Medications work only when patients take them as prescribed. Unfortunately, patients very often skip doses or take them at the wrong time. Nonadherence rates averaged 71% and ranged as high as 97% in >70 studies where patients' dose taking was monitored electronically. Similarly, a review of 14 studies of patients' dose timing showed that <41% of people consistently self-administered prescription drugs on the schedule set by their prescriber.¹ Elderly patients and those with serious psychological problems—the very patients who are most at risk for suffering adverse consequences from poor medication adherence—are particularly likely not to follow dosing instructions.^2,3

Individuals' reasons for failing to take medications appropriately vary. Patients, however, appear most prone to be nonadherent when:

• They are taking several different medications and multiple doses per day
• They must refill prescriptions frequently
• They have trouble affording their drugs

Pharmacists can work with patients and prescribers to mitigate each of these factors by:

• Simplifying drug regimens
• Arranging for 90-day supplies
• Suggesting substitutions of lowercost therapeutic equivalents for expensive brand name products⁴
• Educating patients about how their medications work
• Instructing patients on how to administer doses
• Following up with patients on whether they are using their drugs and whether they are experiencing any problems^5,6

In addition to these strategies, a broad array of tools and devices is available to promote appropriate drug-taking behaviors. Adherence packaging demands the most from pharmacists but can offer patients great benefits in terms of convenience and drug information. Dosing alarms are desirable for patients who must take different medications at different times each day. Pill organizers can help patients adhere to complex therapeutic regimens. Brief descriptions of examples of each type of adherence aid follow. For best results, counseling and followup should be combined with patients' use of adherence aids. Although research has shown mixed results from the simple use of pill organizers, it has consistently demonstrated that appropriate drug use increases when multifaceted approaches to adherence are employed.^3,7

Adherence Packaging

Sending patients home from the pharmacy with their medications presorted into batches as they are meant to be taken can go a long way toward reducing the number of missed and mistimed doses. For example, software and blisterpackaging systems from Medicine-On-Time (www.medicine-on-time.com) can help achieve this goal.

Patients who receive their prescriptions from pharmacists using Medicine- On-Time receive a calendar card that has pockets filled with the tablets they need to take together. The cards come in varying sizes, and the pockets can be filled according to the day or time. Each of the cards and individual pocket seals can be labeled with the name(s), dosage(s), and special instructions for their contents, as well as with the patient's name and other relevant information.

Adherence packaging can be offered to patients for a fee. It also is a valuable service for assisted living facilities and hospices that lack in-house pharmacies.

Dosing Alarms

Numerous wristwatches, pagers, and timers customized to sound alarms when it is time to take medications are available. Most can be programmed to sound several times each day; some watches can sound 30 different alerts. Users typically can choose between audio and vibrating alarms.

A more advanced dosing-alarm system is available from OnTimeRx (www.ontimerx.com). Patients who use computers or personal digital assistants can download OnTimeRx and use the program to keep track of their medications and other health information. The program lets patients enter the names, doses, regimens, and warnings for all their medications, set dosing schedules, receive alerts when it is time to take doses or request refills, and keep records of their drug taking. In addition, OnTimeRx lets patients record and regularly update their medical history.

The company that developed On-TimeRx, AmeliaPlex, also offers personalized voice and e-mail medication reminder services. Patients who register for OnCellRx type in the messages they wish to receive and specify the days and times when they wish to have those messages delivered. The messages can be as detailed as the patients need them to be, and they are sent to patients' e-mail or telephone at the times requested.

Pill Organizers

Pill organizers can be as simple as boxes with bins labeled for days of the week or as complex as automatic dispensers with alarm and drug information display functions. Patient characteristics and preferences, as well as the number and kinds of medications a patient is taking, should guide the selection of a pill organizer. A 35-year-old patient taking a statin and a multivitamin each day probably needs nothing more than the most basic organizer. A 75-year-old being treated for diabetes, early-stage dementia, and glaucoma, however, would be better served with an organizer that features prefilled dosing cups, reminder alerts, and locks to prevent access to medications until it is time to take them.

The many options for pill organizers, along with descriptions of their features, can be reviewed online at www.epill.com and www.forgettingthepill.com. These sites also offer several types of standalone medication alarms.

Mr. Lamb is a freelance pharmacy writer living in Virginia Beach,Va, and president of Thorough Cursor Inc.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Rybovic, Pharmacy Times, Ascend Media Healthcare, 103 College Road East, Princeton, NJ 08540; or send an email request to: arybovic@ascendmedia.com.