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Non-compliance/ concordance with medicines - the never ending challenge! Joan MacLeod, Lead Pharmacist, Aberdeen City CHP [email protected] A few scenarios……. • Patient on warfarin (in blister pack) – has carer support dose is increasing but INR remaining at 1.0 • COPD patient started on Symbicort 200/6 – tells you that it helps sometimes – has ordered 4 in the last yr – says he takes it every day • Care home patient - #NOF – Rx Natecal D3 – usually spits it out or refuses to take • Patient – h/o stroke & glaucoma – using 4op of eye drops each month • Formal carer has not been giving a patient their painkillers – paracetamol & dihydrocodeine. Scenario Explanations • Patient is lonely – stalled the carers by being noncompliant; didn’t think about the implications re: INR • Had never been shown how to use the inhaler – if the inhaler rattled he continued to use (he was hearing the desiccant) • Patient hates aniseed flavour • Limited manual dexterity = poor control = more than one drop at a time • Directions on label were ‘2 as directed’ and ‘2 when required’; carers not able to make clinical decisions What can we do to help? 1. Involvement of Patient (& Carer) in Process • Do they want another medicine? • Think about the OUTCOME that will be achieved – is this agreeable with the patient/carer • Offer choice but be prepared to make the choice! • Keep options open: “How about we trial this ? – if it doesn’t agree with you then we go back to what you had.” • Encourage honesty :“If you don’t want this, just say….” • Review , Review, Review 2. Clear Instructions • Avoid ‘PRN’ & ‘MDU’ wherever possible • State dose, max daily dose and indication e.g. 1 tab up to twice a day for agitation • Formal carers will not make professional decisions re: PRNs • Update repeat prescriptions • Option of care plans for complex patients 3. Timings of Doses • Keep regimens as simple as possible – easier for all to remember! – Consider MR/SR/XL preparations to reduce dose frequency – Consider alternative drugs which may make regimens easier • Compromise – better the statin is given in the morning than forgotten at night • Care packages – find out the times of day they are in – if a carer isn’t in at teatime, don’t prescribe meds at teatime 4. Tolerabilty • • • • Taste (e.g. CaVitD, Movicol, Gaviscon) Texture (e.g. Fybogel, lactulose) Route Side effects – always highlight common side-effects and how to manage/ when to seek help • Monitoring requirements – will the patient want to/be able to comply with blood monitoring etc 5. Do they really need the drug? • What is the outcome you are trying to achieve? – Statins, antihypertensives in frail elderly • Remember the negative consequences of drugs on quality of life – Polypharmacy: falls risk, confusion, constipation – Antimuscarinic s/e • More medicines = reduced ability to manage for many frail elderly – De-prescribing is as important as prescribing 6. Aides • EYE DROPS: Autodrop® Autosqueeze® Opticare® Opticare Arthro® • INHALERS: Haleraid® , Spacers® • Pill splitters/ cutters • Pill punches • Pill boxes (dossette boxes) • Timers (Telecare- Pivotell® ) 7. Pharmacy Filled Compliance Aids Compliance aids (MCAs) • Although ideal for some patients, not the solution we all think • Some drugs cannot be safely packaged in an MCA • They do not help the patient remember • They remove choice • RPS recommendations: http://www.rpharms.com/support-pdfs/rps-mca-july-2013.pdf ‘Marginal Gains’