Is the cause pharmacological, due to failure of
correctly taken drug to work as hoped, or is the
cause due to inadequate compliance?
- The compliance is not a static quantity but a
dynamic process.
Many studies have clearly shown that the
compliance of most patients deteriorates as
treatment progresses. Particularly in diseases
with few or no symptoms, one sees a high rate
of partial compliance or and/or early disconti-
nuation must be reckoned with after a few
months of treatment. If the treatment results
are inadequate, the doctor must judge whether
the disease is taking a progressive course,
whether the drug is losing its effect with pro-
longed treatment (which pharmacologists call
‘tachyphylaxis’) or whether the cause lies with
inadequate compliance.
- The compliance of the patient is not predictable
by clinical examination.
Studies have shown that even experienced
doctors often fail to recognize partial compli-
ance or noncompliance in their patients. There
is no proven relationship between compliance
behavior and parameters such as age, sex, edu-
cational background and social status, specific
drugs, adverse effects of medication and nature
or severity of the disease.
- Compliance monitoring with feedback of the
results to the patient enhances compliance.
The review of the past dosing record with the
patient is a powerful tool to help the patient
recognize when he/she has made errors in dos-
ing likely to undermine efficacy or cause safety
problems. This review can be done by the pre-
scribing physician, the pharmacist, a nurse or
other paramedical staff, depending on the local
circumstances. It is not a single review, but an
ongoing process, so that the patient understands
that, at the next visit, the dosing record during
next interval will be the subject of review, and
that the only way to compile a correct record is
to pay careful attention to the prescribed regi-
men and link it closely to established routines in
daily life. Yet, despite the disciplinary aspect of
the review, most patients regard the review as
a logical extension of the interest of the pre-
scribing physician in their care. Furthermore,
knowledge of the compliance behavior of the
patient gives the pharmacist and the doctor
the possibility of turning attention to the patient
with compliance problems, of re-explaining
the aim of treatment, of clearing up misunder-
standings about the regimen and of reducing
possible prejudices against treatment. Compli-
ance monitoring moreover permits an indivi-
dualization of the treatment, as the treatment
regimen can be optimally adapted to the habits
of the patient, thereby facilitating his correct
execution of the agreed-upon dosing regimen.
To do such adaptation effectively, it is essential
to understand how much forgiveness the pre-
scribed product allows. Without such knowl-
edge, the process of adapting the regimen to
the habits of the patient may stray outside the
bounds of doses and dose-timing consistent
with full therapeutic effectiveness.
27.13 Who are the potential
players involved in the
field of real-time
compliance?
Every healthcare professional who has, direct or
indirect, contact with the patient is a potential
player (Comte ́ et al., 2004). In the forefront is
the physician who has to make sound decisions
about the prescription, basing such judgment
in part on average values coming out of clinical
trials, but tempering judgment with understanding
of the patient’s individual characteristics. During
the past two decades, much has been learned
about many of the various influences on drug
absorption and metabolism that arise from dietary
factors, concomitantly prescribed drugs and
changes in renal or hepatic function. Yet, a major
but hitherto inaccessible component of this
dynamic process is the patient’s actual dosing
history, which has the potential to influence the
clinical manifestations of drug response over its
full range.
27.13 WHO ARE THE POTENTIAL PLAYERS INVOLVED IN THE FIELD OF REAL-TIME COMPLIANCE? 365
