Initial medication adherence in newly diagnosed glaucoma patients

• Autor(a) principal: Menino, Joana
• Data de Publicação: 2023
• Outros Autores: Camacho, Pedro, Coelho, André
• Tipo de documento: Artigo
• Idioma: eng
• Título da fonte: Repositório Científico de Acesso Aberto de Portugal (Repositórios Cientìficos)
• Texto Completo: http://hdl.handle.net/10362/152439
• topic: early discontinuation; glaucoma; glaucoma treatment; initial medication adherence; initiation; Ophthalmology

Funding Information: therapeutic parameter that can be described by a single number, as usually reported in the literature, where quantification of adherence and interventions to its improvement have been largely conditional on patients acquiring their initial prescriptions, and have failed to accurately account for the component of initiation. In this study we found that for the patients diagnosed with glaucoma in 2012 and 2013 in the Lisbon and Tagus Valley Region, almost two out of five failed to engage in anti-glaucoma therapy, by not initiating therapy or by early on discontinuing it. These findings were more relevant for younger patients, those initially treated with three or more anti-glaucoma drugs, including fixed-dose combinations. Based on these results, more attention should be given to this group of glaucoma patients to ensure adequate access to healthcare and medications, adherence to treatment regimes, knowledge of their disease and social support[19]. Possible reasons might have been uncertainty about whether real glaucoma existed (due to the initial asymptomatic nature of this condition) and the appearance of adverse drug effects. During treatment patients may experience no symptom relief and experience more side-effects while taking their medications correctly. Prostaglandin analogues, the most recent drug class in glaucoma therapy, have a superior hypotensive effect to remaining groups, and it is also associated with less adverse drug effects[4], which might explain the higher adherence rates for this drug class when prescribed in monotherapy. Also, and as Wolfram et al[20] found, monotherapies, particularly with prostaglandins, and simplified treatment regimens lead to better adherence and persistence. In spite of fixed-combination eye drops may be a convenient treatment option for glaucoma patients according to the patients’ medical needs, especially for those who are already at the severe glaucoma stage at the initial glaucoma consultation and need early IOP lowering treatment, for those who are relatively young and for whom it is important to delay blindness, or for those who need personalized medication due to their lifestyle[21], the initial medication adherence for this anti-glaucoma drugs was lower than for the monotherapy drugs. Our results also show that younger patients were more likely to early discontinue their treatment, after the first dispensing. In fact, almost one out of five patients under 45y interrupted their glaucoma treatment after the first dispensing. Similar results for other components of medication adherence were found by Rosu et al[13]. Different factors may play a role in this decision: as we already mentioned, it’s well known that the asymptomatic nature of glaucoma reduces patient motivation to take the drugs as prescribed, which might be more relevant for younger patients. Also, younger patients have an active lifestyle and work activity that can relate negatively with the instillation of eye drops, by being more time away from home and forgetting to apply eye drops[22]. Also, the fact that glaucoma is commonly associated with the elderly can represent a lack of literacy in younger patients about this condition and about the importance of adherence to anti-glaucoma therapy[23]. In the opposite end, older patients with more severe forms of glaucoma, as Shu et al[7]reported, by having greater functional changes are therefore more likely to adhere to anti-glaucoma therapy. In spite of the innovative features of this study, our results should weigh against some limitations, most of them related to the method used for estimating adherence to anti-glaucoma therapy. First of all, medication-taking behavior is extremely complex and individual, and influenced by multiple factors[24]. Unmeasured patient and physician factors, such as the extent of physician–patient communication and education about prescriptions, the absence of data on possible confounding factors, such as co-morbidities and severity of concomitant diseases, are likely to influence adherence, and that was not analyzed in this study. Another limitation refers to the diagnosis of glaucoma, which under ICPC-2 is registered as single code, without specifying the type of glaucoma. Still, despite the scarcity of information, this study made it possible to characterize for the first time, according to our best knowledge, the early patterns of adherence to anti-glaucoma therapy, by looking at the initiation rate and early discontinuation, considering some patient and drug-related factors. Second, e-prescriptions data refers only to the PHC network and patients may have received prescriptions from other providers, including specialist and hospital outpatient settings that are not captured by SIARS, which may lead us to underestimate adherence rates. Any other data errors in the prescribing and/or claims records could lead to a drug being falsely labeled as not dispensed; this type of misclassification of the outcome could lead us to overestimate non-adherence. Also, claims-based research is subject to misclassification because all prescriptions not captured in the claims database are considered not dispensed, yet there are other reasons for not capturing drugs dispensed, such as system failure or malfunction of the prescribing software or still an accidental drug entry prescription by the physician during the consultation. Nevertheless, prescription and dispensing/claims (refill) databases have been considered the “gold standard” method for initiation measurement if both databases are combined[25], which as we’ve demonstrated can be done within SIARS, and also for discontinuation. This method would also be important to enhance the usefulness of e-prescribing records in which future glaucoma centers could monitor and collaborate proactively to reduce therapy discontinuation. Being a chronic disease, increasing with age, our findings reinforce the need for health promotion strategies related to the disease but also the importance of treatment and correct placement of eye drops[26]. Physician-patient relationship is of paramount importance to enable more information on glaucomatous disease and its outcomes if neglected, in order to clarify a patient’s need of therapy. Low medication adherence can reflect the uncertainty of patients about the methods of application and the difficulty in administering the drops[26], and new strategies must be developed such as creating new containers that are easier to handle for the elderly. Educational strategies must be carried out to get information to the population, brochures should be available on various shelves of health care units so that patients can be informed, also knowing that patients prefer an oral explanation, brochures, videos and exhibits could be held and/or illustrative educational videos could be shown in the waiting rooms to inform patients[27]. ACKNOWLEDGEMENTS Authors acknowledge and thank the support of H&TRC-Health & Technology Research Center and ESTeSL-Escola Superior de Tecnologia da Saúde, and ARSLVT for the permission to data access. Authors’ contributions: Menino J, Coelho A, and Camacho P designed the study, collected, and treated the data. All the team performed the statistical analysis and prepared the manuscript. Coelho A and Camacho P supervised the project. All authors read and approved the final manuscript. Conflicts of Interest: Menino J, None; Camacho P, None; Coelho A, None. REFERENCES 1 Nucci C, Russo R, Martucci A, Giannini C, Garaci F, Floris R, Bagetta G, Morrone LA. New strategies for neuroprotection in glaucoma, a disease that affects the central nervous system. Eur J Pharmacol 2016;787:119-126. 2 González Fleitas MF, Dorfman D, Rosenstein RE. A novel viewpoint in glaucoma therapeutics: enriched environment. Neural Regen Res 2022;17(7):1431-1439. 3 Shalaby WS, Shankar V, Razeghinejad R, Katz LJ. Current and new pharmacotherapeutic approaches for glaucoma. Expert Opin Pharmacother 2020;21(16):2027-2040. 4 European Glaucoma Society Terminology and Guidelines for Glaucoma, 5th Edition. Br J Ophthalmol 2021;105(Suppl 1):1-169. 5 Zhang N, Wang J, Li Y, Jiang B. Prevalence of primary open angle glaucoma in the last 20 years: a meta-analysis and systematic review. Sci Rep 2021;11(1):13762. 6 Sousa DC, Leal I, Nascimento N, Marques-Neves C, Tuulonen A, Abegão Pinto L. Use of ocular hypotensive medications in Portugal: Publisher Copyright: © 2023 International Journal of Ophthalmology (c/o Editorial Office). All rights reserved.