Tuesday, July 31, 2007

Another Article on the Horrible State of Medication Adherence

Here's an article that is on the wire. I looked for the study Neergaard references, however could not find it. There are some good nugets in here though:

Taking Our Meds? We Are Not Doing It Well
Associated Press – July 31, 2007

Consider it the other drug problem: Millions of people don't take their medicine correctly - or quit taking it altogether - and the consequences can be deadly.

On average, half of patients with chronic illnesses, such as heart disease or asthma, skip doses or otherwise mess up their medication, says a report being issued later this week that calls the problem a national crisis costing billions of dollars.

The government is preparing new steps to try to persuade patients and their doctors to do better.

But with contributors that range from too-hurried doctor visits to confusing pill bottles, there's no easy solution.

"We go into this with some humility," said Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality, which is planning what she calls an "in your face" campaign to improve medication adherence. "It's really pretty appalling how badly we do."

This goes far beyond the issue of affording prescriptions. Often people buy their drugs, but misunderstand what they're supposed to take, or how. Or forget doses. Or start feeling better and toss the rest of the bottle. Or skip doses for fear of side effects.

It's not just a problem of poverty or poor education. Even the rich and highly educated skip their medicine. Perhaps the most high-profile example is former President Clinton, who stopped taking his cholesterol-lowering statin drug and later needed open-heart surgery to avert a major heart attack. Statins offer significant heart protection, but about half of patients on statins quit using them within a year.

And remember the globe-trotting tuberculosis patient who was briefly quarantined in May after ignoring doctors' orders not to travel by airplane? He's out of the hospital now but, like all patients with hard-to-treat TB, must take his remaining antibiotics while health workers watch. So many TB patients skip their pills when they feel better - but before all the bacteria are wiped out - health departments now enforce what's called "directly observed therapy."

For most diseases, however, patients must choose to take their medicines. The new report combs a decade of research to conclude people generally do a lousy job.

Among findings from the nonprofit National Council on Patient

Information and Education:

Particularly at risk are people whose diseases are initially symptom-free. Although high blood pressure more than triples the risk of heart disease, for example, just 51 percent of patients stick with their prescribed antidote.

Also at high risk are the elderly, but adherence is a problem for all ages. As few as 30 percent of teenagers correctly take drugs to prevent asthma attacks, for example.

Dire consequences aren't always a deterrent. Among patients already blind in one eye from glaucoma, only 58 percent were protecting the other eye. Another study found that 18 percent of kidney transplant recipients weren't following instructions to prevent organ rejection.

Even doctors mess up, acknowledging in one study adhering to their own prescriptions just 79 percent of the time.

Poor medication adherence can cost an extra $2,000 a year for each patient in extra doctor visits alone, and it's associated with as many as 40 percent of nursing home admissions, even more costly.

Add preventable hospitalizations and premature death, and the report estimates that poor medication adherence could be costing the country $177 billion in medical bills and lost productivity.

Why is taking medicines correctly so tough? One reason is the general confusion surrounding drugs, said Dr. Ruth Parker of Emory University, a co-author of the new report who has studied the issue for the American College of Physicians Foundation.

When the pharmacy hands over your prescription, there are bunches of papers - stapled to the bag, outside the box, glued to the bottle - that all bear drug information, but often with different wording.

Bottles are covered in warning stickers - such as "Take with food" or "Swallow whole" or "Don't use with XYZ other drug" - in so many colors that Parker compares pill containers to Christmas trees.

What in that jumble should patients pay most attention to?

Then there's the wording. Parker recently helped test the seemingly simple instruction "Take two tablets twice daily." Did that mean a total of two, or a total of four? A third of patients who were deemed literate got confused. A more clear instruction would be: "Take two tablets in the morning and two tablets at night."

Beyond literacy, poor eyesight plays a role. Pill-bottle instructions are rather tiny.

Whatever the cause, Clancy hopes to make "take your medicine" a new priority. Her Agency for Healthcare Research and QUality is starting discussions with the new report's authors, the FDA and health groups about steps to do that. Options range from attention-grabbing ads about the dangers of misusing medicines to better drug labels.

Atlanta Lawyer with DR-TB in Recovery

I found this in the Gainesville Times over the weekend written by Debbie GIlbert. It doesn't really focus on adherence, but it goes with my TB strand from before. The best adherence is the supervised therapy, but it only is the case with these types of diseases in the US.

Andrew Speaker, the Atlanta attorney who set off an international panic when he flew on commercial airplanes after being diagnosed with drug-resistant tuberculosis, now is living in Hall County, at least temporarily. But health officials say there's no reason for local folks to worry.

"Patients with TB, once they're past the contagious stage, are not a threat to anyone's health," said Dave Palmer, spokesman for District 2 Public Health in Gainesville. "But if they quit taking the medication, it's possible for them to become contagious again."

Speaker spent two months at a Denver hospital, where he underwent surgery July 17 to remove an infected lobe of his lung. He was released from the hospital Thursday, with orders to take antibiotics for two years to eliminate the infection.

Because TB is so difficult to cure, public health rules require patients to undergo directly observed therapy. They must report to their local health department every day, where a staff member watches them take their medication.

Speaker took his first dose at the Hall County Health Department Friday morning. Palmer said Georgia law allows patients to be on a five-day dosing schedule so they don't have to take the medicine on weekends when the department is closed.

April Majors, spokeswoman for the Fulton County Department of Health and Wellness, has said Speaker eventually intends to return to Fulton County, where he would then report to the department there for treatment.

Speaker apparently is spending time in Hall while he continues to recuperate from his surgery. Palmer said he does not know how long Speaker plans to stay. Even if Palmer did know, he said federal privacy laws would prohibit him from disclosing any information.

Palmer added that he did not know whether the health department is taking any special precautions to prevent Speaker from being recognized, since images of the attorney have been widely circulated in the media.

Though Speaker may be one of the most famous patients the Hall County Health Department has ever had, Palmer said his treatment regimen is not unusual.

"We've had other TB patients in District 2 who needed supervised therapy," Palmer said.

In the 13 Northeast Georgia counties comprising District 2, there are currently six patients with active TB, he said.

Palmer said patient compliance is typically not a problem.

"Most people work with us because they want to get well," he said. "If they move to another county, they're pretty up-front about notifying us."

Because of the importance of nonstop treatment in TB cases, Palmer said health officials are vigilant about monitoring the patient's whereabouts.

"If the patient stops coming in for treatment, the staff tries to locate that person and will even go to their home if necessary," he said. "We try to make sure people are where they're supposed to be when they're supposed to be."

Wednesday, July 25, 2007

Spiriva Inhaler to help Compliance

I have been hinting about the new pharmaceutical devices that help aid medical compliance, so it is now time to write. It is the best interest of the pharma brands to come up with devices to make their patients more compliance with their medication regime.

First it makes them money (here’s the math: average drug therapy cost: $200; average length of therapy: 3 months - $600 plus another $200 per person per additional month). Second it makes the patient better (sometimes I like to think the pharma companies want to heal people). When the patients are better, their doctor’s look like they know what they are doing and prescribe the medication to more people – thus making the pharma brand more money to put back into their pockets, I mean R & D. It is a great cycle that compliance fuels.

BI and Pfizer just got European approval for Spiriva Respimat Inhaler for people who suffer from COPD. Here are the highlights from their press release:

"SPIRIVA Respimat represents a major step forward in COPD and inhalation therapy. Many patients find certain inhaler devices difficult to coordinate and use," said Professor Marc Decramer, Respiratory Division, University Hospitals, Katholieke Universiteit Leuven, Belgium. "SPIRIVA Respimat has a unique and sophisticated delivery system, and a user friendly design, making it easy to use and suitable for a broad range of patients with COPD. In addition the long-lasting, soft mist cloud generated by SPIRIVA Respimat ensures optimized delivery of SPIRIVA to the lungs, helping patients breathe more easily," he added.

In clinical studies comparing inhaler devices, patients preferred Respimat Soft Mist Inhaler, which may help increase patient compliance with therapy. The novel dose-delivery system of the SPIRIVA Respimat also means that unlike dry powder inhalers, the dose delivered is not dependent on patients' inspiratory flow.

SPIRIVA(R) (tiotropium), a first-line maintenance therapy for COPD, positively impacts the clinical course of the disease, helping to change the way patients live with their condition. The efficacy of SPIRIVA has been demonstrated by an extensive clinical development programme, which has treated over 25,000 patients. It is the most prescribed brand in COPD in the world.

The SPIRIVA Respimat delivery system relies on energy released from a spring, rather than propellants, to produce a long-lasting, slow moving Soft Mist. The innovative design makes SPIRIVA Respimat easy to use, and the Soft Mist results in improved delivery of SPIRIVA to the lungs, with reduced deposition in the mouth and throat compared to a pressurized metered dose inhaler (pMDI). One study showed that 72% of all patients use pMDIs incorrectly and almost half (47%) have problems with coordinating use of the device.

600 million people worldwide live with COPD and its prevalence is predicted to rise making it the world's third leading cause of death by 2020. It is estimated that up to 50% of Americans and 75% of Europeans with COPD are undiagnosed.””

I don’t know if I believe that 600 million people suffer from COPD, but this is from a pharma company so their measurement for COPD is probably a cough. Even though I think the percentages of undiagnosed COPD are high, I am not surprised that is a commonly undiagnosed condition.

I never had an inhaler, but I remember kids in school with them. It was either very nerdy, kinda neat or something for the bullies to steal. Whatever the case, it was always difficult to get a good pull. With the new spring loaded mist, I can hear all the COPD affected breathe a sigh of relief!

Monday, July 23, 2007

The Flip Side of Medication Noncompliance

I usually focus on the negative effects that cause harm to people's health by not taking medications when talking about medication noncompliance, but there is the other side which accounts for abuse. If you think about all those people who are/were addicted to OxyCotin - the scripts had to come from somewhere.

I remember in college a friend always had a prescription of Valium and Percodan (or of that family). Not that she really needed them, but her doctor gave it to her "just in case". I believe there was some recreation use, not only by her but others. I also remember reading a piece a few years ago about kids trading medications. I'll have to find it.

Here is a piece addressing prescription abuse and medication noncompliance from MyWestTexas by Colin Guy:

A study recently completed by Midland-based Ameritox found that out of 240,000 long-term chronic pain patients, 77 percent were not in strict compliance with their physician's instructions.

Ameritox, a company that performs urine analysis for physicians' patients, found 11 percent of all samples contained illicit substances such as cocaine and marijuana and 30 percent of the samples contained prescription drugs that were not prescribed by the patients' doctors.

The study also found 13 percent of the urine samples contained a dosage of medication below the expected range and 30 percent did not contain any of the prescribed medication.

Tobyn Dyer, lab operations manager for Ameritox, told the Reporter-Telegram that in some instances this could indicate patients acquire prescriptions and sell the narcotics on the black market rather than take them as prescribed.

"Diversion is a big issue with the street value of drugs," he said.

According to Ameritox Chief Executive Officer Ancelmo Lopes, the misuse and abuse of prescription pain medication is costing taxpayers an estimated $8.5 billion per year including Medicare and Medicaid expenditures and the cost of treating patients at emergency rooms.

Dennis Wilson, a licensed chemical dependency counselor and program coordinator for Turning Point, told the Reporter-Telegram that many of the people in rehabilitation are abusers of prescription medications. He indicates even the legitimate use of narcotics may lead people with addiciton or a predisposition to addiction to fall into a pattern of substance abuse.

"If a doctor prescribes a 30-day supply it usually lasts 10 days, then five days, then two days," he said. Doctors typically have no way of knowing that their patients are misusing prescription medications unless the patient divulges their addictive tendencies, Wilson said, and are often unaware that prescribing a powerful narcotic could interfere with their rehabilitation efforts.

He said clients are encouraged to recognize the potential for abuse if they use narcotics to treat ailments and to look into alternatives such as non-narcotic painkillers and over-the-counter medications.

According to a press release issued by Ameritox, a Cornell University study found that doctors were unable to detect a patient misusing medications as much as 90 percent of the time and were also likely to mistakenly identify patients who are in compliance as medication abusers.

Ameritox's RxGuardian program, which provides feedback to doctors on what their patients are taking, is intended to help address this problem, Lopes said.

"Even within our own data these are pretty startling numbers," he said. "What Ameritox is trying to do is help physicians monitor their patients who have chronic pain. If they are not taking the medications appropriately doctors can try to get them back to their prescribed regimen."

Thursday, July 19, 2007

ADHD and Compliance

Just a quickie. Dr. Brian Doyle from ADHD Spotlight has a good post on compliance at his blog: http://www.drbriandoyle.com/?p=238.

Restless Leg Linked to Chromosome Six -- At Least

I found this on MedPage Today. It doesn't deal with compliance, but it is a sydrome that fascinates me. When I first heard of RLS, I thought it was all BS. In May, a colleague of mine started taking Musenix (sp?) but had to stop because one of the side effects was RLS and he couldn't sleep.

Three weeks ago I took the same pills as I had a bronchal infection and didn't want to see a doctor. Two days later I began to suffer from RLS and was amazed. I ended up getting a Z pack and blowing it out of my system. Here's some proof and information on genetic coding. All of the doctors mentioned have some financial links to pharmaceutical companies.

By Michael Smith, Senior Staff Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.

REYKJAVIK, Iceland, July 18 -- A major symptom of restless legs syndrome has been associated with a genetic variation on chromosome six, two research groups reported.

The variation has been linked to about half the risk of one of the major symptoms of restless legs syndrome, defined as the periodic limb movements in sleep that are commonly but not exclusively seen in RLS, according to Kari Stefansson, M.D., Ph.D., of deCODE Genetics here.

Using genome-wide association scanning to study patients with RLS, Dr. Stefansson and colleagues found that a genetic variation called rs3923809 accounts for about half the population attributable risk of having periodic limb movements in sleep.

On the other hand, it was not linked to RLS if patients did not also have the periodic motions when they were asleep, he and colleagues reported online in the New England Journal of Medicine.

The study is one of three reports in the journal and in Nature Genetics that detailed results of genome-wide association scanning as a method of linking genetics to disease.

Researchers led by Thomas Meitinger, M.D., of the Institute of Human genetics in Munch, Germany, reported in Nature Genetics that they had used the same method to study RLS and come up with complementary results.

But in addition to the chromosome six result, Dr. Metinger's group linked two other genetic regions to the risk of RLS.

In genome-wide association scanning, researchers use data on genetic variation -- so-called single nucleotide polymorphisms, or SNPs -- amassed by the Human Genome Project and the international HapMap collaboration.

Then, using microarrays that recognize up to 500,000 SNPs, they look for polymorphisms that are more common in people with a disease than in healthy controls.

In a discovery phase look at RLS, Dr. Stefansson and colleagues first tested 306 Icelanders who had RLS with periodic limb movements in sleep, and compared their genetics with 15,664 healthy controls.

That analysis led to a single genetic variation in an intron of the BTB (POZ) domain-containing 9 (BTBD9) gene, which is expressed in many tissues, but whose functions are not well known.

The researchers then replicated the findings using two other cohorts -- one in Iceland with 123 cases and 1,233 controls and one in the U.S. with 188 cases subjects and 662 controls.

All the cases had RLS with periodic limb movements in sleep, and carrying the variant rs3923809 was significantly associated with the condition, Dr. Stefansson and colleagues found.

Indeed, for the groups combined, the odds ratio for the condition was 1.7 for those carrying the variant, which was significant at P=3X10-14.

But when the researchers looked at people who had RLS without the movements in sleep, there was no association with the variant. On the other hand, the risk remained for those with movements but without the other symptoms of RLS, the researchers said.

In other words, they said, "we have identified a genetic determinant of periodic limb movements in sleep" but further research is needed.

Dr. Meitinger's group, on the other hand, did not make the same distinction, but also found a link between RLS and chromosome six. In addition, they found links between the condition and variation in regions on chromosomes two and 15.

The region they cited on chromosome six contains the variant rs3923809, as well as several other polymorphisms in the BTDB9 gene.

On chromosome two, variations in the homeobox gene MEIS1 were associated with RLS, while on chromosome 15, the variation was found in the genes encoding mitogen-activated protein kinase MAP2K5 and the transcription factor LBXCOR1.

As in the other study, the researchers began with a discovery case-control cohort. There were 401 patients with familial RLS and 1,644 healthy controls.

Analysis of their genetics showed 28 single nucleotide polymorphisms in six regions that were possibly linked to the condition, Dr. Meitinger and colleagues said.

The researchers then tried to replicate the findings in two separate cohorts -- one in Germany with 901 patients with either familial or sporadic RLS and 891 controls and the other in Canada with 255 cases and 287 controls.

Analysis of the first group reduced the significant regions to the final three, which was confirmed in the second group, the researchers said.

"A major proportion of the risk for RLS is explained by variants in the loci identified," the researchers said.

The Icelandic finding is "exciting and important," according to sleep researcher John Winkelman, M.D., Ph.D., of Brigham and Women's Hospital and Harvard Medical School, while the Nature Genetics report "makes this finding even more secure."

Writing in an accompanying editorial, Dr. Winkelman noted that the Icelanders appear to have found a gene for periodic limb movements in sleep, rather than RLS itself.

But because the German researchers did not make that distinction "it is unclear whether the other sequence variants they found are truly for RLS, for periodic limb movements in sleep, or for some other RLS marker," Dr. Winkelman said.

But he added that the finding "offers hope" that better understanding of the syndrome's pathophysiology will lead to better treatment.

Wednesday, July 18, 2007

Jamaica Has a Problem with Compliance

I hate to keep posting articles I find, but it is a way to bring to light information that others might have missed. Sometimes there is only so much I can say - other than see, see, it is a problem everywhere! Why don'ts you take your meds!!!!!

I am currently mulling over some information regarding medication patches and gels which will greatly improve adherence. My thoughts coming soon!

When you think of Jamaica, you do not think of medication noncompliance, but this article from the Jamaica Gleaner Newspaper, tells a different story.

Pharmacy Today: Take your pills, NOW! by Ellen Campbell-Grizzle
Medicines work best when they are taken as prescribed. People are buying medication and not taking them or taking them incorrectly. This is emerging as a major public health concern. Persons are not taking life-enhancing medication appropriately and continue to adopt risky behaviours.

We accept that swallowing medication is not a natural act and that some drugs are unpleasant and bitter, and we know that always remembering to take medication on time is most challenging. However, medication wastage is having a devastating effect on the lives of individuals and the public purse.

Privacy is paramount

Jamaica's pharmacists are now being challenged to make a greater effort to be part of the solution to this problem. In order to do this, pharmacists need to spend more time in conversation with each patient and ask some pointed questions.

However, in recent times, our patients are feeling that such queries are intrusive and have not welcomed them. There are good reasons for this. Many patients do not have the opportunity to develop comfort levels with pharmacists who tend to work in various locations. There is always discomfort in sharing private information with strangers.

Patients often resist probing questions from their pharmacists and do not supply the necessary information. Privacy at the point of information and handing over of medication is a major barrier. This situation has to change. The cost of medication noncompliance to the individuals, governments and insurers is spiralling. Pharmacists must develop better therapeutic relationships with patients who will be more comfortable and confident in answering questions related to their health and medication status.

Better medication use

New systems are now being developed to solve this problem at the pharmacy level. Jamaican consumers must be prepared to be more forthcoming to their pharmacists' questions. This will assist in the design of a better medication use plan for you. Here is how you can help to ease this problem. Be prepared to:

Show what medicines you are taking.
Tell how you are currently taking your medication.
Explain (to the extent that you know) what each medicine is intended for.
Talk about side effects that worry you.
Give some information as to whether you feel your medicines are working.
Talk about problems that you have with taking your medication such as difficulty in swallowing tablets, remembering to take your medication, difficulty in opening containers.
Share your difficulty in affording medication, if this exists.
Talk about spare/excess medication that you may have.
Talk about the medication that you purchase from other pharmacies, supermarkets and gas stations and your use of herbal and other types of remedies.
Give information about your favourite fruit juices such as cranberry or grapefruit juice.
Have your questions fully explored and answered.

A different paradigm

In this new type of partnership, pharmacists will have to designate consultation areas in the establishment, ensure that patients and pharmacists can speak in normal volumes without being overheard, keep records of advice given and ensure that patient data is confidential. In recent times, you may have experienced some of these changes but more needs to be done.

Patients and pharmacists working together can help to reduce medication noncompliance.

Tuesday, July 17, 2007

Dermatology Problems with Compliance

Who would have though? It is a problem you see everyday and would want to cure, yet noncompliance still happens!

Patients Not Complying With Treatment A Universal Problem
Science Daily — Patients not complying with their dermatologic treatment is a universal problem that doctors need to address, according to Steven Feldman, M.D., Ph.D., from Wake Forest University School of Medicine in an editorial published in the current issue of Archives of Dermatology. He said non-compliance can explain why some conditions may seem resistant to treatment.

"Physicians must develop practical measures to improve patients' compliance behavior: establishing strong, trusting physician-patient relations, choosing medications that can fit patients' lifestyles, using patient education materials designed to motivate without overly stressing risks, and scheduling a follow-up visit shortly after initiating a new treatment," writes Feldman, a professor of dermatology.

Feldman says that dermatology research studies that involve electronically recording patients' usage of a treatment, without them being aware of it, show that non-compliance is more pervasive that previously estimated.
"Understanding that non-adherence to treatment is widespread is essential for addressing many of the difficult-to-manage skin disease dilemmas seen in dermatology," Feldman said. "By addressing adherence, we can achieve better success for patients with psoriasis and other chronic skin diseases."

Feldman says he has had personal experience with patient noncompliance. He had acne and wanted to see how well current anti-acne medications work. He planned to take a photo of the rash, put the medicine on once a day and then take a photograph one week later.

"I wanted to make sure I didn't forget to apply the medication, so I put it on top of my toothbrush," he said. "The first night I used the medication. The second night I managed to brush my teeth and still forget to put the medication on. The third and fourth nights I went out of town and forgot to bring the medication with me. And I tend to be on the obsessive compulsive side!"

Patient forgetfulness is just one part of the problem, he said. Sometimes, patients consider treatment the worst part of the disease. For example, scalp psoriasis may seem resistant to treatment, he said. Actually, psoriasis treatments probably work better on the scalp than on other areas of the skin, if patients would just apply the medication.
Rather than having patients continually try new treatments for scalp psoriasis, he suggests having patients try the treatment for three to four days.

"It is much easier to be compliant for three or four days than for eight weeks," Feldman said. "After that, patients will know they have a treatment that works and will use it as needed to keep their scalp psoriasis under control."
He said that when prescribing medications, physicians need to consider which form is most likely to be used. Many patients prefer pills over creams and ointments, he said. Another option is physician-administered treatments, such as injections, that will assure adherence.

Feldman says doctors shouldn't be surprised by poor adherence to using creams and ointments in the home environment, especially involving pediatric patients. "Those of us who are parents will recognize how difficult it is to apply sunscreen or other topical agents to our own children," he said.

In addition to considering the form of therapy that patients are most likely to use, Feldman said the patient-physician relationship is an important part of the equation. He said research shows that if patients are satisfied with their physician visit three days afterwards, they are more likely to report an improvement in their condition a month later.

"Patients who are more satisfied with their visit are more trusting of their doctor, worry less about adverse effects and use their medication more regularly," he said. Feldman's co-authors are Saba M. Ali, B.S., Robert T. Brodell, M.D., and Rajesh Balkrishnan, Ph.D., all with Wake Forest.

Note: This story has been adapted from a news release issued by Wake Forest University Baptist Medical Center.

Monday, July 16, 2007

XDR-TB in South Africa due to Noncompliance

Here is more news about the deadly new strain of TB - now in South Africa as well. This feels like something out of a doomsday movie. The increased strength of viral strains due to medication noncompliance.

From The Chronicle Newspaper (Lilongwe) by Moses Kaufa.

In Malawi, Tuberculosis (TB) is closely linked to the HIV epidemic. Of the 28,000 cases of TB reported in the year 2005, approximately 70% of the patients tested HIV positive.

Although TB can be cured, the recent surfacing of an Extensively Drug Resistant-TB (XDR-TB) in South Africa is cause for concern.

With the current official rate of 14% HIV infection in Malawi and the link between HIV and TB, the need to put TB firmly on the political agenda of the country has become more necessary and urgent.

The government, through the Ministry of Health and the National TB Control Programme has committed to making sure that there a plan in place to respond effectively should any cases of XDR-TB surface in Malawi.

Advocacy, Communication and Social Mobilization (ACSM) an initiated component of the Malawi National TB Control Programme, seeks to create awareness, facilitate community involvement and participation and promote activities that will inform the public on the importance of adhering to treatment and medical advice for Tuberculosis in an effort to avoid the possible development of the fatal, Extremely Drug Resistant TB (XDR-TB).

Henry Chimbali, the Communications Officer of the National TB Control Program, ACSM has embarked on an advocacy campaign involving activities designed to place TB high on the political and development agenda.

The campaign also aims to increase financial and other resources on a sustainable basis as well as hold authorities to account. Additionally, the campaign seeks to ensure that pledges are fulfilled at the local level.

A major and very important part of the campaign is to prevent the possible development of the deadly XDR-TB in Malawi.

Reports indicate that XDR-TB probably developed because cases of normal TB are not treated properly. TB that is not effectively treated will resurface with resistance to the drugs used in the treatment and become Multi Drug Resistant - TB (MDR-TB). Concerns are high that XDR-TB could develop if patients are not aware of the importance of following the strict medical regime necessary to treat MDR- TB.

Records indicate that no one knows yet exactly how many cases of XDR-TB exist but surveillance shows that countries most affected by TB are those that are poor.

Chimbali told Health Check that XDR-TB mostly develops in patients who at one time used the drugs for other ailments or if they had defaulted in the treatment of TB.

However, the infection of XDR-TB is transmitted in the same way as the standard TB.

He says the intervention embarked on by ACSM seeks to prevent any possible occurrence of XDR-TB in this country and the further spread of infections should it occur.

"The program will be looking at adherence and compliance of treatment. This will be achieved by ensuring that all TB patients are under closely supervised treatment and all health workers have adequate knowledge on TB treatment guidelines. There will be a need to engage more health care providers in TB treatment monitoring, strengthening treatment monitoring systems at all levels and intensifying proper diagnosis of all TB suspect cases," Chimbali said.

He said the program is also focusing on prevention and control of the transmission of XDR-TB to health workers and the public.

"This will be achieved through early diagnosis of all TB treatment failures, relapses and tracing of all treatment defaulters and the establishment of special treatment centers for XDR-TB," said the Communications Officer.

XDR-TB is said to be very difficult to treat as it involves a regime that lasts for a long period of time. Drugs to treat the infection are extremely expensive making access to treatment of XDR-TB impossible for many under-privileged people

MDR-TB in Pakistan Directly Linked to Noncompliance

From the Daily Times of Pakistan by Urooj Zia

KARACHI: Medication for Multi-Drug Resistant Tuberculosis (MDR-TB) is generally smuggled into Pakistan from parts of India, sources in the federal health department and medicine-vendors in Karachi told Daily Times.

MDR-TB is a “higher form” of TB, and is a lot more difficult to cure than regular TB, mostly because the bacteria in this case have become resistant to most drugs used in the first line of treatment for (regular) TB. Medication for regular TB is provided free by the government, under the WHO-sponsored DOTS programme, run by the National TB Control Programme (NTP).

MDR-TB develops mainly due to non-compliance with the first line of treatment, which lasts around six to eight months. A number of patients, however, stop taking medication after the first three months (around the same time that TB symptoms disappear). “The bacteria are still there, though. They just become dormant, which is why the symptoms disappear. People think they’re cured, and stop taking the medication. The treatment during the next few months, however, works towards killing these bacteria, so the disease doesn’t make a comeback,” doctors said.

Once a patient drops out mid-treatment, the disease comes back with a vengeance, in the form of MDR-TB. These bacteria are resistant to the first line of treatment, and a different combination of drugs has to be used to combat them. These drugs are extremely expensive in Pakistan. Treatment generally lasts around two- to two-and-a-half years, and the total cost of medication alone comes up to around Rs 200,000,” Sindh TB Control Programme director, Prof. Iqtedar Ahmed, said.

Moreover, even a patient who has never contracted TB before can contract the drug-resistant form of the disease, if infected directly by a person suffering from MDR-TB. Four major drugs are used to combat MDR-TB – Cycloserene, Oflobid (a wide-spectrum antibacterial), Pas, and Ethomid.

Each of these medicines costs less than Rs 10 in India. After being smuggled into Pakistan, however, the cost increases to between Rs 50 and Rs 75 per capsule. An MDR-TB patient is expected to take at least two of each daily for the duration of the treatment. The total cost of treatment depends on the combination of drugs being used – all four medicines are not used at the same time.

Interestingly three of the four medicines are also produced locally in Pakistan, “but they are produced by multi-national companies (MNCs), so the difference in cost isn’t much,” a shopkeeper at the Medicine Market in Katchhi Gali # 2 (behind M.A. Jinnah Road) told Daily Times. “MNCs have their own costs of production to look at too.” “Locally-produced” versions of Pas, however, cost Rs 375 for a box of 50 tablets (Rs 7 per tablet). Ethomid costs Rs 476.85 for a pack of 30 tablets (Rs 16 per tablet), and Oflobid costs Rs 115 for a pack of 10 tablets (Rs 11.5 per tablet).

A cheaper variant of Ethomid is sold under the trade name “Marbital.” These are available at Rs 175 for 100 tablets (Rs 1.75 per tablet). Both versions are “legal” – the more expensive Ethomid is produced in Lahore, while the cheaper Marbital is produced in Karachi.

Cycloserene is produced in Seoul, Korea, and is marketed by a firm in Karachi. It is available at Rs 59 for a pack of 30 tablets (Rs 2 per tablet).

These are the prices that are generally applicable. “Most of the time, the supply of the locally-produced medicines falls short in the market, and drugs smuggled in from India have to be used,” medicine-vendors said. “That is when prices shoot up. If a patient has to take these medicines for two years, he or she will find the cheaper versions readily available for merely three to four months out of a total of 24. The rest of the time, the patient’s family will have to search hard and long for even the Indian versions of the medicines. This is how the treatment costs for MDR-TB shoot up. The government should subsidise the production of these medicines, so they are readily available, at cheaper rates.”

Another factor pharmacy salespeople and owners brought up was the fact that the availability of these medicines in rural areas is next-to-zero.

The WHO has a programme for treating MDR-TB. This programme is referred to as DOTS+. It is yet to be implemented in Pakistan, however. “Right now, we are concentrating on implementing the DOTS programme completely. We have been advised by the WHO to not touch MDR-TB as a programme yet,” Sindh TB Control Programme director, Prof. Iqtedar Ahmed, told Daily Times. “Keeping our human resources, financial resources, and technical resources in mind, our first priority is the first line of treatment for TB (under the DOTS programme). Our next target is paediatrics (incidence of TB in children under the age of 12).”

The National TB Control Programme has started to work on a protocol for implementing a programme for MDR-TB too, Prof. Ahmed said, adding however, that implementation will take time. “It could take anywhere from two to six months, I can’t be sure at this time,” he said.

The incidence of MDR-TB is equal all over the country, he added. “According to WHO reports, the incidence of the disease in Pakistan is somewhere around two to three percent. It is higher in more populated areas, and lower in relatively more affluent suburbs, where a lesser number of people share the same living space.”

The problem with the government sponsoring MDR-TB treatment is that the prognoses (results) of the treatment are around 50 percent, Prof. Ahmed said. “At the end of the day, looking at financial constraints, it is more feasible to spend that money on the first line of treatment, so that the disease is nipped in the bud.”

He did agree, though, that some level of coverage should be given to MDR-TB by the federal and provincial health departments.

Wednesday, July 11, 2007

Great Article in NJ Star-Ledger

Great article about medication noncompliance in the NJ Star-Ledger by Jeff May. I don't know how to activate the link, but you can paste this in your browser for a good read!

I really like his tagline, "Healthcare's broken link". Very apropos of the problem as it starts with the MD prescribing the pill, to the pharmacist to the patient. I like the links in the chain.

Tuesday, July 10, 2007

Scientologist's Double Murder Down Under Blamed on Noncompliance

Here is something from the Sydney Herald written by Dylan Welch. I don't want to anger the Scientologists, but it really shows their ignorance and the importance of medication compliance - especially with psychiatric treatment.

SCIENTOLOGISTS were condemned yesterday as "flat-earthers", following statements in court that an alleged murderer was denied psychiatric treatment because of her family's Scientologist beliefs.

The vice-president of the Australian Church of Scientology, Cyrus Brooks, told ABC radio the Scientology link to the killings was "a bit of a red herring".

"The woman was actually under the drugs; she was on drugs at the time of the incident. She was also under the care of a psychiatrist … since January," Mr Brooks said.

"The records show that she was on psychiatric drugs, so to say that it had something to do with us, then I think it's incredibly defamatory and unfair."

A psychiatric report tendered to Bankstown Local Court on Monday said the 25-year-old woman accused of murdering her father and sister in Revesby last Thursday had tried to get help twice last year, but her Scientologist parents had a religious objection to psychiatric intervention.

Mr Brooks said modern psychiatry used many methods that were largely "unproven" and psychiatric assumptions such as chemical imbalances in the brain did not exist.

After Mr Brooks finished his interview, a Sydney University psychiatrist, Chris Tennant, phoned ABC Radio to reject the Scientologist's beliefs.

Professor Tennant said it was "so sad to hear the flat-earthers getting on the radio". He denied modern psychiatry was largely unproven and said the amount of research on mental illness was as strong as that for cancer and heart disease.

"It's a tragedy to hear this mumbo jumbo being proselytised by this group," he said. "The sad thing about this sounds to be that this girl may well have been prescribed some psychiatric treatment but living in a family which had the Scientology attitude there is no way there would have been what we term compliance."

The president of the Australian Medical Association, Dr Rosanna Capolingua, said if the woman had had access to appropriate medical treatment, it could have "changed the course of her life".

Media reports yesterday morning said the accused woman's parents had taken her off anti-psychotic medication and instead treated her with non-psychotic medicine imported from the US.

Mr Brooks denied the US medicine had anything to do with Scientology.

He said the church did not give the family any advice on the daughter's situation and had not recommended the US medication she was alleged to have taken.

Mr Brooks said he was not aware of any US medication used for the same purpose.

The woman accused of the double murder is due to appear in court again today.

Patient Compliance: Is There a Solution? - 3

Here are some more percentages on Noncompliance from the MedAdNews Trend Report:

So here's the MDs take on noncompliance:
Sex Breakdown
Men: 65%
Women: 5%
Equal: 30%
Age Breakdown
18-34: 23%
35-49: 27%
50-64: 23%
65+: 17%

Real numbers based on Guideline Survey:
Female: 62%
18-34 65%
35-54 63%

As you can see, the MDs are really, really wrong about who they believe is compliant. It could go back to the "white coat" adherence I wrote about in June. I would imagine the majority of patients do not get their blood tested regularly, so the MDs have to rely on what their patients tell them. (I have to admit that I have not gone to have my follow-up blood work done - I'm only two months late. Also going to the dentist today but I will not lie - I do not floss as much as I should).

Here are some numbers on specific ailments:
Insomnia: 84% - wouldn't they realize they are awake and take their medication?

Incontinence: 78% - I would think that after one or two public incidents that they would take their meds.

Depression: 77% - this is understandable. One of my psychologist friends told me that the reason sucide rates are higher among teens on antidepressants is because the antidepressants start to work and get the teens into a state of motivation to commit suicide, whereas without them, they are too depressed to do anything. Kind of a horrible fact.

Pain: 77% - again, I would think that if you are in pain, you would take your meds.

Asthma: 76% - if it is hard to breathe, take your meds.

Anxiety: 75% - I can understand this one due to side effects and when their medication is working, they feel they no longer need it, thus they stop taking it and become anxious.

There are more facts and factors covered in the report, but only two more which are reflective of the high costs of medications.

When the MDs were asked what they thought the number 1 reason for noncompliance - 71% responded: "My patients cannot pay for all their medications".

67% of patients and 95% of MDs stated their #1 interest in a program to enhance compliance would be "a discount program for those who renew their scripts on time" .

At least we all can agree on one thing - medications are too expensive and if they were cheaper, everyone would take more.

Speaking of paying for medications, my new company is on an HSA program (which is supposed to save us money) but with my medications (2), my wife's meds (2) and our son's single prescription, the monthly cost was aobut $435 - not the $25 co-pay with my old program ($125). Granted with the HSA less is taken out of my pay and after the deductible ($4,000) is hit, everything is covered. However, getting to that number would take eight months of medication plus our twice a year check-ups - given that we are healthy. But HSAs are another post.