Methotrexate intoxication: the Pharmaceutical Care process reveals a critical error.

WHAT IS KNOWN AND OBJECTIVES: Intoxication with oral low-dose methotrexate (MTX) is a well-known and frequent problem, which is often discovered accidently. The major reason is error in the frequency of dosing, mostly of daily instead of weekly intake. We report a case where the critical error was discovered by the community pharmacist during the routine implementation of the Pharmaceutical Care process SOAP while dispensing a new prescription for the patient. DETAILS OF THE CASE: A 78-year-old widow went to her regular community pharmacy to pick up a prescription for oral mucositis. The evaluation of the case by the pharmacist using the SOAP (an acronym for Subjective, Objective, Assessment and Plan) note method revealed the underlying oral low-dose MTX intoxication which led to hospitalization a few days later. The incorrect interpretation of the required dose had arisen from the written instructions for use and led to the erroneous intake of MTX daily (instead of weekly). We interviewed the patient at her home 2months after discharge. She explained that her continued intake of MTX in spite of manifest adverse effects was because of a profound conviction that she was doing right. Her confidence in physicians remained unchanged after the incident, but she would now refuse to take MTX. WHAT IS NEW AND CONCLUSION: The reasons for the intoxication were not discovered accidently but by the routine use of the Pharmaceutical Care process SOAP by the community pharmacist. We describe three main errors that might have been avoided and provide solutions for physicians, pharmacists, manufacturers and patients, to reduce such risks. Our case highlights the dangers of teleconsultation, the crucial role of Pharmaceutical Care provided by community pharmacists and the continued need to supply advice to patients being prescribed low-dose MTX. The fact that a patient has had a previous and successful experience with a similar treatment should not deter health professionals from verifying a patient's understanding via questions and feedback.

[Individualization of compliance]. / Individualisierung der Compliance.

Almost half of all prescribed drugs is taken by patients in an incorrect way, in a deficient way or not at all. Reasons for such an insufficient compliance behavior are multifaceted. In order to optimize patients' compliance, an individualized approach is necessary which requires both medical intervention and preventive measures. In the present article tools are described that may assist the physician in optimizing individual compliance. Such strategies are information, communication and verbal contract, treatment plan, auxiliary aids and follow-up appointments.

Overconsumption detected by electronic drug monitoring requires subtle interpretation.

BACKGROUND: Electronic compliance monitoring has provided new variables to describe drug intake behavior and new strategies to improve compliance. However, as evaluated in this study, the recording of opening events of pill bottles does not necessarily mean drug intake. METHODS: In an open 3-week trial with an oral vitamin combination, drug intake was recorded with use of an electronic pill box that contained 25 capsules and that registered each opening of the bottle. Thirty-seven patients were asked to take one capsule every morning for 21 days. Opening and closing events were related to the results of pill counts and patient interviews at the end of the trial. RESULTS: Drug consumption was 101.8% (663 recorded opening and closing events) in the 31 patients who completed the trial. Pill boxes were opened more than once by 10 patients on at least one monitored day. For seven patients the total number of openings was >25 (range, 26 to 29) and thus exceeded the number of capsules provided. A third interview of these patients revealed real overconsumption in only two patients. Six patients remembered that they had shown the device to relatives or friends or that they had checked to see whether they had closed the pill box well, thus turning a "curiosity event" into a drug intake event. CONCLUSION: In short-term studies particularly, such curiosity events may substantially modify the electronic assessment of compliance surrogates. In these trials the combined evaluation of electronic openings, pill counts, and interviews may be a suitable way to reveal such openings without pill intake.

[Conviction as a basis for compliance and strategies for improving compliance]. / Uberzeugung als Fundament der Compliance und Techniken zur Compliance-Optimierung.

The aim of the present study was to correlate statements made by 100 patients of an internal medicine ward regarding their compliance before hospitalization, with their personal knowledge of an convictions about their own pharmacotherapy. Data were collected in structured interviews of 9 questions carried out by a medical person not involved in current treatment. The patient sample (mean age +/- SE: 6.8 +/- 1.3 years) included 42 women and 58 men whose mean number of prescribed medications before hospitalization was 4.7 +/- o.22. Good treatment compliance was reported by 78% of the patients, while 13% admitted non- compliance. Knowledge about the drugs they had been prescribed ranged from perfect (30%) to none (34%) and was significantly different between compliers and non-compliers, with patients who know their medications at least by name being fairly compliant (p = 0.048). Independently of the statement about compliance, the patients used three main strategies to ensure regular intake of daily medication: visual aids (69%), coupling to a ritual (26%) or supervision by a third person (6%). Criteria such as gender, the number of prescribed medications, personal perseverance, or personal definition of the sense of the prescribed pharmacotherapy, or the arguments expected to be used by a physician when recommending a pharmacotherapy did not differ between compliers and non-compliers. Thus, compliance appears to have its roots mainly in the conviction level of each patient : intention will be transformed into action when deemed correct according to the individual's personal criteria. This may lead to both compliance and to non-compliance with medical recommendations. This study, which is based on patient reports, supports the conclusion that drug compliance may be enhanced by increasing patient's knowledge about their own pharmacotherapy and by having patients use specific strategies to guarantee regular daily intake of drugs. Prospective studies should therefore address the question of whether providing specific information according to a patient's convictions will untimately translate into improved compliance.