The Pharmaceutical Journal
Vol 271 No 7256 p14
5 July 2003

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Letters to the Editor

Compliance

Need to balance safety with compliance

From Dr C. F. Green, MRPharmS

I am awaiting with a little dismay, if my gut feeling is correct, the withdrawal of methotrexate 10mg tablets. I fully appreciate the background to the impending change and the reasons behind the move. However, I think if we, that is, the profession and the manufacturers had got it right the first time, in terms of product presentation and patient education, then we would not be talking about it now and patients would not have suffered. My main concern is about compliance and patient choice. For example, for patients taking 30mg of methotrexate, instead of taking three tablets they may soon have to take 12.

What about other medicines? We recently had a patient admitted with phenytoin toxicity. She had been prescribed 300mg nocte, for which her hospital discharge prescription was dispensed as 3 x 100mg capsules to be taken at night. Once these ran out, she got a new prescription from her general practitioner and 300mg capsules were dispensed. The patient popped the capsules out of the blister pack and into the bottle we had dispensed from the hospital and proceeded to take 3 x 300mg at night. When the patient came into hospital it looked like a dispensing error had been made, however, on full investigation, the confusion became apparent. Although 300mg capsules were dispensed in the community to aid compliance, we dispensed 100mg capsules as a risk management strategy because a decision was taken to remove 300mg capsules from our shelves following similar problems.

There are now rumblings that all patients may be given warfarin 1mg tablets instead of 3mg or 5mg tablets depending on their needs. For those patients on 10 to 15mg daily, two to three tablets daily now becomes 10 to 15. Where will this stop?

Although I think these are important decisions, we should not forget that such actions improve safety but have major implications for compliance and convenience. Where medicines are flat priced, there is also a potentially significant cost implication.

Patients should be appropriately counselled about their medicines, packaging should be clear and appropriate, and tablets and capsules should be colour coded and even shaped to ensure that patients notice a discernable difference between strengths. Adequate communication between primary and secondary care also needs to improve. Apparently, there is no legal obligation for manufacturers to follow packaging guidelines; this also needs to change.

Although we need to think of safety there will always be errors, no matter how hard we try to change things. We need to balance this safety conscious approach and make sure that patient compliance does not suffer as a result.

Chris Green
Assistant Director of Pharmacy, Clinical Services
Royal Liverpool and Broadgreen University Hospital,
Liverpool

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