Day in the Life: Adherence

Nicholas Karalis, RPh
Published Online: Tuesday, March 22, 2011
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Medication management programs rely on communication between the pharmacy, the patient, and the prescriber.  Here are one specialty pharmacist's thoughts on adherence. 


According to the Office of the US Inspector General, “Non-compliance with drug treatments accounts for 125,000 deaths per year. Up to 10% of hospital admissions and 23% of nursing home admissions each year could be avoided if people took their medications as prescribed. Neither gender, age, ethnicity or educational level seem to be an indicator of compliance.”

The World Health Organization says adherence to therapy for chronic diseases in developed countries averages 50%. When you consider these statistics—and think of patients with chronic complex disease states requiring specialty medications—one can only imagine the probability of failure.

The mechanics of compliance and adherence in specialty pharmacy have many different definitions. When you think about the one-third rule, where one-third of patients take all their medications, one-third take some, and onethird don’t take any at all (never fill the prescription), a specialty pharmacy needs to have a well-defined plan in place. For example, many pharmacies have an automatic refill or a refill reminder program to help patients with compliance, but that is only one portion of successful medication management.

The term “compliance” is most often used, but really “adherence” is more accurate because it implies and recognizes patient choice in therapy. Specialty pharmacies have an opportunity and an obligation to provide patient education, patient support programs, and continual communication in an effort to maximize adherence and ultimately improve patient outcomes.

In our practice, we understand that all patients are not created equal. We offer individual medication management programs based on the patient’s disease state and their requirements. For instance, patients receiving a complex antiviral regimen who have multiple disease states are offered weekly pillbox programs, compliance packaging (individual multidose pouches), or a scheduled calendar for optimal dosing.

For anxious patients starting an injectable medication, we offer oneon- one training and support with their injections until they are comfortable doing them on their own. We manage the side effect profile of specialty medications in a proactive manner by informing and educating our patients not only on what to expect, but what they can do to combat these unwanted side effects.

One of the most important components in our medication management program is the communication between our pharmacy, the patient, and the prescriber. In our practice, it is just as important to document and understand why a patient is reluctant to start therapy, has stopped therapy, or is not being compliant with their dosing regimen, as it is to fill a prescription. Understanding, documenting, and closing the loop with the prescriber is the backbone of our adherence program. The procedure of refilling and calling the patient to schedule delivery is the operational process to assist in compliance.

As the United States evolves into a greater evidence-based health model, the importance of adherence and improved outcomes for all the stakeholders in specialty pharmacy cannot be understated. The FDA Amendment Act of 2007 focused efforts on Risk Evaluation and Mitigation Strategies (REMS) requirements in order to ensure the safe prescribing and use of certain medications. The Clozaril Registry program that started in 1990 is a perfect example of how a beneficial medication with potentially dangerous side effects can be managed in a community setting. In fact, one could argue that strict monitoring and distribution systems only work effectively when administered by properly trained and capable community pharmacies.

When new patients are limited to a 7-day supply of medication, physicians and mental health clinics look to partner with a community specialty pharmacy that can execute the program requirements in a timely, responsive manner—continuity of care is paramount. Looking to the future, I believe that community specialty pharmacies have an enormous opportunity to be a factor in delivering REMS programs for specialty medications, without limiting access, and offering patients a viable choice in managing their medications. SPT




Mr. Karalis, RPh, is a specialty pharmacist and co-owner of Elwyn Specialty Care, which offers specialty pharmacy services in HIV, oncology, hepatitis C, multiple sclerosis, rheumatoid arthritis, Crohn’s disease, psoriasis, and other areas. A leading voice in community pharmacy, he is a founding member and board member of the Community Specialty Pharmacy Network (CSPN), as well as a board member of the Cardinal Health National Home Health Care Advisory Board. Mr. Karalis is also an editorial board member of Specialty Pharmacy Times and shares his experiences with SPT readers.



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