To improve compliance in glaucoma patients, keep it simple

Take-home message: Noncompliance with glaucoma medication is a familiar issue. There is no one-size-fits-all solution, but aiming for simplicity, consistency, and stability from the start of treatment could help more patients adhere to their treatment plan.

By Nancy Groves; Reviewed by Nathan Radcliffe, MD

New York-It’s a given that a certain percentage of patients will not be compliant with their glaucoma medication. Instead of banging your head against a wall at this behavior or nagging patients like parents who want their kids to eat fruit and vegetables instead of junk food, it makes more sense to have a plan to address this common situation. One line of thought is to take a more proactive approach aimed at eliminating some of the factors likely to cause noncompliance.

Dr. Radcliffe“I assume that every patient is going to struggle with compliance. That, for me, is a more fruitful strategy than trying to identify which patient might be noncompliant,” said Nathan Radcliffe, MD, director, Glaucoma Service, and clinical assistant professor, New York University Langone Ophthalmology Associates.

“The concept for every patient is to make things as simple as possible, as efficient and as parsimonious as possible. That means picking who to treat very carefully, so you don’t treat people who don’t need it; picking good medications that are efficacious that will help you keep the patient’s regimen simple; not changing the patient’s regimen unless it’s absolutely necessary because consistency is an important principle for patients; and treating as little as possible, for example keeping the dosing schedule as simple as possible.”

The initial step is deciding who to treat, or in some instances whether to discontinue treatment. He said the key point is don’t treat unless you have to.

“I think the biggest single moment where a patient has a decline in their quality of life is when you start them on a drop,” Dr. Radcliffe said. “If you are preventing blindness, that is a perfectly acceptable tradeoff. But if someone is low risk, if their life expectancy isn’t that long and they have very mild disease, initiating therapy is going to cause compliance problems and other quality of life problems.”

If the conclusion of your risk assessment is to proceed with treatment, then pick a good agent. A number of studies have shown that of the three prostaglandin analogs widely used in the United States as first-line therapy (travoprost, bimatoprost, and latanoprost), travoprost and bimatoprost are more effective. In a 2006 study, Covert and Robin found that the use of adjunctive medications to control elevated IOP was significantly higher for patients using latanoprost than in those who had been prescribed the other two drugs.¹

Using a more effective medication pays off, Dr. Radcliffe said. It lowers the patient’s need for a second medication, as well as the risk of noncompliance.

“When you add a second medicine, compliance drops. And it not only drops for the second medicine you added, it drops for the first one you picked, and since the first one is the best one, that’s bad because now you’re adding more but the benefit is not necessarily linear,” he explained.

However, when a single drop isn’t effective, the principles of simplicity and consistency should still apply if possible. If compliance is an issue, consider adding laser therapy instead of a second drop. For patients who are good at remembering what medications they take and how often, adding a fixed combination medication to the first drop may be right. “I think that is a regimen that most patients can live and they can understand and that works well for them,” he added.

When trying to improve compliance, doctors have to identify the patients for whom taking medication regularly is a challenge. One way to screen patients is fairly basic: ask them to name the drops they are taking. “It’s hard to understand how someone could supposedly take a drop in both eyes several times a day for years and then not know the name of it, but that’s something I see every day,” Dr. Radcliffe said. “That to me is a red flag, and that is a patient who shouldn’t get another medicine added.”

It also helps to find out why the patient is noncompliant. Poor compliance may be “intentional,” a tactic for making medication last longer because of the cost of refills. If a patient acknowledges that the cost of medication is a problem, you may need to pick drugs with an eye on the price as well as the efficacy or consider laser treatment.

Reference

• Covert D, Robin AL. Adjunctive glaucoma therapy use associated with travoprost, bimatoprost, and latanoprost. Curr Med Res Opin. 2006 May;22(5):971-6

Nathan Radcliffe, MD

E: drradcliffe@gmail.com

Dr. Radcliffe is a consultant for Allergan, endo optiks, Glaukos, Iridex, Lumenis, and New World Medical.