Addressing Patient Adherence in Glaucoma Management

Shared insight on the importance of patient adherence in glaucoma management, and how this is influenced by therapeutic regimens.


Neil Minkoff, MD: What are the things that you folks see in your practices that seem to be related to adherence or persistence, more patients taking their medication? Because from what I understand, is that 1 of the big issues here is people get tired of taking their drops, they’re not using their drops appropriately or so on and persistence, adherence, compliance becomes an issue. What do you feel helps with that?

Terri-Diann Pickering, MD: Part of the problem with adherence to glaucoma therapy is that for most patients, glaucoma is kind of a theoretical disease. They don’t have any pain, they still see 20/20, and you’re asking them to put something in their eye that burns and stings them and makes their eye red and is very expensive.

Also, there’s no way to know if they’re doing it correctly while they’re at home. If you think about blood pressure, it’s theoretical. Most people don’t know when their blood pressure is high, but they do have blood pressure cuffs that they can check at home. We don’t have that yet on a wide scale for mass production, mass use in glaucoma for people to check their eye pressure at home. It gets tricky to motivate, encourage patients to demonstrate that they’ve got to stick with their regimen. And the eyes are visible. I’ll have patients say, “Yes, the drops are working but my coworkers are asking me why are my eyes so red?” In San Francisco, people don’t ask. They assume you’re taking the other medicine for lowering eye pressure that we don’t prescribe but is out there. This is a very visual medication where your blood pressure medicine, your inhalers, people don’t know that you’re sick. When you take a lot of eye drops and your eyes are really red, or you get crazy long lashes, or the eye color changes, suddenly people are like what’s wrong. It’s tricky.

Neil Minkoff, MD: Anything to add to that, Dr Radcliffe?

Nathan Radcliffe, MD: I guess I would say that we see a few things. One is in the LiGHT trial, which was [a] prospective study comparing laser or drops. Patients had the same pressures in their eye for 3 years, but it was patients who had drops that were getting worse and the laser patients had stability. We assume that that’s a marker that patients take their drops the days before. It’s like brushing your teeth and flossing the night before you go to the dentist. And that’s problematic for us. It would be better if they just came in not taking the drop and fess up to it. But things being what they are, social pressure, whatever it is, we have a lot of patients getting worse who seem to have low pressures and seem to be compliant. That’s when you start to suspect noncompliance. No one likes to accuse a patient of lying to them about taking their drops, but that’s why you just tend to do better if you just try to keep it simple for them because you know that some patients aren’t going to be able to do it, and you aren’t going to be able to tell which ones they are.

Neil Minkoff, MD: The last question I’ll ask in this thread is what are the adverse events that you think are the ones that lead to the most discontinuations?

Nathan Radcliffe, MD: I would say hyperaemia is 1, 2, and 3. The new class, the rho kinase [rho-associated protein kinase inhibitor, or ROCK inhibitor] inhibitors have almost a 50% hyperaemia rate. Prostaglandin analogues, depending which molecule you use, are between 15% and 30%. Now, some patients will keep taking the drops and just have red eyes, as we were discussing. But, for patients with mild disease, it doesn’t seem appropriate to have very red eyes. There’s a whole other list.

Terri-Diann Pickering, MD: I would also add, I agree with you, redness is 1, 2, and 3. Chronic dryness, unfortunately, does develop over the long term and just pain, the stinging from the drops because they’re medicated. They’re not formulated to be lubricating,

Neil Minkoff, MD: One of the things that goes back to what we touched upon earlier that we do in population management is measuring persistence and/or adherence. Are either of you doing anything in the persistence or adherence management around glaucoma or eye drops?

Maria Lopes, MD, MS: I’ll go first. We typically do not. There’s no disease management specifically for glaucoma, and, in part, what drives that again are the quality measures. And just hearing Dr Pickering and Dr Radcliffe, this disease is so nuanced, that as I think about multi-drug combinations, what does goal even look like? What are we aiming for in terms of persistence, which is something called PDC [proportion of days covered]. It would be helpful to have something that [is] shared with clinicians, so that you know if you have an adherence problem as far as refills or an efficacy problem. Typically, in my experience, whether it’s on the PBM [pharmacy benefit managers] side or on the health plan side, this is not something that health plans are very focused on—ensuring adherence.

Kevin Stephens, Sr., MD: I agree 100% with Dr Lopes. We have very few arrows in our quiver to deal with this, and this is something that we can learn from this and to develop more sophisticated monitoring and management tools so that we can help a) predict who will have adherence problems and then just not predict it but then assist them so that we can overcome it. Because, as we said earlier, the burden as this disease progresses gets to be more progressive so it is certainly a quality-of-life issue that we should address.

Neil Minkoff, MD: The next question I would have for both Drs Pickering and Radcliffe are, have you ever been notified by a payor or a PBM that a patient has been noncompliant or hasn’t been doing their refills? How has that spurred action for you?

Terri-Diann Pickering, MD: Yes. There’s 1 or 2 plans, it’s not very often, that will send a note that my patient hasn’t filled their prescriptions in 2 or 3 months. Usually, I can recognize if I’ve given that person some samples just to try to keep them using the medication that’s typically a brand name and I know that they can’t afford the copay, we try to help them. If it’s not the case, then I’ll have my staff contact them and find out what’s going on. Sometimes that just triggers some adherence, and other times makes us realize that they’re using their friend’s cousin’s drops because they got switched to something else and they gave them some drops. People do not waste medication. People will share it, give it away, give it to church. Medicine is like gold. It doesn’t get wasted.

Nathan Radcliffe, MD: I would just add to that, if you look at my patients’ prescription histories, they’re often a mess. I will have prescribed 8 different medications. One of them had a side effect, 1 of them had a copay problem, we added another thing. And I find the tools in my EMR [electronic medical record] to even discontinue and reconcile medications aren’t built for glaucoma where things seem to be shifting all the time. Then, of course, you have sampling and sampling. If a patient has a high copay, it can really interfere with those perseverance, compliance records because it will make it look like there’s a gap in therapy that was just the patient saving money. I’m even skeptical with some of the literature showing a 0.6 mean possession ratio for glaucoma patients. I feel like most of them do better than that. They’re taking their drops but there’s so much going on, including all the things that Dr Pickering described. It’s complex.

Transcript edited for clarity.

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