Rudd P
Department of Medicine, Stanford University Medical Center, California 94305-5475.
J Cardiovasc Pharmacol. 1993;22 Suppl A:S1-5.
Modern therapeutics unavoidably requires integration of a patient's medication-taking behavior in assessing the clinical response to treatment. Automatic escalation of the drug regimen whenever the treatment goal is not achieved carries major risks and should be discouraged. Medication-taking behavior, when studied carefully by dynamic measures like electronic monitors, displays marked inter- and intra-subject variability over time. Most deviations from the prescription are underdosings and occur randomly, rather than consistently or systematically. Such deviations are frequent, difficult to detect by traditional measures, and hard to predict from common baseline characteristics. Compliance tends to fall as dosing frequency rises above once daily. Better measures of medication-taking behavior permit evaluation of both adverse drug reactions and secondary resistance to therapy as resulting from pill taking itself. Negative consequences of partial compliance among hypertensive patients include marked increases in rates of rehospitalization and rates of coronary events. One alternative strategy to labor-intensive interventions for improving compliance is to develop longer-acting medications, which compensate in part for lapses in dosing frequency. Such a strategy reflects a search for therapeutic sufficiency rather than a rigid concordance between the prescription and medication-taking behavior.
现代治疗方法不可避免地需要在评估治疗的临床反应时综合考虑患者的用药行为。每当治疗目标未达成时就自动增加药物剂量会带来重大风险，应予以避免。当通过电子监测器等动态手段仔细研究用药行为时，会发现受试者之间和受试者内部在不同时间存在显著差异。大多数与处方的偏差是剂量不足，且是随机发生的，而非持续或系统性的。此类偏差很常见，传统方法难以检测，也很难根据常见的基线特征进行预测。当给药频率超过每日一次时，依从性往往会下降。更好地衡量用药行为有助于评估药物不良反应以及服药本身导致的继发性治疗抵抗。高血压患者部分依从性的负面后果包括再住院率和冠状动脉事件发生率显著增加。相较于为提高依从性而进行的劳动密集型干预措施，另一种策略是开发长效药物，这在一定程度上弥补了给药频率的不足。这种策略反映的是对治疗充分性的追求，而非处方与用药行为之间的严格一致性。
