Example: patient 33
Woman, 59 years. She is taking drugs for congestive heart failure and hypertension. She also has a newly diagnosed gastric ulcer, for which she has been prescribed another drug. As the doctor is explaining why she needs the new drug and how she should take it, her thoughts are drifting away. The doctor's voice sinks into the background as she starts worrying about the new illness, afraid of the consequences and how she will remember to take all these drugs. The doctor doesn't notice the loss of attention, doesn't encourage a dialogue but just keeps on talking and talking. In the pharmacy her thoughts are still wandering off even when the pharmacist is explaining how to take the drug. When she gets home she finds her daughter waiting to hear the results of her visit to the doctor. Without telling her the diagnosis she talks about her worry: how to cope with all these different drugs. Finally her daughter reassures her and says that she will help her to take the drugs correctly.
On average, 50% of patients do not take prescribed drugs correctly, take them irregularly, or not at all. The most common reasons are that symptoms have ceased, side effects have occurred, the drug is not perceived as effective, or the dosage schedule is complicated for patients, particularly the elderly. Non adherence to treatment may have no serious consequences. For example, irregular doses of a thiazide still give the same result, as the drug has a long half-life and a flat dose-response curve. But drugs with a short half-life (e.g. fenytoin) or a narrow therapeutic margin (e.g. theophylline) may become ineffective or toxic if taken irregularly.
Patient adherence to treatment can be improved in three ways: prescribe a well chosen drug treatment; create a good doctor-patient relationship; take time to give the necessary information, instructions and warnings. A number of patient aids are discussed in Box 9. A well chosen drug treatment consists of as few drugs as possible (preferably only one), with rapid action, with as few side effects as possible, in an appropriate dosage form, with a simple dosage schedule (one or two times daily), and for the shortest possible duration.
How to improve patient adherence to treatment
* Prescribe a well-chosen treatment
* Create a good doctor-patient relationship
* Take the time to give information, instructions and warnings
A good doctor-patient relationship is established through respect for the patient's feelings and viewpoint, understanding, and willingness to enter into a dialogue which empowers the patient as a partner in therapy. Patients need information, instructions and warnings to provide them with the knowledge to accept and follow the treatment and to acquire the necessary skills to take the drugs appropriately. In some studies less than 60% of patients had understood how to take the drugs they had received. Information should be given in clear, common language and it is helpful to ask patients to repeat in their own words some of the core information, to be sure that it has been understood. A functional name, such as a ‘heart pill’ is often easier to remember and clearer in terms of indication.
Box 9: Aids to improving patient adherence to treatment
Patient leaflets reinforce the information given by the prescriber and pharmacist. The text should be in clear, common language and in easily legible print.
Pictorials and short descriptions
If the patient cannot read, try pictorials. If they are not available, make pictorials or short descriptions for your own P-drugs, and photocopy them.
A day calendar indicates which drug should be taken at different times of the day. It can use words or pictorials: a low sun on the left for morning, a high sun for midday, a sinking sun for the end of the day and a moon for the night.
A small book or leaflet with an overview of the different drugs that the patient is using, including recommended dosages.
The dosage box is becoming popular in industrialized countries. It is especially helpful when many different drugs are used at different times during the day. The box has compartments for the different times per day (usually four), spread over seven days. It can then be refilled each week. If cost is a problem, the box can be made locally from cardboard. In tropical countries a cool and clean place to store the box will be necessary.
Even if the patient aids described here don't exist in your country, with creativity you can often find your own solutions. The important thing is to give your patients the information and tools they need to use drugs appropriately.
The six points listed below summarize the minimum information that should be given to the patient.
1. Effects of the drug
Why the drug is needed
Which symptoms will disappear, and which will not
When the effect is expected to start
What will happen if the drug is taken incorrectly or not at all
2. Side effects
Which side effects may occur
How to recognize them
How long they will continue
How serious they are
What action to take
How the drug should be taken
When it should be taken
How long the treatment should continue
How the drug should be stored
What to do with left-over drugs
When the drug should not be taken
What is the maximum dose
Why the full treatment course should be taken
5. Future consultations
When to come back (or not)
In what circumstances to come earlier
What information the doctor will need at the next appointment
6. Everything clear?
Ask the patient whether everything is understood
Ask the patient to repeat the most important information
Ask whether the patient has any more questions
This may seem a long list to go through with each patient. You may think that there is not enough time; that the patient can read the package insert with the medicine; that the pharmacist or dispenser should give this information; or that too much information on side effects could even decrease adherence to treatment. Yet it is the prime responsibility of the doctor to ensure that the treatment is understood by the patient, and this responsibility cannot be shifted to the pharmacist or a package insert. Maybe not all side effects have to be mentioned, but you should at least warn your patients of the most dangerous or inconvenient side effects. Having too many patients is never accepted by a court of law as a valid excuse for not informing and instructing a patient correctly.
Exercise: Patients 34-38
Review the following prescriptions and list the most important instructions and warnings that should be given to the patient. You may consult your pharmacology books. Cases are discussed below.
Man, 56 years. Newly diagnosed depression. R/amitriptyline 25 mg, 1 tablet daily at night for one week.
Woman, 28 years. Vaginal trichomonas infection. R/metronidazole 500 mg, 1 vaginal tablet daily for 10 days.
Man, 45 years. Newly diagnosed essential hypertension. R/atenolol 50 mg, 1 tablet daily.
Boy, 5 years. Pneumonia. R/amoxicillin syrup, 5 ml (= 250 mg) three times daily.
Woman, 22 years. Migraine. R/paracetamol 500 mg, 2 tablets 20 min. after R/metoclopramide 10 mg 1 suppository, at the onset of an attack.
Patient 34 (depression)
It will take approximately two to three weeks before the patient starts to feel better, but side effects, such as dry mouth, blurred vision, difficulty in urinating and sedation, may occur quickly. Because of this many patients think that the treatment is worse than the disease and stop taking the drug. If they are not told that this may happen and that these effects disappear after some time, adherence to treatment will be poor. For this reason a slowly rising dosage schedule is usually chosen, with the tablets taken before bedtime. This should be explained carefully to the patient. Older people, especially, may not remember difficult dosage schedules. Write them down, or give a medication box. You can also ask the pharmacist to explain it again (write this on the prescription). Instructions are to follow the dosage schedule, to take the drug at bedtime and not to stop the treatment. Warnings are that the drug may slow reactions, especially in combination with alcohol.
Patient 35 (vaginal trichomonas)
As in any infection the patient should be told why the course has to be finished completely, even when the symptoms disappear after two days. The patient should also be informed that treatment is useless if the partner is not treated as well. Careful and clear instructions are needed for vaginal tablets. If possible, pictures or leaflets should be used to show the procedure (see Annex 3). Side effects of metronidazole are a metal taste, diarrhoea or vomiting, especially with alcohol, and dark urine. Give a clear warning against the use of alcohol.
Patient 36 (essential hypertension)
The problem with the treatment of hypertension is that patients rarely experience any positive effect of the drugs, yet they have to take them for a long time. Adherence to treatment may be very poor if they are not told why they should take the drug, and if treatment is not monitored regularly. The patient should be told that the drug prevents complications of high blood pressure (angina, heart attack, cerebral problems). You can also say that you will try to decrease the dosage after three months, or even stop the drug entirely. Remember to check whether the patient has a history of asthma.
Patient 37 (boy with pneumonia)
The patient’s mother should be told that the penicillin will need some time to kill the bacteria. If the course of treatment is stopped too soon, the stronger ones will survive, and cause a second, possibly more serious infection. In this way she will understand why it is necessary to finish the course. Knowing that any side effects will disappear soon will increase the likelihood of adherence to treatment. She should also be told to contact you immediately if a rash, itching or rising fever occur.
Patient 38 (migraine)
In addition to other information the important instruction here is that the drug (preferably a suppository) should be taken 20 minutes before the analgesic, to prevent vomiting. Because of possible sedation and loss of coordination she should be warned not to drive a car or handle dangerous machinery.
Sample page of a personal formulary
Tablet 50, 100 mg
Hypertension: start with 50 mg in the morning. Average: 50-100 mg per day.
Angina pectoris: 100 mg per day in 1-2 doses
Adjust to each patient individually, start as low as possible. Raise the dose after 2 weeks, if needed.
* WHAT TO TELL THE PATIENT
Hypertension: drug decreases blood pressure, patient will usually not notice any effect. Drug will prevent complications of high blood pressure (angina, heart attack, cerebrovascular accident).
Angina pectoris: decreases blood pressure, prevents the heart from working too hard, preventing chest pain.
Side effects: hardly any, sometimes slight sedation.
Take the drug.. times per day, for.. days
Angina pectoris: do not suddenly stop taking the drug.
Hypertension: one week.
Angina pectoris: within one month, earlier if attacks occur more frequently, or become more severe.
Hypertension: during first few months pulse and blood pressure should be checked weekly. Try to decrease dosage after three months. Higher dosages do not increase therapeutic effect, but may increase side effects. Try to stop treatment from time to time.
Angina pectoris: in case frequency or severity of the attacks increase, more diagnostic tests or other treatment are needed. Try to stop drug treatment from time to time.
Your personal formulary
During your medical studies you should continue to expand your list of common complaints and diseases, with your P-drugs and P-treatments. However, very soon you will notice that many drugs are used for more than one indication. Examples are analgesics, certain antibiotics, and even more specific drugs like beta-blockers (used for hypertension and angina pectoris). You can, of course, repeat the necessary drug information with each disease or complaint, but it may be easier to make a separate section in your personal formulary where you collect the necessary information for each of your P-drugs. This way you write down or update the drug information only once. You can also find the information more easily when you need it.
It is good advice to note the essential instructions and warnings with each P-drug in your personal formulary. If you do this for every new drug you learn to use, the formulary will be reasonably complete and ready for use by the time you finish your medical studies. An example of the contents of such a personal formulary is given on the previous page. Please note that this is not a published text, but should be your personal (handwritten?) summary of important information.
STEP 5: Give information, instruction and warnings
1. Effects of the drug
Which symptoms will disappear; and when; how important is it to take the drug; what happens if it is not taken;
2. Side effects
Which side effects may occur; how to recognize them; how long will they remain; how serious they are; what to do if they occur;
When to take; how to take; how to store; how long to continue the treatment; what to do in case of problems;
What not to do (driving, machinery); maximum dose (toxic drugs); need to continue treatment (antibiotics);
5. Next appointment
When to come back (or not); when to come earlier; what to do with left-over drugs; what information will be needed;
6. Everything clear?
Everything understood; repeat the information; any more questions.