At times, it can be difficult for patients to remember to take their medications, especially those with a new or complex dosing regimen. Even if a patient knows that it is vital for them to take their medication for a chronic disease state, there is still a large percentage of patients who are non-adherent.
 
Patients who have undergone an organ transplant often fall into this category. Those who have received a transplant and are non-adherent to their medication regimens are more likely to experience graft failure and higher health care costs.
 
There have been some improvements in adherence when patients are counseled on the importance of taking their medication as prescribed, but there are still a large percentage of patients with chronic disease states that are non-adherent. Medication aids, such as pillboxes and reminder devices like alarms, have been shown to cause an increase in adherence across multiple disease state populations. Transplant recipients have been shown to be more successful with adherence when utilizing one of the many medication aids available, as opposed to remembering on their own. 1
 
When a patient experiences organ failure, they may be a candidate for the organ transplant process. This process includes the surgical transfer of a donated organ to another patient who has been diagnosed with organ failure. 
 
Failure of a patient’s organs can be attributable to various sources such as injury, chronic disease states, lifestyle, or birth defects. There are many factors in determining placement on the national waiting list, allocation of organs, and proper coordination between donor and recipient.2 
 
Determining if a patient is a candidate for transplantation requires the assessment of psychosocial factors such as level of social support, history of substance abuse, financial status, and non-adherence to medical recommendations.3 Some of the factors that are taken into consideration in matching a patient with a donor include blood type, body size, severity of the patient’s medical condition, geographic location, and availability.2 
 
When an organ is transferred from a donor to a patient, the patient’s immune system detects the organ as being foreign to the body, realizes that it may cause harm, and subsequently initiates an immune response to protect itself from this potential invader. Through this immune cascade, the patient’s body will attempt to destroy the foreign matter. 
 
There are two types of rejection that can occur:
  •      Acute rejection happens quickly after organ transplantation.
  •      Chronic rejection is defined as the slow failure of an organ over time. 2
Therefore, it is essential that post-transplant patients remain on immunosuppressive medications to prevent their bodies from not only rejecting the organ immediately, but also long term.
 
After the patient receives the transplant, they are put on a very complex dosing regimen, typically including at least 2-3 oral immunosuppressive medications taken multiple times per day to prevent rejection, along with various other medications. 
 
They are also subject to intensive monitoring throughout their medication therapy. These complex dosing regimens can very easily lead to patients becoming non-adherent. 
 
Non-adherence in these patients is associated with an increased number of organ rejections, increase in health care costs, and decreased survival of the transplanted organ.1 Immunosuppressive non-adherence is one of the most common causes of transplant failure. 
 
Because of this higher failure rate that is observed, it is imperative that a post-transplant patient takes their medications exactly as prescribed to help to reduce the risk of rejection. It is estimated that “on average, the post-transplant health care provider can expect to see 23 non-adherent patients for every 100 individuals during a given year of follow-up.”4
 
Some of the primary causes of medication non-adherence that are observed in transplant patients include forgetting to take the medication or refill it on time, financial burdens, distractions, comorbid diseases, changes in daily routine or lifestyle, and changes in sleep patterns. A qualitative study determined that most post-transplant patients understood the importance of taking their immunosuppressive medication as prescribed; however, unintentionally became non-adherent due to various factors as previously mentioned.5 
 
Upon recognizing the importance of adhering to this rigorous dosing regimen, many patients were willing to utilize medication aids to help with remembering to take their medication at the precise dosing intervals as determined by their physician. Some of the medication aids that can help a patient to remember to take their medication at the proper time include a cell phone or tablet application, standard pill boxes, setting alarms, written notes, and specific placement of medication, and electronic dispensing devices. 
 
These tools utilize visual and/or auditory cues to remind the patient when it is time for a dose, thus improving adherence. Choosing a system to successfully help the patient remember to take their medication has been determined to be highly patient specific. 
 
For example, an elderly patient who does not own a cell phone may find it more beneficial to write themselves reminders and place their medications on the counter or bedside, depending on time of dose and daily routine. These systems can range in complexity with some patients needing little help compared with patients who need additional caregiver support or assistance to achieve success.
In conclusion, utilizing medication aids in patients with complicated dosing regimens, particularly post-organ transplant, has been shown to be highly effective in improving adherence and promoting positive patient outcomes. Patients should maintain an open line of communication with their physician and pharmacist about difficulties that they experience with their medication regimen. 
 
This patient-provider relationship will allow for the patient to work closely with their physician or pharmacist in order to determine the primary cause of their non-adherence. This will allow the patient and provider to collaborate to develop a treatment plan that will promote success in medication therapy, thus improving overall health outcomes.   
        
References
 
1.  Denhaerynck K, Steiger J, Bock A, et al. Prevalence and Risk Factors of Non-Adherence with Immunosuppressive Medication in Kidney Transplant Patients. American Journal of Transplantation. 2007;7(1):108-116. doi:10.1111/j.1600-6143.2006.01611.x.
 
2.  USDHHS. The Organ Transplant Process. The Organ Transplant Process. https://organdonor.gov/about/process/transplant-process.html. Accessed June 16, 2017.
 
3.  Lieber SR, Volk ML. Non-adherence and graft failure in adult liver transplant recipients. Dig Dis Sci. 2013;58(3):824-34. https://search.proquest.com/docview/1323598238?accountid=10610. doi: http://dx.doi.org/10.1007/s10620-012-2412-0.
 
 
4.  Dew MA, Dimartini AF, Dabbs ADV, et al. Rates and Risk Factors for Nonadherence to the Medical Regimen After Adult Solid Organ Transplantation. Transplantation. 2007;83(7):858-873. doi:10.1097/01.tp.0000258599.65257.a6.
 
5.  Israni A, Dean C, Kasel B, Berndt L, Wildebush W, Wang CJ. Why do Patients Forget to Take Immunosuppression Medications and Miss Appointments: Can a Mobile Phone App Help? JMIR Public Health and Surveillance. 2016;2(1). doi:10.2196/publichealth.5285.
 
 
About the Authors
Brianne Molnar and Kara Patterson are PharmD candidates at Duquesne University School of Pharmacy.

Jonathan Ogurchak is Vice President for Business Operations at PANTHERx Specialty Pharmacy and serves as adjunct faculty for the University of Pittsburgh’s MSPBA program, leading the Specialty Pharmacy Management curriculum.