Drug therapy: patient compliance

Relationship between carbamazepine concentrations in plasma and saliva in man as determined by liquid chromatography

The concentration of carbamazepine in plasma and saliva was determined in 7 subjects receiving carbamazepine. Plasma and saliva samples were assayed was an excellent linear relationship between carbamazepine concentrations in saliva and plasma (r = 0.991, p less than 0.001) over a plasma concentration range of 0.2--8.0 microgram/ml. The saliva/plasma ratio for carbamazepine was 0.26 +/- 0.02 (S.D.). Since carbamazepine binding to plasma proteins is in the order of 75%, the saliva concentration seems to reflect the concentration of the free drug in plasma. There is very little intrasubject and intersubject variation in the concentration ratio of carbamazepine. This study demonstrates that carbamazepine determination in saliva is a convenient method for optimizing blood levels of patients as well as for the study of pharmacokinetic properties.

Patient compliance in glaucoma

Of a randomly selected sample of 40 patients with chronic simple glaucoma 11 were identified as having failed to comply adequately with medical advice. Noncompliers were more likely: to be men, to have had no other medical disorder but glaucoma, not to rank glaucoma as most troubling if they had another illness, to have experienced side effects from the treatment, and not to have appreciated the association between glaucoma and blindness. Detailed clinical study revealed that several interrelated psychosocial factors contributed to noncompliance.

A study of the efficacy of the Feingold diet on hyperkinetic children. Some favorable personal observations

A study was conducted with 59 children, ages 6 to 14 years, heterogeneously grouped together under the diagnosis of the hyperkinetic, minimal brain dysfunction syndrome. Of 32 who were able to tolerate the Feingold salicylate-low and additive-free diet, 11 were markedly improved. A placebo effect could not definitely be ruled out, but the startling changes seen in patients who had been followed for years with other forms of therapy suggest strongly that this improvement was genuine.

Reducing hospital readmission rates among schizophrenics

Most schizophrenics become in-patients in State mental hospitals, and most improve on neuroleptic medication and are rapidly discharged. The majority require long-term medication; the single most important factor in maintaining remission. This paper describes a mirror-image study using patients as their own controls, and demonstrates the highly significant differences in hospitalization before and after the administration of a depot phenothiazine. It highlights the need for vigorous and determined out-patient follow-up. It is suggested that the costs of an adequately staffed clinic are still small when compared with the costs of hospitalization. Subgroups of poor drug-responders, sex differences, variations in side effects and frequency of administration of the depot drug require further evaluation.

Treatment adherence

A large part of medical practice is complicated by two problems; the degree to which treatments are specific (the placebo problem) and the extent to which they are implemented (the adherence problem). Depending on setting and circumstance, up to half of the benefits of treatment are either non-specific or never obtained. This review considers the problem of adherence in the context of use of medication in psychiatry.

Communication, compliance, and concordance between physicians and patients with prescribed medications

Forty-six practicing physicians and 357 patients with diabetes mellitus or congestive heart failure were the subjects for this study, which focuses on the impact of medication regimen and doctor-patient communication in affecting patient medication-taking behavior and physician awareness of these behaviors. Four types of medication errors were defined: omissions, commissions, scheduling misconceptions and scheduling non-compliance. The average error rates were 19 per cent, 19 per cent, 17 per cent and 3 per cent, respectively. The combined average error was 58 per cent; scheduline non-compliance on the part of the patient was a minor component. Specific aspects of the medication regimen were associated with increased errors: (1) the more drugs involved between the doctor-patient pair, the greater the errors of omission and commission; and (2) the greater the complexity of the scheduling, the greater the errors of commission and scheduling misconceptions. If the patient did not know the function of all his drugs, errors of commission and scheduling misconception increased. Neither characteristics of patients nor the severity of disease were influential in determining the extent of medication errors. For patients with congestive heart failure, good communication of instructions and information from physician to patient was associated with low levels of all types of errors.

Once daily dosage beta-blockade: antihypertensive efficacy of slow release oxprenolol as related to renin and age

A single daily dose antihypertensive therapy with a new slow-release (SR) form of the beta-adrenoceptor blocking agent oxprenolol was as effective as a standard tid beta-blocker regimen in maintaining therapeutic effects over 24 hours. The good overall response rate (target larger than or equal to mmHg diastolic) of 67% was achieved in eight of the 11 high renin patients and 16 out of the 20 normal renin ones; the five low renin patients, who were also older, proved to be non-responsive. In terms of age, 83% of the patients aged under 40 years showed a reduction in diastolic pressure to larger than or equal to 95 mmHg, this percentage being significantly better than the 50% response rate in the 40--56-year-olds. In nine of the 12 beta-blocker non-responders the diastolic blood pressure was reduced to larger than 95 mmHg by adding a diuretic, and in four of the nine, all of them low renin patients, this effect persisted in response to diuretics alone. Oxprenolol SR suppresses renin acutely (59%) and chronically (62%), and it blunts the renin stimulatory effects of diuretics.

A mirror image Out-patient study at a depot phenothiazine clinic

This Mirror Image Study, at a specialised clinic, has shown a significant reduction in days spent in Hospital. Individual features of the sample include sex and age difference in the sub-groups for dosage, duration of treatment and anti-Parkinsonian medication. Preliminary cost-effectiveness analysis has been reported.

Once-daily dosing with Atenolol in patients with mild or moderate hypertension

Because of the difficulties patients have in adhering to their drug regimens a trial was performed in which patients with essential hypertension were given, in random order and for four weeks each, three different doses of atenolol to be taken once daily. Atenolol effectively decreased lying and standing blood pressures, and there was no difference between the effects of the three doses. The simplicity of the regimen, as well as atenolol's freedom from troublesome side effects, should be valuable in helping patients adhere to long-term treatment.

[The treatment of excessive arterial hypertension by a permanent cardiac pacemaker system: a case report concerning the possibility to influence the disturbed harmonization between the heart and the arterial system (author's transl)]

In a 63 year old female patient with a history of longstanding arterial hypertension the implantation of a permanent cardiac pacemaker system resulted in a drastic reduction of the elevated blood pressure values, allowing to reduce the formerly necessary high dosage of antihypertensive drugs. It can be assumed that in the case presented the insertion of the permanent pacemaker leads to several hemodynamic changes: firstly, the heart rate is elevated slightly, secondly, the course of the ejection of the stroke volume is changed and consequently the contour of the pulse wave. Especially the latter factor may have an influence on various regulating mechanisms of the circulatory system and thereby on the lowering of the arterial blood pressure and the consecutive reduction of the hypertrophy of the left ventricle. Most probably the baroreceptor reflex system may be of additional great importance. In addition the "desynchronization" of the spread of excitation by the cardiac pacer might be assumed to change the action of the heart in the beginning of the ejection phase into a "softer" way of pumping. The alteration of a rather "rigid" pump (during normal excitation) into a "soft" pump (during desynchronized excitation) thus may lead to a lowering of the arterial pressure a) by decreasing the speed of ejection of the stroke volume and b) by improving the matching between the heart and the arterial "Windkessel".

Behavioral science applied to cardiovascular health: progress and research needs in the modification of risk-taking habits in adult populations

Epidemiological and experimental studies provide evidence that a complex of behavioral, biological and environmental factors interact in the etiology of many cardiovascular diseases. A survey of research and theory concerning training and counseling programs for adult populations is provided. Six basic behavioral recommendations are made for the maintenance of cardiovascular health. Problems in the design of mass media and interpersonal campaigns to alter the health habits of large populations are considered.

Transcendental meditation in hypertension. Individual response patterns

Seven selected hypertensive patients were stabilized on drugs at a research clinic. Subjects learned transcendental meditation (T.M.), were seen weekly, and took their own blood pressure several times daily. After 12 weeks of T.M. six subjects showed psychological changes and reduced anxiety scores. Six subjects also showed significant reductions in home and four in clinic blood-pressures. Six months later four subjects continued to derive psychological benefit and two showed significant blood-pressure reductions attributable to T.M. at home and clinic.

Guanethidine in antihypertensive therapy: experience with an oral loading regimen

Guanethidine sulfate, a potent antihypertensive agent with a prolonged duration of action, was given in large oral doses to eight hypertensive patients in a loading technique. Blood pressure control resulted within one to three days without side effects, with total loading doses varying from 125 to 650 mg. Based on the drug's pharmacokinetic properties, a maintenance dose required to sustain the desired antihypertensive effects was calculated from the loading dose for each individual. Blood pressure was satisfactorily controlled in the seven patients followed for at least 12 months, and no modification of the calculated guanethidine dose was required. Side effects were minimal and well tolerated. The ease of initial blood pressure regulation with this regimen and the precision with which a maintenance dose can be determined suggest that guanethidine deserves a more prominent role in the therapy of established hypertension.

The serum level approach to individualization of drug dosage

The importance of individualizing the dosage of potent drugs in order to maximize their therapeutic effectiveness and safety is generally accepted. Whenever possible the dosage of a drug should be "titrated" directly in each patient against the intensity of its therapeutic or toxic actions. Unfortunately, for many drugs convenient clinical yardsticks of the intensity of their pharmacologic effects are lacking. Determination of the serum concentration of such compounds can help to guide adjustment of dosage during their therapeutic use. By measuring the serum level of drugs one bypasses the largest source of individual differences in dose-effect relationships-the pharmacokinetic variation between subjects. However, the relationship between the serum concentration of a drug and the intensity of its pharmacodynamic action is influenced by many other factors, which must always be considered in interpretation of serum levels. Therapeutic decisions should never be based soley on the serum concentration of a compound, nor can such measurements ever substitute for careful medical observation and judgement.