There’s no doubt that many individuals struggle to adhere to their treatment regimens. It can be overwhelming for patients when they begin to take new medications and experience undesirable side effects. Research has shown that patient nonadherence towards medication for chronic diseases has reached approximately 50 percent.¹ In order to drive patients to adhere to their medications, physicians need to use all the resources and tools at their disposal to better educate, facilitate and motivate their patients.

There’s more than one reason why patients struggle to take their medication. In a study to understand the interventions needed to improve glaucoma medication adherence, Paula Anne Newman-Casey, MD, MS, an associate professor of ophthalmology and visual sciences at the University of Michigan, and her colleagues laid out the framework on how counseling and education can improve medication adherence. “We did a systematic literature review to discover what barriers glaucoma patients struggle with in terms of taking their medications, and we came up with eleven different reasons that seemed to be repeated with some frequency,” she says. “The different barriers patients identified in our study were not knowing the severity of glaucoma, not trusting in the benefits of the medication, side effects and forgetfulness, among others,” lists Dr. Newman-Casey.

“People mentioned issues with how difficult the medication’s schedule is sometimes, especially with midday doses,” Dr. Newman-Casey continues. “Some people have difficulty physically instilling the eye drop. They miss a lot, run out of medication early or a lot of it gets on the skin of their eye and it can irritate the skin and cause periocular skin maceration and breakdown. Also, people talked about not trusting their doctor, not trusting their doctor’s recommendations, or not trusting the health-care system and having trouble with accessing the health-care system or insufficient time and feedback from their doctor. 

“Obviously, medications are expensive, and a lot of the burden is on people over the age of 65 who are often on a limited and fixed income,” Dr. Newman-Casey continues. “So, their income isn’t going up as the price of drugs and copays go up. Another reason, which is a big one, is life stress. I think that’s magnified by your socioeconomic status because the less money you have, the more stressful and difficult life becomes.”

In her study, Dr. Newman-Casey surveyed glaucoma patients to understand which barriers patients struggled with the most, and her results led her to realize medication nonadherence couldn’t be easily fixed. “We surveyed around 180 people in two different practices, a private practice setting and an academic practice setting,” she says. “About 30 percent of people endorsed every single problem. I think motivation towards adherence can be complicated and you really have to discuss patients’ problems with them. Try to meet them halfway because there’s not really a magic bullet.”

Glaucoma medication nonadherence isn’t the only issue for ophthalmologists, but Dr. Newman-Casey’s study brings up a valid point in the realm of glaucoma treatments: eye drops are difficult for some people to instill. “It requires more dexterity because it’s a movement that’s outside the norm of what you’re used to doing (i.e. taking your pills with your coffee),” she says. “Sometimes people use a mirror to assist with their eye drops. Sometimes people like to instill them lying down. These are tactics that can be perceived as more of a nuisance than taking pills.”

For every barrier a patient must overcome, there are often ways clinicians can help guide them. “The first step that clinicians can take is normalizing the fact that taking chronic medications, in particular eye drops, isn’t easy,” says Dr. Newman-Casey. She explained how monitoring patients’ adherence can help a physician better assess and manage the patients who are struggling with their treatment plans. For example, in another study conducted by Dr. Newman-Casey, patients were asked, “Over the past month, what percentage of your drops do you think you took correctly?”² She says, “If patients responded that they took 85 percent or less of their medications, then they were at a high risk for poor medication adherence. Simply asking patients this screening question can help identify which patients need additional support for optimal glaucoma self-management.” 

Another way to assist patients is by providing them with support staff. Dr. Newman-Casey is currently conducting a randomized controlled clinical trial of the Support, Educate, Empower (SEE) program, a personalized glaucoma coaching program. The SEE program uses a care team model where health educators, trained as glaucoma coaches, work to provide additional support to patients who report poor glaucoma medication adherence. “The glaucoma coach is someone who’s been trained in motivational interviewing, which is a style of coaching that attempts to promote a person’s autonomy rather than telling them what to do,” she says. “The whole part of the motivational interviewing-based health coaching is trying to get people to identify their own problems and solutions. Additionally, the coach helps guide patients through their glaucoma diagnosis. They also have access to a software program that individualizes a glaucoma education program to help explain a patient’s test results and the doctor’s recommendations.” 

During a pilot study for the SEE program, a total of 48 participants with glaucoma were enrolled. Each participant received medication alerts, in-person coaching with personalized education sessions and between-visit phone calls with their coach. Researchers measured baseline adherence using an electronic medication monitoring system for three months. They reported that the baseline adherence started at 59.9 percent and improved to 81.3 percent by the end of the seven-month trial.³

Throughout the SEE trial period, glaucoma coaches met with participants for three counseling sessions, each lasting a different length of time. The first counseling session on average lasted 68.2 minutes, the second session on average lasted 27.9 minutes and the third session on average lasted 31.7 minutes. According to the study, the researchers hope their robust findings will shape clinical practice guidelines by promoting evidence-based models that will improve overall medication adherence and ultimately, visual outcomes.³ “We saw a huge increase in adherence just with electronic dosing reminders,” says Dr. Newman-Casey. “Then, a boost in adherence on top of that after the coaching session started, and that adherence was maintained throughout the study period when coaching was ongoing.”

Dr. Newman-Casey explained how an alarm system is very helpful but may not be the only necessary tool for all patients. “Over time, people get sick of alarms and reminders unless they’ve already made taking their medication into a habit,” she says. “It doesn’t always elicit the same behavioral response overtime.” She referenced the Medication Adherence in Glaucoma to Improve Care (MAGIC) study by Kelly Muir, MD, which was a randomized, controlled trial to test the efficacy of a comprehensive education-based intervention to improve medication adherence in glaucoma patients.⁴ “That’s a seminal trial in medication adherence interventions,” she explains. “[Dr. Muir] and her colleagues compared an educational intervention arm combined with dosing reminders to a control arm. Overtime, there was a 20-percentage point difference in adherence between the two arms, which is a remarkable effect. However, adherence in both arms went down over time even though the intervention arm continued to receive dosing reminders.” 

Rather than enforcing an alert system in their trial, the SEE program combines various components and enables patients to choose what might work best for them in terms of a dosing reminder. “Participants can elect to not have reminders, or they can elect to have multiple reminders,” says Dr. Newman-Casey. “We didn’t want to make that decision for people.”

Smart Devices

For patients who struggle with adherence and would prefer an alert system, there are many devices and applications that have been developed for these needs. 

Aidia can be set to alert caregivers about upcoming doses. They can receive text and/or phone reminders. (Courtesy AdhereTech)

• Aidia (AdhereTech). Smart pill bottles offer a simple solution to medication adherence for patients taking oral prescriptions. The Aidia system, from AdhereTech, is a smart pill bottle given to patients by their health-care provider. According to AdhereTech, the device is shipped to the patient’s pharmacy with their pre-set dosing schedule. An hour before a dose is scheduled, the device will light up blue at the base of the bottle. When it’s time for the patient to take their medication, the device will remind the patient with a gentle chime as well as a text or phone call alert. Once the patient opens the pill bottle, the alert will stop, and the device will reset its alarms for the next scheduled dose.

AdhereTech states that if a patient needs to edit their dosing schedule, then they must contact their pharmacy or an Aidia Specialist to assist them with their changes. The Aidia system may not come prefilled with a patient’s medication. Therefore, they must take their prescription and load it into the pill bottle themselves. Additionally, the device holds a charge for 10 months, but it can be recharged if needed. Patients shouldn’t get the device wet, allow it to overheat or clean it with chemical-based cleaners due to the sensitive electronic controls inside the device, so they need to keep the smart pill bottle in a safe and secure location.

Furthermore, AdhereTech offers the Aidia Smart Cap, a separate device compatible with standard pill bottles. Similar to the Aidia system, the Smart Cap is used to alert patients about their upcoming dose. According to AdhereTech, the Smart Cap is equipped with a blue button that provides information about previously scheduled doses, upcoming doses and battery life. The cap’s battery life lasts about two to three months, but it can be recharged easily. Both the Aidia system and Smart Cap are HIPAA-compliant products.

• ID-Cap System (etectRx). Imagine a pill that could be monitored after ingestion. EtectRx’s novel solution to medication nonadherence provides just that. According to etectRx, the ID-Capsule is a digital pill consisting of a pharmaceutical-grade capsule shell with an embedded ingestible sensor. When a capsule is consumed, the ID-Tag sends a low frequency signal to a portable device that must be on the patient when taking their medication. This device sends a message via Bluetooth to the ID-Cap Patient App. This app allows patients to view their medication history and set reminders and alerts for their next dose. 

This unique system helps clinicians monitor their patients. According to etectRx, the patient’s information stored in the Patient App gets uploaded to their clinician’s dashboard provided by etectRx. The dashboard allows physicians to monitor adherence and follow their patient’s schedule.

For patients worried about digesting the capsule, etectRx notes that the ID-Cap’s sensor is ultra-thin and flexible, allowing for it to pass naturally through the patient’s gastrointestinal tract. Additionally, the capsule is FDA-approved for addressing patient adherence to oral medications. 

• e-Novelia (Nemera). Glaucoma patients struggling to adhere to their eye drop medications may benefit from this device. E-Novelia is a smart ophthalmic add-on that facilitates the use of preservative-free multidose eye droppers. Nemera offers the Novelia eye droppers to work effectively with the e-Novelia. 

According to Nemera, patients can insert the eye dropper into the smart device, which will then provide the patient with a host of information to assist with adherence. The e-Novelia is equipped with a tile sensor and LED indications for positioning the device, a drug indicator to monitor the level of medication left in the eye dropper, and an electronic IFU, or information for use, to assist patients with using the device. Treatment history and compliance can all be monitored through a patient’s dashboard online. The e-Novelia will alert the patient when they need to instill another dose. 

The device is bulkier than the average eye dropper, but Nemera mentions that it was designed with an ergonomic eye cup to assist patients with the instillation process. The device is re-usable and rechargeable, so patients can continue using the device after every prescription refill. 

• Medisafe. There’s a whole host of medication adherence applications on the iTunes and Google Play stores. One in particular is Medisafe, the HIPAA-compliant medicine reminder app. According to Medisafe, users can create an account to manage their health or another patient’s health. The dashboard features will be slightly different depending on the user’s choice. 

Once logged into the app, users can set their medications or the medications of another patient. Medisafe states that it’s compatible with the Apple Health App, so if a patient is an Apple user, then they can upload their prescriptions from the Health app to Medisafe. Otherwise, Medisafe users will have to add their medications manually. The app offers the ability to set treatment duration, set refill reminders, add instructions and more.

Medisafe’s toolbar features user-friendly buttons to navigate through Home, Updates, Medications and More dashboards. The Home dashboard organizes the patient’s dosage schedule and allows the user to interact with their different medications. They can choose to skip, take or reschedule a dose and even edit or delete selected medications. The Updates dashboard provides the user with notifications about upcoming doses and changes to the Medisafe app. Next, the Medications dashboard allows the user to edit their medicines and access information about their medications, conditions and dosage reminders. Lastly, the More dashboard provides the option for patients to manage and organize their appointments, doctors and diagnosis reports. Medisafe offers a Health Tracker where the user can identify and measure their disease or illnesses by documenting symptoms as they progress. This is similar to the Diary feature which allows the user to document their medications and other notes. This application does include an extensive catalogue of ophthalmic medications.

• EyeDropAlarm. Also offered on iTunes and Google Play stores, Eye
DropAlarm is a free, ophthalmic-patient-centered medication reminder app. The app offers an extensive database of eye drops that can be selected or searched manually. 

EyeDropAlarm will alert the patient based on the treatment plan that they manually add to the app. According to EyeDropAlarm, eye specifications, start date, treatment length, frequency of dosage, taper drops and multiple alarms can be set for alerts. Patients can also change the alarm sound, snooze duration and gap between drops that are scheduled for the same time. 

For patients who are struggling with instilling their eye drops, EyeDropAlarm provides a guide on how to properly put in drops. Once the patient instills the drops, then they can open the app and check off which medications they took. Patients should remember to turn on notifications on their phone’s control panel whenever using a medication reminder app.

Between the number of smart devices and in-house counseling options, there’s no doubt that patient nonadherence can be effectively addressed. “I think, intrinsically, clinicians are motivated to do everything they can to preserve vision,” says Dr. Newman-Casey. “People who aren’t taking their medications are going to lose vision. That lies at the heart of the problem.” 

Dr. Colvard is a surgeon at the Colvard-Kandavel Eye Center in Los Angeles and a clinical professor of ophthalmology at the Keck School of Medicine of the University of Southern California. Dr. Charles is the founder of the Charles Retina Institute in Germantown, Tennessee.

Dr. Newman-Casey has no financial interests to disclose.

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^{2. Cho J, Niziol LM, Lee PP, et al. Comparison of medication adherence assessment tools to identify glaucoma medication nonadherence. Ophthalmol Glaucoma 2022;5:2:137:145.}

^{3. Newman-Casey PA, Niziol LM, Lee PP, et al. The impact of the Support, Educate, Empower Personalized Glaucoma Coaching pilot study on glaucoma medication adherence. Ophthalmol Glaucoma 2020;3:4:228:237.}

^{4. Rosdahl JA, Hein AM, Bosworth HB, et al. Randomized controlled trial of an education-based intervention to improve medication adherence: Design considerations in the medication adherence in glaucoma to improve care study. Clin Trials 2021;18:3:343:350.}