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Arthritis Today

Skipping Your Medication Dose?

The risks of missed doses can be serious, say doctors. Here’s why you should never miss a dose and how to stay on a medication schedule.

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Some days it’s hard to remember life before pills. Every day, you face a sometimes confusing calendar of when to take what pills, and sometimes you wonder, when you stare at your empty pocketbook or feel the side effects kicking in, if you wouldn’t be better just chucking the drugs – or at least taking a break from them.

You have plenty of company. According to two studies of adherence rates at the MD Anderson Cancer Center in Houston, which were presented at the American College of Rheumatology 2010 Annual Scientific Meeting, sticking to a medication regimen is tough. In one study of 110 people with rheumatoid arthritis, RA, prescribed disease-modifying antirheumatic drugs, DMARDs, the adherence rate was 59 percent. For the second study, of 74 patients with lupus who were prescribed prednisone, the adherence was 64 percent. And in both groups, only one in five people took their drugs as prescribed at least 80 percent of the time.

The Cost of Skimping on Meds

As former U.S. Surgeon General C. Everett Koop once said: Drugs don’t work in patients who don’t take them.

The result for people with arthritis? “A worsening of disease and an increase in healthcare and hospitalizations,” says rheumatologist Leslie R. Harrold, MD, an associate professor at the University of Massachusetts Medical School in Worcester, who studies medication adherence in rheumatic patients, particularly those with gout. Failure to treat these conditions leads to further joint damage. “The consequences are [less function] and more pain, and an [inability] to be independent and to go to work,” he says.

“If you look at conditions such as rheumatoid arthritis, the drugs are not curative,” says Jack E. Fincham, PhD, professor of pharmacy practice and administration in the School of Pharmacy at the University of Missouri – Kansas City. “If patients don’t take the meds as they should, they’re going to see a progression of symptoms, more falls and a decreased ability to carry on the activities they’re interested in. And if you can’t move and can’t participate in life, then you’re going to have depression.”

In the MD Anderson Cancer Center lupus study, depression was associated with lower adherence. Those with better mental health were more likely to follow their treatment plans.

M. Robin DiMatteo, Distinguished Professor of Psychology at the University of California, Riverside, and co-author of Health Behavior Change and Treatment Adherence (Oxford University Press, 2010), has studied patient-doctor interactions and medication adherence. She says that better communication could improve adherence rates. “Doctors usually don’t know that patients are non-adherent,” she says. “The patients act as if they’re adherent because they don’t want to disappoint the doctor, and doctors don't provide the opportunity for the patients to be honest.”

Why the Medication Rebellion?

In search of explanations, researchers for a 2009 report by the nonprofit RAND Corp., “A Review of Barriers to Medication Adherence,” combed through 4,660 related articles written between 1998 and 2009. But answers weren’t easy to come by; reasons for noncompliance tend to be individual and the ways of measuring it vary, says lead author Walid Gellad, M.D., adjunct researcher for RAND and an assistant professor of medicine at the University of Pittsburgh. “I think adherence involves several steps: filling the prescription, staying on the prescription and taking it as you’re supposed to.”

Still, three barriers to compliance stood out: cost, the complexity of the medication regimen and beliefs about the medication.         

“If costs are higher, people take their medications less,” says Gellad. “If you’re paying out of pocket and you don’t see results, that has to be incredibly frustrating,” says Fincham.

For some, a challenge to adherence is remembering to take medications throughout the day – or even prioritizing that need. It’s especially challenging if you have other burdens like depression or dementia, or if you’re taking care of someone else, says rheumatologist Robin Dore, MD, clinical professor of medicine at the University of California, Los Angeles. “Some people don’t take their medications because their lives are complicated.”

And many people with arthritis may be taking drugs for other conditions. According to AARP, the average American over 75 takes more than 11 drugs per year.

“People get tired of having a chronic disease,” says DiMatteo. “Maintenance and management take a lot of energy, and it keeps reminding you that you have the disease.”

Having to self-inject medicine, such as certain disease-modifying antirheumatic drugs (DMARDs), adds an additional layer of complications, says Fincham. “It hurts and it’s difficult to do. I don’t blame anyone who would want to take a holiday from that.”

Certain perceptions about medicine can also hinder adherence to a drug regimen, says Gellad. “People may have fears about a medication’s side effects or think it won’t work.”

They might also believe erroneous information they get from friends, family members or the Internet. Or they may simply be cynical about medical care. “If they believe that doctors overprescribe, they could reject what their doctor says,” says DiMatteo.

Pathways to Compliance

No one can argue that the reasons for skipping medications are trivial. But there are just as many reasons – primarily health and happiness – for working to overcome the barriers you face.

If you’re one of those people who isn’t taking medications as prescribed, think about why you don’t. If costs, side effects and doubts about their effectiveness or even doubts about your doctor are stopping you, talk to your doctor and be honest about it. She might be able to give you a different drug, a different dosage, or offer advice and information about how medications can relieve your symptoms – or even suggest lifestyle changes that could reduce your need to take certain medications.

Here are some more strategies to help you find a medication plan that works – and stick with it.

Soak up accurate information. “Patients need to be active participants,” says DiMatteo. “Ask your doctor questions. If you don’t understand something, ask him to explain and give you additional resources.

Find financial assistance. “Ask your insurance company about co-pay assistance,” suggests Dr. Dore. Your doctor and pharmacist might also know about prescription assistance programs that could help you.

Don’t accept side effects. Your doctor might be able to offer a similar medication that won’t have that effect, or let you know that the side effects will diminish as your body acclimates to the drug, says DiMatteo.

Ask about combination or long-lasting drugs. They may or may not be preferable in terms of safety record, cost, side effects and effectiveness, but they can be taken less frequently. Says DiMatteo, “In general, easier regimens achieve greater adherence than more difficult ones.”

Use gimmicks. One reason people don’t take medications is they forget to take them – or whether they’ve already taken them. Researchers at Washington University in St. Louis, Mo., came up with a solution. In a 2009 study, the researchers found that older adults were better able to remember if they’d done a habitual task – like taking medicines – if they also performed a unusual movement, like tapping their head, at the same time. Other gimmicks: pill organizers, calendars, beeping computers, drug diaries, text messages and medication charts.

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