Multiple factors underlie non-compliance with treatment

"Just writing a prescription is not enough. In order to be successful in the medical management of glaucoma, the clinician needs to define the maximally tolerated, effective medical therapy that is acceptable to each patient. If the treatment is not acceptable, the patient will probably not follow the program," said Dr. Cyrlin, director, Glaucoma Service, William Beaumont Hospital, Royal Oak, MI.

There are a number of reasons that can account for poor compliance or adherence. Awareness of those factors allows for a productive discussion with the patient to determine obstacles to treatment.

Not only will that question enable optimal treatment, but it reinforces the physician's commitment to patient care and the importance of using the medication as prescribed.

"Don't overlook that the quality of the provider-patient relationship can be a determinant of treatment adherence. Patients are very interested in your spending time discussing the medication with them," Dr. Cyrlin said.

Patient-related variables Among the factors to consider in adherence and compliance problems are patient-related variables. Of those, forgetfulness is most common. When that is an issue, reminder systems and written schedules are worthwhile for helping patients to remember when to use their medications.

"We hope to see the advent of some more sophisticated compliance devices in the future," Dr. Cyrlin said.

Inability to pay is another common patient-related factor in poor compliance/adherence.

"Insurance and industry patient assistance programs have helped with economic issues, but be sure to determine if the patient can afford the medication and be aware that some patients may skip on dosing to try to save money," he said.

The fact that glaucoma is asymptomatic until the late stages can also compromise patient motivation to use treatment as prescribed.

"How often have you heard patients say they stopped using their medication because it wasn't helping? This is your chance for patient interaction. Patients and family members need to understand glaucoma as a chronic disease necessitating consistent treatment," Dr. Cyrlin said.

Treatment-related variables, particularly regimen complexity and side effects, are paramount to patients. Therefore, patients should be asked during the follow-up visit about adverse events and should be prescribed monotherapy whenever possible. If IOP control is insufficient, consideration should be given to a monotherapy with an alternative drug rather than combination treatment.

"Laser treatment may be a useful adjunct for allowing patients to continue to use one medication, and when a second topical therapy is needed, consider a combination product or another medication that will simplify the dosing regimen. The goal is to achieve the greatest IOP reduction with the fewest medications while minimizing side effects and controlling cost," Dr. Cyrlin said.

Even when physicians have done their part and the patient is motivated, administration difficulties may interfere with compliance. Problems such as misdirecting the bottle are common and may be alleviated with certain devices for improving administration. Refrigerating the medication, if it does not interfere with product stability, can be helpful because it is easier for the patient to determine whether the medication has been instilled into the eye if the drop is cold.

In investigating noncompliance, Dr. Cyrlin cautioned his colleagues not to be fooled by good IOP control.