treatment plan
Teach Your Patients the Importance of Persistence
BY LEO SEMES, OD, FAAO

One of my high school coaches used to tell us that "stick-to-itivness" was a winning strategy. Today I understand this as persistence paying off. But do our patients understand it? When I make a treatment recommendation to a glaucoma patient, for example, I presume that he'll follow it to the letter. Unfortunately, emerging data suggest that this isn't generally the case.

Persistence Resistance

What is persistence in this context? A convenient synonym is adherence. When a patient adheres to a scheduled medication regimen, he doesn't voluntarily discontinue it or switch to another medication.

We can use data about chronic systemic diseases as a guide for what to expect from, for example, our glaucoma patients. Arthritis patients, for instance, comply better with COX-2 specific inhibitors than they do with non-specific non-steroidal anti-inflammatory drugs (NSAIDs). But, in the best-case scenarios, patients limit strict adherence to about 30 days (Moride et al, 2003). The researchers found this regardless of age group or dosing.

Surprised? What about patients who are on lipid-lowering therapy? At one year their persistence is less than 50 percent (Simons et al, 1996). Other data suggest that nearly 90 percent of patients treated for overactive bladder are still on therapy at one year, whereas oral hypoglycemics have a one-year discontinuation rate of about 60 percent.

So, back to our glaucoma patients. Their simple regimens that include once-daily dosing would seem like no-brainers, right? But discontinuation rates for IOP-lowering medications range above 70 percent. One recent study (Dasgupta et al, 2002) found that latanoprost had superior persistence (at about 50 percent) to beta-blockers, carbonic-anhydrase inhibitors (CAIs) and brimonidine. In a poster from this year's ARVO meeting, data suggested discontinuation rates from 31 percent (latanoprost) to 63 percent (miotics) at one year. Discontinuation rates among the prostaglandin analogues, while similar, are still dismal. One study (Reardon et al, 2003) found persistence rates ranging from 20 percent (travoprost and bimatoprost) to 30 percent (latanoprost) for a period of just over one year.

Improving Patient Adherence

When we consider the factors that influence persistence, we find some guidance as to how we may improve patient adherence to our recommended treatment regimens. The factors include:

• Denial and complacency
• Complicated treatment/dosing schemes
• Side effects
• Economic issues

Addressing glaucoma medication side effects may prove the most useful place to begin for improving persistence. Specific side-effects of burning, tearing and blurred vision were the top three that patients reported in a study from France (Nordmann et al., 2003). In this survey, patients reported one side effect in nearly two-thirds of instances.

When economics plays an adverse role in adherence to the recommended regimen, educate patients about patient assistance plans, which all major pharmaceutical manufacturers offer.

For a winning strategy against chronic diseases, of which glaucoma is the poster child in ophthalmic practice, "stick-to-itivness" is key. Discuss side effects and other noncompliance-generating issues with patients to help maximize persistence. If you take the time to do this, then you can have a positive impact on visual disability that may result in a significant clinical outcome.

To obtain references, visit www.clspectrum.com/references.asp and click on document #108.

Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.