Transcript RESPIRATORY - Robert Gordon University

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’