/timolol 0.5% provided significantly lower mean ocular discomfort scores than dorzolamide 2%/timolol 0.5% (P < 0.0001). This pattern persisted at 5 min but was not statistically significant. Significant differences were seen in the subjects' determination of the more comfortable treatment (P < 0.0001): brimonidine 0.2%/timolol 0.5% was rated as more comfortable than dorzolamide 2%/timolol 0.5% by 80% of subjects at 30-40 s and by 27% at 5 min. Only 10% of subjects at each time point rated dorzolamide 2%/timolol 0.5% as more comfortable. The remaining subjects reported no preference at either time point. No adverse events were reported.

CONCLUSIONS

Brimonidine 0.2%/timolol 0.5% was significantly more comfortable than dorzolamide 2%/timolol 0.5% upon instillation. Patients with ocular hypertension or glaucoma may be more compliant with brimonidine 0.2%/timolol 0.5% treatment.

Fixed-combination and emerging glaucoma therapies

Ocular hypotensive agents are the only approved pharmacotherapy for glaucoma. Despite significant advances during the past two decades, a large proportion of glaucoma patients require more than one drug. The most recent additions to the armamentarium of antiglaucoma drugs are fixed-combination products for the glaucoma patient who is insufficiently responsive to monotherapy. Fixed-combination products have the combined efficacy of two ocular hypotensive drugs, and the convenience of a two-drug treatment regimen in a single container, which may aid patient adherence to treatment. Available fixed-combination products consist of timolol 0.5% as an invariant with brimonidine 0.2%, dorzolamide 2%, travoprost 0.004%, latanoprost 0.005% or bimatoprost 0.03%. Research on more advanced antiglaucoma medications continues. Promising new directions appear to be the Rho-kinase inhibitors, microtubule-disrupting agents, serotonergics and cannabimimetics. Efforts continue to improve existing antiglaucoma drugs in an attempt to design second-generation cholinomimetics, adrenergics, prostaglandins and prostamides.

Patients' and physicians' perceptions of the travoprost dosing aid: An open-label, multicenter study of adherence with prostaglandin analogue therapy for open-angle glaucoma or ocular hypertension

OBJECTIVE

This study describes patients' and physicians' perceptions of issues related to dosing adherence with topical therapies for lowering intraocular pressure before and after use of the travoprost dosing aid (Travatan Dosing Aid, Alcon Research Ltd., Fort Worth, Texas).

METHODS

The study had an open-label, multicenter, single-treatment-arm design that included sequential patients with open-angle glaucoma (with or without pigment dispersion or pseudoexfoliation component) or ocular hypertension who were taking any prostaglandin analogue monotherapy. Ten participating physicians were chosen on the basis of factors such as their experience, qualifications, and previous clinical study participation. The study consisted of 2 visits: screening and week 4. Patients were asked to complete a survey about their medication adherence before study entry at the screening visit and at study exit during the week-4 visit. In addition, each physician was asked to complete an entry and exit survey on each patient as well as a survey to provide feedback on the travoprost dosing aid.

RESULTS

Of the 87 enrolled patients, 6 did not complete the exit survey; therefore, 81 patients were included in the intent-to-treat analysis. Mean (SD) age at enrollment was 65.4 (11.6) years; 61.7% (50/81) of the patients were women and 60.5% (49/81) were white. Most patients (96.3% [78/81]) had open-angle glaucoma. Participating physicians perceived that problems involving dosing and adherence were reduced after patients used the dosing aid. Physicians indicated that they would recommend continued use of the travoprost dosing aid for 91.3% (73/80) of patients. All 10 participating physicians said that they would recommend the dosing aid to patients in the future. Of the 81 patients, the majority (68.8% [55/80]) indicated that they would like to continue using the travoprost dosing aid. For 67.5% (54/80) of patients, dosing adherence as recorded by the travoprost dosing aid was >70%. The dosing lever (39.7% [31/78]) and the visual alarm (29.5% [23/78]) were the 2 most favored features of the dosing aid reported by all evaluable patients. The majority of patients (58.8% [47/80]) indicated that they were "relieved" or "very relieved" that the doctor was able to monitor when they dosed their medication; few (7.5% [6/80]) were "concerned" or "very concerned" that the doctor was able to monitor their dosing.

CONCLUSIONS

The travoprost dosing aid was perceived to be effective in reminding this group of patients to take their medication as prescribed. In this study, the device was well accepted by both patients and physicians.

Adjunctive glaucoma therapy use associated with travoprost, bimatoprost, and latanoprost

PURPOSE

This study contrasts the utilization of adjunctive medication associated with travoprost, bimatoprost, or latanoprost, as primary glaucoma therapies.

METHODS

Patients in the Medco Health database who initiated prostaglandin analog therapy on travoprost, bimatoprost or latanoprost between January 1, 2002 and July 31, 2002 were selected if they had no prostaglandin analog use in the prior 6 months. Patients were also required to have 12 months of prostaglandin therapy subsequent to the initial prescription. Data were available through July 31, 2003. The t-test and chi-square were used where appropriate to calculate p-values and assess significant differences.

RESULTS

A total of 13 171 benefit-eligible subjects were identified of which 8381 (64%), 2637 (20%), and 2153 (16%) patients were treated with latanoprost, bimatoprost, and travoprost, respectively. There were no significant differences in mean age or gender between the three study groups with the exception that latanoprost patients were statistically older than travoprost patients (69.0 vs. 68.0). This was not considered a clinically meaningful difference. Overall, patients using travoprost or bimatoprost had a significantly lower rate of adjunctive medication use compared to patients starting on latanoprost monotherapy (22.5%, 23.2%, and 30.2 %, respectively). Therefore, for every 14 patients treated with latanoprost instead of travoprost or bimatoprost, one additional patient would be expected to need adjunctive therapy with another agent. The difference between travoprost and bimatoprost patients was not significant.

CONCLUSIONS

The use of adjunctive medications to control intraocular pressure was significantly higher for latanoprost patients compared to travoprost and bimatoprost patients. This finding should be interpreted in the context that this study was based only on prescription claims data. It is important to simplify ophthalmic medical regimen as it is more cost effective, better for the patient, and minimizes the washout effect from administering two eye medications within 5 min. Decreasing the complexity of the patients' drug regimen may lead to increased adherence to prescribed therapy and a decreased risk of the incidence of blindness.