Medication Nonadherence: Implications for patient health outcomes in pharmacy practice

ABSTRACT Objectives: The primary objective of this review is (1) to better understand the prevalence and impact of medication nonadherence, (2) to identify risk factors for medication nonadherence, (3) to understand the association between nonadherence and its implications on patient health outcomes in pharmacy practice, and (4) to study interventions designed to improve patient adherence to prescribed medications for medical conditions, considering its impact on both medication adherence and patient health outcomes. Methods: Published journal articles were manually sorted. Additional references were obtained from citations within the retrieved articles. This review surveyed the findings of the identified articles with data extracted to presents various strategies and resources on medication nonadherence related to patients and healthcare providers. English languages were considered inclusion criteria in reviewing published articles related to medication nonadherence. This review also surveyed identified articles to determine both subjective and objective medication adherence measures. Key findings: The research in this field needs advances, including improved design of feasible long‐term interventions, objective adherence measures, and sufficient study power to detect improvements in patient health outcomes. Conclusion: Current methods of improving medication adherence for chronic health problems are mostly complex and ineffective so full benefits of treatment cannot be realized. To date, monitoring of patient medication adherence and use of interventions to improve adherence are rare in routine clinical practice.

Expectations and educational needs of rheumatologists, rheumatology fellows and patients in the field of precision medicine in Canada, a quantitative cross-sectional and descriptive study

Background Precision medicine, as a personalized medicine approach based on biomarkers, is a booming field. In general, physicians and patients have a positive attitude toward precision medicine, but their knowledge and experience are limited. In this study, we aimed at assessing the expectations and educational needs for precision medicine among rheumatologists, rheumatology fellows and patients with rheumatic diseases in Canada. Methods We conducted two anonymous online surveys between June and August 2018, one with rheumatologists and fellows and one with patients assessing precision medicine expectations and educational needs. Descriptive statistics were performed. Results 45 rheumatologists, 6 fellows and 277 patients answered the survey. 78% of rheumatologists and fellows and 97.1% of patients would like to receive training on precision medicine. Most rheumatologists and fellows agreed that precision medicine tests are relevant to medical practice (73.5%) with benefits such as helping to determine prognosis (58.9%), diagnosis (79.4%) and avoid treatment toxicity (61.8%). They are less convinced of their usefulness in helping to choose the most effective treatment and to improve patient adherence (23.5%). Most patients were eager to take precision medicine tests that could predict disease prognosis (92.4%), treatment response (98.1%) or drug toxicity (93.4%), but they feared potential negative impacts like loss of insurability (62.2%) and high cost of the test (57.5%). Conclusions Our study showed that rheumatologists and patients in Canada are overall interested in getting additional precision medicine education. Indeed, while convinced of the potential benefits of precision medicine tests, most physicians don’t feel confident in their abilities and consider their training insufficient to incorporate them into clinical practice.

Chitosan-Based Thermo-Responsive Scaffold for Wound Heal-ing Provides Dexketoprofen Trometamol Controlled Release for 24 Hour-Use

Chronic and non-healing wounds demand personalized and more effective therapies for treating complications and improve patient adherence. This work aims to develop a suitable chitosan-based scaffold to provide 24 hours controlled release of DKT, by taking advantage of chitosan’s thermo-responsive behavior as well as local hyperthermia in wounds. Three formulation prototypes were developed using chitosan (F1), 2:1 chitosan: PVA (F2), and 1:1 chitosan:gelatin (F3). Compatibility tests were done by DSC, TG, and IR spectroscopy. SEM was employed to examine the morphology of the surface and inner layers from the scaffolds. In vitro release studies were performed at 32 °C and 38 °C to evaluate the release profiles, which were later adjusted to different kinetic models for the best formulation. F3 showed the most controlled release of DKT at 32 °C for 24 hours (77.75 ± 2.72 %), and reduced the burst release in the initial 6 hours (40.18 ± 1.00 %), while at 38 °C the release reached 88.52 ± 2.07 % at 12 hours. The release profile for this formulation fits with Hixson-Crowell and Korsmeyer-Peppas kinetic models at both temperatures. Therefore, the developed chitosan/gelatin thermo-responsive scaffold provides a suitable system for wound healing with a controlled release of DKT for 24 hour-use, which can overcome adherence issues and wound complications.

Selective Serotonin Reuptake Inhibitors and Clozapine: Clinically Relevant Interactions and Considerations

The monoamine hypothesis of depression attributes the symptoms of major depressive disorders to imbalances of serotonin, noradrenaline, and dopamine in the limbic areas of the brain. The preferential targeting of serotonin receptor (SERT) by selective serotonin reuptake inhibitors (SSRIs) has offered an opportunity to reduce the range of these side effects and improve patient adherence to pharmacotherapy. Clozapine remains an effective drug against treatment-resistant schizophrenia, defined as failing treatment with at least two different antipsychotic medications. Patients with schizophrenia who display a constellation of negative symptoms respond poorly to antipsychotic monotherapy. Negative symptoms include the diminution of motivation, interest, or expression. Conversely to the depressive symptomology of interest presently, supplementation of antipsychotics with SSRIs in schizophrenic patients with negative symptoms lead to synergistic improvements in the function of these patients. Fluvoxamine is one of the most potent inhibitors of CYP1A2 and can lead to an increase in clozapine levels. Similar increases in serum clozapine were detected in two patients taking sertraline. However, studies have been contradictory as well, showing no such increases, which are worrying. Clinicians should be aware that clozapine levels should be monitored with any coadministration with SSRIs.

Controlling medication nonadherence in chronic illness

Patient adherence during the treatment period must be considered, because patient adherence plays an important role in achieving therapeutic success, especially for chronic diseases. Treatment non-adherence is a common and complex problem. Failure to follow a treatment schedule can lead to major health complications, including death. To avoid it, several interventions are needed to control patient non-adherence. There are several interventions that can support and improve patient adherence. These include digital interventions; increasing patient knowledge and understanding of the treatment being undertaken with counseling, Drug Information Services (PIO), providing educational leaflets, digital pillbox reminders and Pill Cards; family support; diaries; keep treatment commitments. Based on this, it is necessary to have an intervention method in terms of education (educational), behavior (behavior), and attitude (affective) in order to achieve patient adherence and the success of chronic disease therapy.

Significant Reduction in Hba1c and BMI After Three Months of Personalized Glycemic Response Based Coaching for Patients With Type 2 Diabetes

Background/Objective: Patients with type 2 diabetes face challenges when it comes to following recommendations (nutrition, exercise and medications). Using technology to understand glycemic responses can increase patient awareness about dietary and lifestyle changes. Coupled with coaching by an expert nutritionist, such a program may help improve patient adherence, resulting in a reduction in HbA1c and body mass index (BMI). Method: Fifty-seven patients with type 2 DM not at goal (HbA1c ≥ 6.5%) either on lifestyle modification, OHA with or without insulin, consenting to participate in the study were enrolled in the DIABEFLY program which included Ambulatory glucose monitoring (AGM) and correlating it with dietary intake for 14 days using a technology platform (FITTERFLY wellness app). Patients were explained their AGM graphs, in relation to their daily food and activity log, to make them aware of their personalised glycemic responses to various foods and accordingly diet plan was suggested. Nutritionists (coaches) interacted with patients over calls on Day 1, 7, 14, 30, 60 and Day 90 to explain recommendations, address any diabetes related queries and evaluate adherence to diet & exercise plans. Patients also had access to daily chat support for 90 days and received daily messages on glycemic responses, healthy food choices, exercise options, stress management, sleep, medication adherence, self-monitoring of blood glucose and complications of diabetes. Strictly, no advice on type or dosage of medication was given by the coaches. Statistical analysis for outcomes was done by t-test using SPSS software. Result: Out of 57 patients, mean age was 46 years, of which 70% were male and 30% were females. The baseline HbA1c was found to be 8.3% ± 1.68 which significantly decreased (p<0.05) to 7.4% ± 1.36 in 3 months. The Baseline BMI of 27.1± 4.9 kg/ sq m was significantly reduced (p<0.05) to 26.6±4.6 kg/sq m in 3 months. Discussion: With the availability of AGM devices, powerful food databases and technology to correlate these two had led to a new era of diabetes coaching. The personalised glycemic responses so calculated for every patient lead to more concrete understanding of changes necessary for better glycemic control. Regular interactions or reminders from an expert may act as a unique and necessary way of reinforcement to follow recommendations. In our study, though increased engagement with the programme resulted in a significant reduction in HbA1c and BMI. Conclusion: Personalized Glycemic response led coaching benefits patients with Type 2 diabetes mellitus helping them achieve two critical outcomes - lowering of HbA1c and reduction of BMI as early as three months. Keywords: AGM; Personalised glycemic response; Diabetes lifestyle coaching

Missed Opportunities in Contraceptive Counselling: Findings from a European Survey-based Study with Simulated Patient Consultation

Background: Available evidence highlights unmet needs in contraceptive counselling practices. The aim of this study was to better understand current practices and clinician behaviour across Europe.Methods: This survey-based study used a novel, online approach to simulate contraceptive counselling discussions based on three, predefined patient types, each with a hidden need. Clinicians were asked to recommend a contraceptive method for their randomly assigned patient at two time points: 1) after a simulated discussion, during which they were given a brief patient profile and the opportunity to question their patient to obtain further information; 2) after they had been presented with a full patient profile. Descriptive statistics were used to analyse the clinicians’ counselling approach, how successful clinicians were at uncovering the hidden needs of their patients, and whether an understanding of these needs would cause clinicians to change their contraceptive recommendation. Results: In total, 661 clinicians from 10 European countries participated in the study, including obstetricians/gynaecologists, midwives and general practitioners. Clinician specialty varied by nation. Most clinicians (78.8% and 70.5%, respectively) failed to uncover the hidden needs of patients X and Y, both of whom had requested prescription renewals. By contrast, 63.4% of clinicians uncovered the hidden need of patient Z, who had requested a review of her contraceptive method. Clinicians who did uncover their patients’ hidden needs asked significantly more questions than those who did not (mean 5.1–7.8 vs 1.5–2.2). Clinicians were more likely to recommend a change of prescription once they had seen the full patient profile than after the simulated discussion (12.3–30.2% increase in prescription change), indicating that clinicians rely on their patients to speak up proactively about any concerns. Family planning and bleeding issues were frequently not discussed in consultations.Conclusions: Existing counselling practices appear insufficient to capture patient needs, with opportunities for shared decision-making and discussion being missed. Clinicians and contraceptive counselling services should aim to introduce more in-depth contraceptive counselling, incorporating clear, open-ended questions, to improve patient adherence and enhance reproductive planning. Women should be empowered to actively voice both their needs and any dissatisfaction with their current contraceptive.

Does the Polypill Improve Patient Adherence Compared to Its Individual Formulations? A Systematic Review

Many patients, especially those with a high pill burden and multiple chronic illnesses, are less adherent to medication. In medication treatments utilizing polypills, this problem might be diminished since multiple drugs are fused into one formulation and, therefore, the therapy regimen is simplified. This systematic review summarized evidence to assess the effect of polypills on medication adherence. The following databases were searched for articles published between 1 January 2000, and 14 May 2019: PubMed, Web of Science, Cochrane Library, and Scopus. Medication adherence was the only outcome assessed, regardless of the method of measuring it. Sixty-seven original peer-reviewed articles were selected. Adherence to polypill regimens was significantly higher in 56 articles (84%) compared to multiple pill regimens. This finding was also supported by the results of 13 out of 17 selected previously published systematic reviews and meta-analyses dealing with this topic. Adherence can be improved through the formulation of polypills, which is probably why the interest in researching them is growing. There are many polypills on the market, but the adherence studies so far focused mainly on a small range of medical conditions.