Causes of medication non-adherence, pharmacist role in medication adherence, and monitoring of patient medication adherence.

1. UNIT-II
CHAPTER- 4
Medication Adherence
Mrs Chanda Ranjan
Department of Pharm Chemistry
The Oxford College of Pharmacy, Bangalore

2. SYLLABUS
Medication adherence (1)
Causes of medication non-adherence, pharmacist role in the medication adherence, and monitoring of
patient medication adherence.

3. MEDICATION ADHERENCE :
It is defined as the exact or extent to which a patient medication taking behavior concedes with the
intention of the health advice he/she has been given.
Adherence with medication usage is defined as the proportion of prescribed doses of medication actually
taken by a patient over a specified period of time.
Compliance, a synonymous term which was commonly used in the past, implies a passive role and
simply following the demands of a prescriber, and non-compliance has been regarded as associated with
deviant or irrational behavior.
The term “Adherence”, implies an active role in collaboration with a prescriber, and “non-adherence”
encompasses the diverse reasons for patients not following a treatment recommendation.

4. Causes of medication non-adherence
Adherence is a multidimensional phenomenon determined by the interaction of five sets of factors, termed
"dimensions" by the WHO. These dimensions are:
1. Social/economic:
People who have social support from family, friends, or caregivers to assist with medication regimens have
better adherence to treatment. Unstable living environments, limited access to health care, lack of financial
resources, cost of medication, and burdensome work schedules have all been associated with decreased
adherence rates.
2. Provider-patient/health care system:
The relationship of the doctor-patient is one of the most important health care system-related factors
impacting adherence. A good relationship between the patient and health care provider, which features
encouragement and reinforcement from the provider, has a positive impact on adherence. Poor or lack of
communication concerning the benefits, instructions for use, and side effects of medications can also
contribute to nonadherence, especially in older adults with memory problems.

5. Causes of medication non-adherence
3. Condition-related:
Long term drugs administration for many chronic illnesses and adherence to such treatment regimens
often declines significantly over time. This often happens when patient have few or no symptoms and the
absence of them is a barrier for people to take their medication. It is important for the patient to
understand the illness and what will happen if it is not treated.
4. Therapy-related:
The complexity of the medication regimen, which includes the number of medications and number of
daily doses required; duration of therapy; therapies that are inconvenient or interfere with a person's
lifestyle and side effects have been associated with decreased adherence.
5. Patient-related factors:
Physical impairments and cognitive limitations may increase the risk for nonadherence in older adults.
Lack of knowledge about the disease and the reasons medication is needed, lack of motivation, low self-
efficacy, and substance abuse are associated with poor medication adherence.

6. Pharmacist role in the medication adherence
1. Suggest patients only use 1 pharmacy
This approach ensures that all patient records are at a single location, which can help pharmacists mitigate
adverse events. With each new prescription, the risk of drug-drug interactions increases. It also allows
pharmacists to better track patient progress over time and potentially guide new therapeutic recommendations.
2. Recommend the use of pill dispensers or reminders
A standard pill box with compartments for each day of the week is a great way to organize medications. The
visual element of the pill box can tell the patient instantly if they did not take their prescription drugs that day.
3. Discuss the option of early refills whenever possible
For some patients, getting to the pharmacy may present a barrier to medication adherence. If medication refills
are all scheduled for the same time of the month or every 90 days, patients may be less likely to forget to refill
their prescription.

7. 4. Encourage patients to keep a medication list
Patients should keep a list of medications they take, including the name of the drug, the dosage, when
they take it, and what condition it is for, according to the article. Pharmacists should advise patients
to give a copy to their physician and loved ones in case of an emergency. This can allow providers to
quickly determine whether side effects or interactions may occur.
5. Give yearly “brown bag” medication reviews
Patients should round up all of the medications they take—including OTC drugs and dietary
supplements—for an annual review at the pharmacy. Pharmacists can make sure that patients are on
the right medications and are not taking OTC treatments or vitamins that may diminish the efficacy
of important therapies.
Pharmacist role in the medication adherence

8. Monitoring of patient medication adherence
Methods to measure adherence
1. Various methods have been reported and are in use to measure adherence. The methods available for
measuring adherence can be broken down into direct and indirect methods of measurement.
2. Direct methods include direct observed therapy, measurement of the level of a drug or its metabolite in
blood or urine and detection or measurement of a biological marker added to the drug formulation, in the
blood.
3. Direct approaches are one of the most accurate methods of measuring adherence but are expensive.
Moreover, variations in metabolism and "white coat adherence" can give a false impression of adherence.
4. Indirect methods include patient questionnaires, patient self reports, pill counts, rates of prescription refills,
assessment of patient’s clinical response, electronic medication monitors, measurement of physiologic
markers, as well as patient diaries.
5. Each method has its own advantages and disadvantages and no method is considered as the gold standard.
6. The simplest way of measuring adherence is from the patient’s self report.
7. Assessing children’s adherence can be done by asking the help of a care giver (school nurse or teacher).
8. Among the various methods questioning the patient, patient diaries and assessment of clinical response are
all methods that are relatively easy to use, but questioning the patient can be susceptible to misrepresentation
and tends to result in the health care provider overestimating the patient’s adherence.

9. 9. Pill counts i.e. counting the number of pills that remain in the patient’s medication bottles or vials is a
common method to measure adherence. Though this method is simple, it has many disadvantages that the
patients can switch medicines between bottles and may even discard pills before hospital visits in order to
appear to be following the regimen.
Hence, this is not an ideal measure of adherence. Furthermore, this method does not provide
information on dose timing and drug holidays, where the medication has to be omitted on 3 or more sequential
days, both of which help to determine clinical outcomes.
10. Rates of refilling prescriptions are an accurate measure of overall adherence in a closed pharmacy system
(health maintenance organization countries with universal drug coverage) since refills are measured at several
points in that time.
11. Electronic monitors capable of recording and stamping the time of opening bottles, dispensing drops (eye
drops) or activating canister (metered dose inhaler for asthma) can also give a measure of adherence.
The disadvantage with this method is that the measure of adherence is not accurate as the patients
may open the container and not take the medication, take the wrong amount of medication or take multiple
doses out of the container at the same time (or place multiple doses in another container).
Monitoring of patient medication adherence

10. Thank You