Pharmacists are vitally important in enhancing patients’ adherence to oral chemotherapy medications, and there are approaches that pharmacies can take to improve compliance, Sylvia Bartel, RPh, told attendees of the NCCN Pharmacy Program held during the 17th Annual Conference of the National Comprehensive Cancer Network (NCCN) in Hollywood, Florida.
“While oncologists prescribe oral chemotherapy for an increasing number of indications, we know little about safeguards, common practices for using these medications, and how to ensure adherence,” said Bartel, of the Dana-Farber Cancer Institute (DFCI) in Boston. “Pharmacists are in the best position to dispense medications. Without them, you are bypassing a key component of safety with oral medications.”
By her definition, patients are adherent when they take at least 85% of their prescribed medication. Patients are nonadherent by failing to fill or refill their prescription, sharing medication, taking too little or too much, and substituting other products.
While oral chemotherapy has quality-of-life advantages, it offers less opportunity for interaction with providers and clinical staff, especially if infusion is not part of the regimen, and providers are often unaware when patients are not compliant with treatment, she said. Nonadherence contributes to variability of therapeutic effect, which may lead to unnecessary changes in dose and regimen. It is associated with increased physician visits, higher hospitalization rates, longer hospital stays, worsening of disease, increased mortality, and higher healthcare costs.
“We know that one-third to two-thirds of medication-related hospital admissions are related to poor adherence,” she noted. “Suboptimal adherence may be the greatest barrier to the effective use of new oral agents.”
Barriers to Adherence
There are many reasons for nonadherence. The usual barriers, as reported in the literature and in Bartel’s own experience, include psychological problems, cognitive impairment, misperceptions (eg, “If I feel good I don’t have to take my medicine today”), complexity of dosing schema, presence of comorbidities, older age, lack of social support, low literacy, inadequate follow-up, and cost of the drug.
Measuring adherence is generally by indirect means: patient query or questionnaires, clinical response, pill counts (which can be manipulated), refill data, and patient diaries. Electronic medication monitors are used in clinical trials but are generally not available in usual practice.
“We assume patients are taking their medications, but we really don’t know,” Bartel said.
In a survey from DFCI, 30 oral chemotherapy patients were assessed for their understanding of their regimens. Eleven patients had limited understanding about the management of side effects; 7 had limited knowledge of what to do if a dose is missed; 5 reported missing at least 1 dose in the past month due to side effects and forgetfulness; and 8 reported having no strategy to support adherence, such as an information sheet from their provider or pharmacy.
Programs to Increase Adherence
“Pharmacists play a key role in adherence. Establish honest and open communication with your patients so they will tell you the issues they are struggling with,” Bartel told attendees. At the very least pharmacists should review with patients and their families the medication timing, potential side effects and their management, and what to do with missed doses. They can help incorporate the drug schedule into the patient’s routine and improve the dosing schedule if needed. They can instruct patients on the use of schedule reminders such as calendars, pill organizers, alarms, and cell phone apps.
“An interactive dialogue is important,” she continued. “Ask if the patient understands the purpose of the medication, dose and schedule, side effects to look for, and strategies for missed doses. Provide written material and involve the patient’s partner.” Since such comprehensive counseling is hard to accomplish “at the pickup window,” she advocates structured programs.
At DFCI, several such programs are in place. One is expressly for patients (and their caregivers) receiving autologous bone marrow or stem cell transplants. Pharmacists review in detail their prescriptions (including a look at the actual pills or tablets) and provide written materials, managing about 15 patients each. An assessment of the program revealed that providers perceive their patients to be well informed, and the patients express a good understanding of their post-transplant medication needs.
“Having this program has been helpful in this population of patients, and we are now extending this to the outpatient clinic,” she said.
DFCI also has a similar program through its specialty pharmacy. Pharmacists review the medications when patients pick up their prescriptions. At the conclusion of the first cycle of treatment, the pharmacist calls the patient to discuss any issues, and calls whenever patients fail to pick up their next prescription. With this approach to patient consultation and follow-up, adherence to treatment has improved from about 50% to 97%, she reported.
Bartel acknowledged that counseling for oral medications adds to the labor burden within pharmacy. It takes the pharmacist about 1 hour for the initial counseling of transplant patients and about a half hour within the specialty pharmacy program.
Not all patients warrant this degree of intensive counseling. It would be ideal to have a screening instrument to help identify patients at risk for nonadherence, which can often be predicted by type of drug and complexity of treatment schedule. Efforts are under way at DFCI to create such a tool.