Appropriate use of dose administration aids

Abstract

Dose administration aids can improve medicines management for some people. However, they have a number of limitations and are not suitable for all patients.

Patient assessment is required to identify factors contributing to non-adherence or medication errors. Strategies like simplifying the drug regimen, education and counselling, and a medicines reminder chart or alarm, should be considered before using a dose administration aid.

The patient’s preferences and attitude to medicine-taking, and their suitability for a dose administration aid, should also be explored.

When dose administration aids are packed by a third party such as a community pharmacy, interdisciplinary communication and teamwork, patient education, monitoring and regular medicines reconciliation and review are vital to minimise the risk of problems.

Introduction

Dose administration aids organise doses of tablets and capsules according to when they should be taken (Table 1). The devices may be filled by the patient, or by a third party such as a community pharmacy.

Dosing aids may improve medicines management for some people, but they are not without limitations and problems (Table 2)^1-13 and are not suitable for all patients. Careful patient selection and awareness of the limitations of dosing aids are vital for ensuring appropriate and safe use.

Table 2 The limitations of dose administration aids

The evidence for using dose administration aids

There have been few well-designed controlled trials evaluating the impact of dosing aids on medication adherence and clinical outcomes. Most studies have had methodological flaws (for example inadequate randomisation, short duration, high loss to follow-up, and variations in concurrent adherence strategies provided with the device).^14,15 Most trials have focused on a single health problem, for example hypertension, limiting their generalisability to typical users of dose administration aids (older people with multiple comorbidities).

A recent Cochrane review¹⁵ pooled data from several studies (none focusing on older people) and found that dose administration aids modestly increased the percentage of pills taken (mean difference of 11%, 95% confidence interval 6–17%). Meta-analyses of studies that focused on patients with hypertension or diabetes suggested some improvements in diastolic blood pressure and HbA1c in users of dose administration aids, but with low certainty.¹⁵ Only one small study focusing on older people met the criteria for inclusion. This study reported a non-significant effect on the mean number of missed doses and clinical outcomes.¹⁶

The UK National Institute for Health and Clinical Excellence reviewed the use of dosing aids. It concluded that the evidence for their benefits was not strong enough to recommend widespread use and they should only be used to overcome practical problems if there is a specific need.¹⁷

There has been limited evaluation of sachet dosing aids and automated medication dispensing devices.¹⁵ A qualitative study of Danish patients using a sachet system found that it did not eliminate non-adherence, especially conscious non-adherence, or stockpiling of medicines in the home.¹⁸ A large, non-randomised, retrospective cohort study in the USA reported that a sachet dosing system combined with regular telephone follow-up improved medication refill adherence, but did not reduce health service use or costs in a middle-aged population with multiple comorbidities.¹⁹ Two low quality studies reported that automated dispensing devices led to fewer missed doses compared with manually operated dosing aids,^16,20 but the differences were unlikely to be clinically important.

Few trials on dose administration aids have been conducted in Australia. However, unpublished Australian studies and clinical experience suggest that dosing aids provided as part of a medicines management service by community pharmacies may benefit appropriately selected patients (Box 1).^5,10,21 These studies have led to government-subsidised dosing aid programs in Australia and professional practice standards to support this service.³

When should a dose administration aid be considered?

Australian guidelines recommend that dispensed medicines should be retained in their original packaging unless a dose administration aid could help to overcome specific problems.⁴ Practical aids or strategies such as simplifying the regimen, reminder charts, calendars and alarms should be considered before trying a dosing aid filled by a third party.^1,17,22 Assessing the patient is vital to identify the type of medicines management problem and whether it is likely to be resolved by using a dosing aid.

A dose administration aid may be considered when a person is struggling to manage a complex medicine regimen that cannot be simplified and primarily consists of regularly scheduled, solid oral dose forms that are suitable for packing. They may also be considered for a person who sometimes forgets whether or not they have taken their medicines (leading to risk of double dosing) and requires a visual cue, or a patient whose medicine-taking is being monitored by a carer. Ideally the medicine regimen should be stable and unlikely to change frequently.

Dosing aids are most effective in people who are motivated and willing to take their medicines and possess adequate vision, cognition and dexterity to use the device. Although they may be helpful in people with mild cognitive impairment, there has to be an adequate level of cognition. For example, the patient needs to be able to understand how to use the device, orientated to the day and time, and be able to remember when medicines need to be taken or respond to a reminder.

Dose administration aids are not effective for addressing deliberate non-adherence, poor motivation and errors due to more severe cognitive impairment.

What do patients think of dose administration aids?

Studies assessing patients' opinions report that some users like the fact that the device simplifies their medicine-taking and reduces stress associated with managing multiple medicines.^2,5,18,23 Other users prefer to manage their medicines from original packs or experience difficulties using the devices.^{2,5,6,8,15,18} Some users feel that the decision to issue a dose administration aid reflects a paternalistic or ageist attitude by health professionals.² A small study assessing user acceptability of several automated dispensing and reminder devices found that most patients would be unlikely to want to use one.²⁴ Cost and the need for technical support are also barriers to their use.^20,24

Inappropriate use

Dosing aids are sometimes used by patients who could potentially manage their medicines from original packs with appropriately targeted information, counselling and simple adherence strategies or aids, and would prefer to do so.^1,2,5,6,8,18 In these circumstances, using a dose administration aid may lead to unnecessary patient disempowerment and de-skilling.^2,5,6,8

Often other strategies to improve medicine-taking are not tried before implementing a dosing aid.^1,8,25 Patient suitability is not always assessed,^5,6,8,26 and initiation and subsequent choice of device sometimes focuses on the needs of health professionals and carers rather than the patient.^8,18,25

Results of a recent NPS MedicineWise hypothetical case study for health professionals suggested that there are misunderstandings about when it is appropriate to use a dose administration aid. In response to the case, 77% of GPs and 76% of pharmacists recommended a dose administration aid for a 65-year-old woman with heart failure despite the fact that her non-adherence appeared to be a result of uncertainty about why she needed to take the medicines rather than her inability to manage them.²⁷ Providing information and education to the patient was suggested by only 44% of GPs and 62% of pharmacists. Practical aids or strategies – for example reminder charts, alarms, placing medicines in a prominent place, simplifying dose times or linking them to meals – were recommended by just 21% of GPs and 27% of pharmacists.²⁷

The suitability of medicines

Despite the widespread use of dosing devices, there are few data regarding the stability (and therefore efficacy and safety) of medicines during packing and storage.^3,28 Some medicines may not be suitable for use in a dosing aid (see Box 2)^3,4,28,29 or may have reduced shelf-life when re-packed (for example thyroxine is only stable for 14 days in a sealed, light protected dosing aid stored below 25^o C). In warm and humid climates, stability of medicines in dosing aids may be further reduced.

Avoiding problems with dose administration aids

The risk of problems with dose administration aids may be minimised in a number of ways.^3,4,28 These are best achieved through active collaboration between the general practitioner, pharmacist and patient or carer:

assess the patient's suitability (see Box 3)

consider whether the potential benefits outweigh the potential problems (Table 2)

determine the most suitable type of device in consultation with the patient, and provide education and counselling about its use

provide education and counselling about the medicines packed in the device, including a printed medicine list*, preferably with images of the medicines

document the patient's current medicine regimen, type of device, which medicines are to be packed, packing interval and harm–benefit assessment. This document should be shared between the packing pharmacy, prescriber(s), the patient (and their carer if applicable), and updated whenever there are changes to the medicines or packing arrangements³

put in place a system to ensure good reciprocal communication between prescriber(s), the packing pharmacy and the patient or carer to ensure medicine changes are implemented accurately and in a timely fashion

consider delaying non-urgent medication changes until the next packing cycle to minimise wastage and costs

avoid prescribing medicines that are not suitable for packing in a dosing aid

ensure the device is packed as close as possible to the date that it will be used, and protect from direct light and heat during storage and use to minimise risks of drug degradation

provide regular patient follow-up and monitoring to ensure that the patient is successfully managing the device and that it has addressed their medication management problem. Make sure that better adherence has not led to increased adverse effects, and that ongoing information and education needs are met

conduct regular medication reconciliation to ensure that the medicines packed in the device match the prescriber's intended regimen.

A Home Medicines Review can help to identify factors contributing to medication errors or nonadherence, and assess the patient's suitability for a dose administration aid or other strategies to improve medicines management. A pharmacy MedsCheck^† or Home Medicines Review can also provide education and medication reconciliation for users.

Conclusion

Dose administration aids are not a panacea for all medicines management problems. They only benefit appropriately selected patients when a specific medicines management problem has been identified and less complex adherence strategies have been tried. In such patients a dosing aid, as part of a coordinated multidisciplinary approach to medicines management, may support the person to remain independent with medicine-taking and reduce the risk of medication administration errors. Healthcare providers need to be aware of the benefits and limitations of dosing aids, and carefully assess patients to determine whether potential benefits outweigh risks and costs.

^* www.nps.org.au/conditions-and-topics/topics/how-to-be-medicinewise/managing-your-medicines/medicines-list

^† http://5cpa.com.au/programs/medication-management-initiatives/medscheck-diabetes-medscheck/

Conflict of interest: none declared