Adherence to therapy

Monitoring for efficacy, adverse events, and adherence to therapy is key to achieving the long-term goals of reducing the risk of morbidity and mortality associated with cardiovascular disease. 

Adherence to therapy is another important factor in increasing and maintaining SVR. Patients who were adherent with interferon and ribavirin therapy (taking more than 80% of doses for more than 80% of the treatment duration) had an SVR of 52% whereas those who were not compliant had an SVR of 44% 42... 

How to prevent an acute adrenal crisis (adhere to therapy, and do not stop glucocorticoid treatment abruptly). There may be a need to increase the dose of glucocorticoid during excessive physiologic stress. 

Reinforce the importance of adherence to therapies and specific drug regimens. 

As such, patients with penicillin allergies should be treated with a first-generation cephalosporin (if non-type I allergy), a macrolide/azalide, or clindamycin. Recurrent infections caused by reinfection, poor adherence to therapy, or true penicillin failure can be treated with amoxicillin-clavulanate, clindamycin, or penicillin G benzathine.45... 

Treatment considerations for antiretroviral-experienced patients are much more complex than for patients who are naive to therapy. Prior to changing therapy, the reasons for treatment failure should be identified. A comprehensive review of the patient s severity of disease, antiretroviral treatment history, adherence to therapy, intolerance or toxicity, concomitant drug therapies, co-morbidities, and results of current and past HIV resistance testing should be performed. If patients fail therapy due to poor adherence, the underlying reasons must be determined and addressed prior to initiation of new therapy. Reasons for poor adherence include problems with medication access, active substance abuse, depression and/or denial of the disease, and a lack of education on the importance of 100%... 

Improper BP measurement Volume overload and pseudotolerance Volume retention from kidney diseaase Excess salt intake Inadequate diuretic therapy Drug induced or other causes Non-adherence to therapy Doses too low Inappropriate combinations Non-steroidal anti-inflammatory drugs Cocaine and other iflicit drugs Sympathomimetics (decongestants, anorectics)... 

Side effects of medications, often not recognized as such by patients or inadequately inquired about by the clinician, also complicate adherence to therapy. The delay or time lag in the onset of action of many psychotropics, as well as a delayed time course for a recurrence triggered after stopping medication, also contribute. In this regard, the concept of prevention and prophylaxis must be carefully reviewed with the patient. Finally, the implications for various treatment costs related to compliance need to be explored and the means to circumvent impediments to a patient s cooperation sought (see Cost of Treatment later in this chapter). 

Since both raloxifene and the non-hormonal drug alendronate reduce the incidence of osteoporotic fractures in postmenopausal women it is relevant to determine which approach is better tolerated and thus most likely to promote long-term adherence to therapy. Adverse effects and compliance have been studied in a direct randomized comparison over 12 months in 902 women attending 154 treatment centres in Spain (21). They took either raloxifene 60 mg/day or alendronate 10 mg/day. Those who took raloxifene reported significantly better compliance than those who took alendronate more patients discontinued alendronate prematurely than raloxifene (26% versus 16%. The main reason for premature discontinuation was adverse reactions, particularly gastrointestinal reactions (9.9% with alendronate, 3.4% with raloxifene). 

The most common adverse effect of colestipol is constipation (30%). In the first months of therapy nausea and bloating can also occur. There is disappointingly poor adherence to therapy in young patients (9). The encapsulated form of the drug is better tolerated (10). 

Skin problems can be persistent in a proportion of patients, variously estimated at 10-59%, and this can severely limit adherence to therapy. The skin reaction can be ameliorated by concomitant use of non-steroidal anti-inflammatory drugs such as aspirin and indometacin (SEDA-15, 412). Transient exanthems, pruritus, and sometimes wheals are seen, as well a uniform dryness and scaling of the epidermis, brown pigmentation, and even on occasion an acanthosis nigricans-like dermatosis (15). Persistent rashes can also occur. Doses in excess of 5 g/day are routinely associated with skin manifestations and can on occasion cause liver damage, gout and ulcer formation. These reactions can be associated with nicotinic acid rather than nicotinamide, which is sometimes recommended as an alternative (37). Increased hair loss has been described. 

Both immediate-release and modified-release formulations of lithium carbonate are available. Peak blood concentrations are lower and occur more slowly with modified-release formulations than with immediate-release formulations, but all formulations are supposed to deliver equivalent amounts of lithium per millimole. The effectiveness of lithium should not be altered by the formulation used or the number of daily doses (assuming full adherence to therapy), but if it is given once a day the 12-hours serum lithium concentration will be somewhat higher than if the same amount is given in divided doses. 

While the efficacy of lithium alone or in combination continues to be reconfirmed, drawbacks related to adherence to therapy or genetic links to poorer outcomes have also been highlighted. For those reasons, alternatives to lithium, such as anticonvulsants and antipsychotic drugs, have often been discussed (77). However, several studies have reconfirmed the efficacy of lithium in acute mania and its equivalence to some of the newer options. 

Patients with good adherence to therapy have a higher incidence of adverse effects (12). Logistic regression analysis identified four factors that discriminate adherent (n = 48) from non-adherent (n = 30) patients the course of the illness, the employment status of a key relative, age at onset of the illness, and the presence or absence of adverse effects. 

Conversely, tardive dyskinesia is said to be less common in young than in old patients, and a lower incidence has been observed in a retrospective chart review in 40 adolescents taking neuroleptic drugs (289). After 2 years, the figure was 18% although comparability of those studies is far from optimal. Average daily dose, non-adherence to therapy, early age of illness, and concomitant use of antiparkinsonian drugs were associated with increased susceptibility. 

After controlling for other factors, African-Americans and Mexican-Americans were significantly less adherent to therapy than white patients for all ethnicities, olanzapine was associated with 23 more adherent days than risperidone and 55 more adherent days than haloperidol. 

Patients with bipolar disorders may benefit from risperidone. This has been observed in an open trial of ten patients with rapid cycling bipolar disorder who were refractory to lithium carbonate, carbamazepine, and valproate eight improved after 6 months of treatment. One patient dropped out through non-adherence to therapy and one because of adverse effects (agitation, anxiety, insomnia, and headache) (5). There was a similar beneficial effect in eight adults with moderate to profound mental retardation (6). Risperidone was associated with a significant reduction in aggression and self-injurious behavior, whereas adverse effects were primarily those of sedation and restlessness. 

In a review based on the Medline and PsycINFO databases from 1999 to 2002, six articles focusing on the issue of adherence to therapy in schizophrenia and two metaanalyses of depot typical antipsychotic agents in schizophrenia were identified (27). The usual adverse effects... 

Hypersalivation or sialorrhea has been reported with all neuroleptic drugs, and has been associated with risperidone as one of the most frequently mentioned adverse effects in patients with disturbing extrapyramidal symptoms during previous neuroleptic drug treatment (SEDA-25, 68). Hypersalivation is a troublesome adverse effect that can contribute to non-adherence to therapy, but it can be treated with clonidine. 

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