Adherence and Persistence with Glaucoma Therapy

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Abstract

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.

Section snippets

Adherence

Assessing adherence accurately poses a significant challenge. The methodology used to measure adherence has typically followed one of three techniques: patient self-report, electronic monitoring, or pharmacy refill data assessed by an index called Medication Possession Ratio (MPR). Patient self-report, although simple and inexpensive, tends to overestimate adherence, whether assessed by self-administered questionnaire or interview by trained personnel,22, 31 and it is subject to both recall

Persistence

Persistence with glaucoma medication has been found to be low in several studies (Table 2), varying from 20%47 to 64%.7 Glaucoma suspects beginning latanoprost or a beta-blocker drop had persistency rates of 39% and 25%, retrospectively, at 1 year.44 Another study of patients who began one of seven ocular hypotensive therapies found rates of persistence at 1 year of 33% for the prostaglandin group compared to 19% for the six other classes.38 In a study of 2,850 patients prescribed an ocular

Variability by Drug Class

Several studies have found differences in adherence and persistence by class of ocular hypotensive medication. Separating adverse events/tolerability from frequency of dosing cannot be conclusively determined from retrospective pharmacy claims analyses in the absence of chart review or patient interview. Cost may also play a role; however, the majority of studies evaluating class differences were performed in a setting of pharmacy benefit coverage. Prostaglandins have been found to have higher

Clinical Implications and Techniques for Improving Adherence and Persistence

Determining, maintaining, and adjusting a target pressure range for patients are important parts of glaucoma care. A patient who resumes medication shortly before an office visit after a gap in therapy may appear to be at an optimal pressure, yet visual field progression may have occurred. It becomes impossible to sort out if the pressure goal needs to be further lowered, typically requiring additional therapy, or if the pressure goal is appropriate, but the patient is progressing because of

Summary

Medications only work for patients who take them.5 Glaucoma patients may have variable clinical courses based on the disease itself, but this is further confounded by improper or irregular medication use. Greater awareness by the physician of the widespread nature of nonadherence is a very important component of patient care. Tracking of patients who fail to follow-up is crucial; this can be improved with the use of telephone reminder calls for appointments.13 Discussion with patients should

Method of Literature Search

Database used: www.pubmed.com. Years searched:1970–present. Search terms: compliance, persistence, adherence, glaucoma, glaucoma medication. Additionally used references cited in the reference lists of other articles. Busche and Gramer3 is the only non-English reference used, for which the English translation was used.

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  • Cited by (0)

    The supplement in which this article is published was funded by Pfizer. Dr Schwartz serves as a consultant to Pfizer and has received research grants from Pfizer and Allergan. Dr Quigley serves as a consultant to Pfizer, Allergan, and Alcon. The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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