Are My Patients Taking Their Meds?

Sunanda V. Kane, MD, MSPH

Disclosures

May 24, 2012

Question:

How can I identify the patient who is not being adherent with therapy for inflammatory bowel disease? How can I convince them to stay on their medications?

Response from Sunanda V. Kane, MD, MSPH
Professor of Medicine, Mayo Medical College; Consultant, Mayo Clinic, Rochester, Minnesota

You can identify a patient who is nonadherent to therapy for inflammatory bowel disease (IBD) in several ways, including the following:

  • Direct, albeit nonthreatening, inquiry. For example, ask, "How is it going with your medicines? Are you finding it hard to remember to take them as directed?" or "How often do you think you forget to take your medicine in a typical week?" or "Are you having any trouble with side effects from your medications?";

  • Ask a family member if the patient is taking their medicine; and

  • Call the patient's pharmacy to find out how much they are refilling (most time-consuming but very enlightening).

I like direct inquiry because it is the easiest way to do a "root-cause analysis." Once a patient admits that he or she is not taking more than 80% of the prescribed therapy (the accepted definition of nonadherence) then a discussion about how to make it easier can take place. Remember, you can bill for this time under the V code for high-risk medication.

If patients say they simply forget, then make their regimen as simple as possible. This is not difficult with IBD medications. No 5-ASA product needs to be taken more than twice a day, and most can be taken once a day whether the patient has active disease or is in remission. Thiopurines can also be taken once a day. Most trials used a twice-daily schedule because of side effects, but there is no compelling pharmacokinetic rationale for more than once a day. If patients say they can't afford their medication, then switch to something they can afford. If they don't tolerate what is on formulary, fill out a single prior authorization form documenting intolerance to obtain coverage. If the patient has no insurance, patient assistance programs are available for almost every brand-name therapy.

For patients who fear side effects or believe they don't need therapy, point out the cost of a visit to the emergency room or a hospital stay vs staying on the medication. Clarify the lack of causation of side effects; explain that most adverse events are merely an association with therapy. Emphasize that active disease is more harmful than a potential side effect and is the reason for monitoring.

Several recently published review articles[1,2,3] have discussed the risk for recurrent disease if a patient stopped therapy. A patient with Crohn disease has a 40% chance of recurrence (even if there has not been a flare for years) after the first year of stopping therapy.

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