Compliance a serious issue for glaucoma therapy

Philadelphia-Glaucoma specialists agree that lack of compliance with medical therapy is a significant barrier to successful disease management. Patients have a multitude of reasons for failing to comply with their medical regimen. Some, such as the cost of medication, are largely beyond physician control, but any measures that can be taken to improve compliance should help somewhat with this difficult issue.

"Compliance is a huge problem for any chronic disease, including glaucoma," said L. Jay Katz, MD, professor, Jefferson Medical College, Philadelphia, and co-director of the Glaucoma Service and director of the clinical fellowship program, Wills Eye Hospital, Philadelphia. "There's no easy way for us to measure how adherent patients are to medical therapy, but the best estimates we have, based on fragmentary evidence, are that maybe half of our patients aren't taking their medication the way they're supposed to be taking it."

Lack of symptoms

"If you have a disease where if you take your medication, the symptoms go away, you'll take it," Dr. Piltz-Seymour added. "Glaucoma has no symptoms, so it is very hard for patients to have the reinforcement that they may need to take their medicine. The medicines don't help them feel better or help them see better, so it's very hard for patients to remember."

She advises patients to tie their medication dose into their routine, such as taking it every night at the same time as they brush their teeth, or to keep a chart or check off doses on the calendar, but notes that these strategies don't always work.

"We have to do whatever we can to encourage compliance and regular use of their medication," she added.

Simplifying the regimen

Simplifying the regimen is another tactic. Since elderly patients commonly take a variety of medications for different medical problems, adding to their burden with a glaucoma drug that needs to be taken several times a day, or prescribing two or three glaucoma drugs, is not likely to foster compliance.

A prostaglandin analogue that can be taken once a day to provide 24-hour control is often effective, Dr. Piltz-Seymour said.

Another obstacle is the difficulty elderly patients may encounter in simply trying to open a bottle of drops if their hands are stiff with arthritis. They may be unable to use the medication unless someone else is available to help by opening the bottle, administering the drops, or both, Dr. Katz said. Patients might also be squeamish about putting things in their eye and prefer to have someone else do it, skipping doses if no one is on hand.

Drug costs are also a major issue affecting compliance. Sometimes patients who have difficulty instilling their drops may run out before their formulary allows a refill. Faced with the choice of paying out of their own pockets or waiting until a new prescription is covered by their drug plan, patients often choose to go without the medication, Dr. Katz said.

Similarly, some patients are lax in obtaining a refill even when it is fully covered, Dr. Piltz-Seymour said. If possible, physicians should prescribe several months' worth of medication at the same time to reduce the number of opportunities that a patient might have to forget or postpone a refill, she added.

Returning to the cost issue, she noted the doctors are often unaware of the costs of medication or which drugs are covered under which plans and may unwittingly contribute to a compliance problem.

"You really have to discuss with your patients what they're paying and which medications are first-line on their pharmaceutical plans so that they minimize the costs," Dr. Piltz-Seymour said.

Patients who do not have prescription drug coverage should be urged to shop around, since the price of medication can vary widely at different pharmacies, she added.