Glaucoma Medication Adherence

Educational Objectives

The goal of this program is to improve management of glaucoma medication adherence. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the types and reasons for poor glaucoma medication adherence.
2. Outline the impact of poor glaucoma medication adherence.

Summary

Epidemiology: the prevalence of glaucoma increases with age (40s, <2%; 80s, 8%-12%); in 2010, the prevalence of glaucoma was 61 million worldwide; glaucoma is the second leading cause of irreversible vision loss worldwide

Definitions: adherence — a quantifiable measure of how often a patient follows prescription instructions; compliance — whether a patient follows physician’s orders; persistence — duration of continuous use of a prescribed drug

Ways to measure adherence: include surveys, prescription refills, and electronic adherence monitors (EAMs); pharmacy claims data can only show whether medication was obtained; EAMs provide data on daily use and appropriate timing of the dosage; observation or videography can reveal whether the drug was instilled correctly into the eye; Kass et al (1986) found that patients self-reported 97% adherence, while EAMs indicated 76% adherence; refill data are retrospective

Levels of nonadherence: primary nonadherence (20%-40%) — patients never fill the prescription after diagnosis and often never return for follow-up care; secondary nonadherence (25%-85%) — patients refill the prescription, return for follow-up, but do not take drugs consistently; tertiary nonadherence (20%) — patients have difficulty instilling eye drops correctly

Patterns of medication adherence: Newman-Casey et al (2015) identified 5 adherence patterns after 4-yr follow-up in patients who were newly diagnosed with open-angle glaucoma; 16% of patients were never adherent, 23% had poor adherence (25% adherence), 9% had declining adherence, 37% had moderate adherence (50% adherence), and 15% had good adherence (≥75% adherence)

Medication persistence: Nordstrom et al (2005) found that <50% of newly diagnosed patients continued to take medications >1 yr, and persistence continued to decline; prostaglandin analogues had the best adherence

Social desirability: even though patients are not adherent, they want to appear adherent; adherence monitor may not provide an accurate picture of adherence

Eye-drop instillation: Stone et al (2009) found that, of patients who reported no difficulty, 20% could not instill eye drops; obstacles — include difficulty opening the bottle and inability to instill correctly into the eye; Weber et al (2024) evaluated hand function in patients with glaucoma >65 yr of age; patients with glaucoma had reduced pinch force and grip strength, longer completion times for the Grooved Pegboard Test, difficulty with safety pins, worse tactile acuity on monofilament test, and longer completion time in tactile assessment; patients with glaucoma may unknowingly limit their tasks, leading to declining hand function

Reasons for poor adherence: include learning about glaucoma only from the physician, not believing that poor adherence leads to vision loss, problems paying, forgetting when away from home, not acknowledging side effects, receiving samples, not receiving a phone call visit reminder, and belonging to a racial or ethnic minority group; Unni et al (2011) found that patients who “forgot” to take medications (socially acceptable) were more likely to have concerns about the medications; explore further if patients report forgetfulness; early refills — insurance companies deny early refills, and patients may not be able to afford extra medications; not all insurers refill at 21 days

Common barriers to adherence: include problems instilling eye drops, lack of knowledge, skepticism about vision loss and medication efficacy, stress, forgetfulness, side effects, cost, difficulty with the schedule, and lack of trust in physician; in a survey, ≤30% of patients reported all common barriers to be important; no single effective solution exists for resolving nonadherence

Impact of poor adherence: in the Early Manifest Glaucoma Trial (Leske et al [2007]), the hazard ratio for progression was 0.60 in treated patients compared with untreated patients; The United Kingdom Glaucoma Treatment Study (Garway-Heath et al [2015]) demonstrated a 56% decrease in glaucomatous progression in the treated group in 2 yr; glaucoma medication adherence is inversely related to glaucoma progression; in a cross-sectional study, Sleath et al (2011) reported a 7-fold increased odds of severe visual field (VF) loss with medication nonadherence (>80%); in a longitudinal study, Rossi et al (2011) found that patients with poor adherence had worse VF loss over time; Newman-Casey et al (2020) analyzed the medication arm of the Collaborative Initial Glaucoma Treatment Study and found a dose-response relationship between the medication dose and the extent of VF that was preserved

Cost-utility analysis: a conservative willingness-to-pay (WTP) threshold is $50,000 per quality-adjusted life year (QALY); the cost of adherence ($18,000-$29,000/QALY) is below the WTP threshold; for fast progressors, being adherent to medications dominates being nonadherent

Selective laser trabeculoplasty (SLT): the LiGHT trial (Gazzard et al [2023]) demonstrated that SLT is better at slowing glaucomatous progression than latanoprost; however, all patients cannot be treated with SLT, and SLT is not a cure-all

Engagement in care: patients who are not engaged in their care are more likely to be lost to follow-up (LTFU); Williams et al (2023) found that 33% of patients were LTFU (>1 yr); of those, 17% returned to care (of those, 50% had disease progression and others had complications)

Readings

Garway-Heath DF, Crabb DP, Bunce C, et al. Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial. Lancet. 2015;385(9975):1295-1304. doi:10.1016/S0140-6736(14)62111-5; Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: Six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-151. doi:10.1016/j.ophtha.2022.09.009; Kass MA, Gordon M, Meltzer DW. Can ophthalmologists correctly identify patients defaulting from pilocarpine therapy? Am J Ophthalmol. 1986;101(5):524-530. doi:10.1016/0002-9394(86)90940-2; Leske MC, Heijl A, Hyman L, et al. Predictors of long-term progression in the early manifest glaucoma trial. Ophthalmology. 2007;114(11):1965-1972. doi:10.1016/j.ophtha.2007.03.016; Newman-Casey PA, Blachley T, Lee PP, et al. Patterns of glaucoma medication adherence over four years of follow-up. Ophthalmology. 2015;122(10):2010-2021. doi:10.1016/j.ophtha.2015.06.039; Newman-Casey PA, Niziol LM, Gillespie BW, et al. The association between medication adherence and visual field progression in the Collaborative Initial Glaucoma Treatment Study. Ophthalmology. 2020;127(4):477-483. doi:10.1016/j.ophtha.2019.10.022; Newman-Casey PA, Robin AL, Blachley T, et al. The most common barriers to glaucoma medication adherence: a cross-sectional survey. Ophthalmology. 2015;122(7):1308-1316. doi:10.1016/j.ophtha.2015.03.026; Nordstrom BL, Friedman DS, Mozaffari E, et al. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140(4):598-606. doi:10.1016/j.ajo.2005.04.051; Rossi GCM, Pasinetti GM, Scudeller L, et al. Do adherence rates and glaucomatous visual field progression correlate? Eur J Ophthalmol. 2011;21(4):410-414. doi:10.5301/EJO.2010.6112; Sleath B, Blalock S, Covert D, et al. The relationship between glaucoma medication adherence, eye drop technique, and visual field defect severity. Ophthalmology. 2011;118(12):2398-2402. doi:10.1016/j.ophtha.2011.05.013; Stone JL, Robin AL, Novack GD, et al. An objective evaluation of eyedrop instillation in patients with glaucoma. Arch Ophthalmol. 2009;127(6):732-736. doi:10.1001/archophthalmol.2009.96; Unni EJ, Farris KB. Unintentional non-adherence and belief in medicines in older adults. Patient Educ Couns. 2011;83(2):265-268. doi:10.1016/j.pec.2010.05.006; Weber MK, Kabil GG, Niziol LM, et al. Eye drop instillation success and hand function in adults with glaucoma: a pilot study. Ophthalmology Glaucoma. 2024;0(0). doi:10.1016/j.ogla.2024.12.008; Williams AM, Schempf T, Liu PJ, et al. Loss to follow up among glaucoma patients at a tertiary eye center over 10 years: incidence, risk factors, and clinical outcomes. Ophthalmic Epidemiol. 2023;30(4):383-391. doi:10.1080/09286586.2022.2127787.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Newman-Casey was recorded at the 23rd Annual Downeast Ophthalmology Symposium, held September 27-29, 2024, in Bar Harbor, ME, and presented by The Maine Society of Eye Physicians and Surgeons, Manchester, ME. For more information about upcoming CME activities from this presenter, please visit https://maineeyemds.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

OP631004

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.