Detecting medication non-compliance: electronic devices or candid patients?

Although we all are aware that non-compliance is a problem in renal transplantation, the contributions in this forum emphasise that it is indeed a major problem, especially in the adolescent patient. The first paper in the forum is a systematic review of non-adherence or non-compliance in adult renal transplant recipients from the literature over a 21 year period between 1980 and 2001. Thirty six studies, made up of cross-sectional studies, cohort studies and case series were identified. These provide information suggesting that non-compliance occurs in around 22% of graft recipients, and results in a seven fold increased risk of graft failure. Nevins and Matas confirm that medication non-compliance leads to an increase of acute rejection, chronic rejection and graft loss. They discuss a very interesting study performed by one of the authors on the natural history of Azathioprine compliance after renal transplantation using electronic monitoring. They were able to show that recipients began missing drug doses early after transplantation, and indeed frequently during the first week after their discharge from hospital. Furthermore, half of all the patients studied showed evidence of non-compliance during at least one of the first six months after transplantation. Ettenger and his group at UCLA discuss non-compliance in the pediatric transplant population and point out that non-compliance in the adolescent transplant recipient is four times greater than in adults, and that this is responsible for the poorer five year graft survival of adolescent recipients of a renal transplant. They discuss the enormous problems of non-compliance in children with chronic disease as it is not confined to transplant recipients. They make firm suggestions as to how medication compliance can be improved in the pediatric recipient and especially the adolescent recipient. Chapman discusses the definition of non-compliance, accepting that it is an increasingly significant long term problem in transplantation as the failure rates from other causes have diminished. He discusses the various ways that the non-compliant behaviour can be diagnosed and feels that the only certain diagnosis comes from frank patient admission of non-adherence to the prescribed immunosuppression. However, the final paper by Butler and colleagues reports an interesting study which compares the measurement of adherence to drug regimens after renal transplantation using either self report or clinician rating and electronic monitoring. Adherence was measured using self-report questionnaires and interviews, clinician rating and cyclosporine levels. The sensitivity and specificity of these measures was then determined by comparison with electronic monitoring in a randomly selected subsample of the total group. They showed that measures of adherence do not perform well when tested against electronic monitoring. Although self reported confidential interview was the best measure of adherence especially with respect to detection of missed doses and erratic timing of doses, they did not feel that this was directly applicable to a clinical setting. Thus the problem is a major one and more effort needs to be put in to predicting non-compliant behaviour, diagnosing non-compliance and preventing non-compliance. This is particularly important in the adolescent patient but is also a significant factor in the adult recipient. Successfully tackling this problem would lead to marked reduction in graft loss and we feel that there is no more appropriate conclusion to this problem than the last sentence of the paper by Nevins and Matas: “What is more important, such improvements are available today and don’t require the development of a single new drug—rather they only require patients to consistently take the medications already available!” ONLINE LINKS www.uib.no/ipq www.aardex.ch www.concordance.org Access to these interactive links are free online. Note: The views expressed on these sites are independent and do not necessary reflect the opinions of the authors or Editors of this forum.