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For patients given treatment for self administration
at home, there is inherent problem of regularity of intake of drugs
particularly if the treatment is long term. It is a common observation
that patients with myxoedema, auricular fibrillation, or epilepsy
even when their malady is under control are not completely regular.
It is just that they take sufficient number of doses of the medicine
for successful control of their disease. In leprosy, self administration
is rarely relied upon and some form of supervised administration
of Diaminodiphenylsulphone (DDS) is devised. This phenomenon is
observed even with short term treatment with acute diseases. In
1955, Mohler et al., reported that 32% of 217 patients took less
than prescribed doses of one week oral penicillin course for treatment
of acute pharyngitis/otitis media. Turning from treatment to prophylaxis,
reference may be made to rheumatic fever. WHO expert committee in
1957, stated that unless physician take continuous responsibility,
the patient and his family are motivated to take drugs regularly
and continuous medical surveillance is done by Public Health Services,
the prophylaxis cannot be given successfully. The difficulty in
keeping persons who adopt small family norms to observe contraceptive
measures is well known. It therefore seems likely from experience
in other fields that self administration of drugs may present some
problems in TB also.
Experience in Pulmonary TB: Although the effective
drug regimen for treatment of TB on mass scale is mandatory, the
regularity with which patients will self administer the anti TB
drugs for long time is also of fundamental importance. Some amount
of information obtained on self administration of anti TB drugs
at home from an on going study on Home Vs Sanitorium treatment
at Tuberculosis Chemotherapy Centre, Madras (Bull WHO 1959, 21,
51-144) is presented here. This will be useful in indicating the
problems of self administration of drugs in TB. The regimen used
in the study is 12PH (PAS & Isoniazid for 1 year) six to seven
cachets (each cachet containing 1.25 gm PAS & 25 mg of Isoniazid)
according to body weight. Once a week the patient collects supply
of drugs from the centre. They are motivated along with their family
about the importance of regularity for the total duration of one
year and informed that early disappearance of symptoms may not be
considered as cured. Home visits by the field staff are made once
a week in the initial 2 months & later on fortnightly basis
to collect urine for ferric chloride test for presence of PAS, sputum
for culture & sensitivity for Mycobacterium TB (M.tb) and counting
of stock of cachets. Some of the visits made are unexpected. The
patients are assessed clinically, radiographically and bacteriologically
every month.
Preliminary analysis of urine for the presence
of PAS was made in a group of 79 patients on home and 81 on sanitorium
series. Of the 79 patients on home, 58 patients who completed one
year of treatment, 20% gave at least one test negative in the first
six months, 14% in the later six months & 9% of the remaining
21 recently admitted patients. In the sanatorium group, 58 of the
81 patients who completed one year of treatment, 4% gave negative
results during first six months of treatment and only 0.6% during
the second six months. Thus showing the irregularity is high during
first six months and the problem of missed treatment is peculiar
to the group treated at home, where the patients are not under direct
observation. Rregularity by counting cachets is not accurate as
the drugs can be sold, given or thrown away; it is best reliable
during unexpected visits & can be only complimentary to urine
testing. During interviews, reasons for omitting doses were never
forthcoming & were obtained by deep probing and suggestions.
Thus the questioning indicated the reasons for failure of drug intake
as follows: i) Very few patients have minor side effects. ii) Some
are unable to satisfy hunger & some attribute-unassociated complaints
to the medicine. iii) Few are irregular due to religious reasons.
iv) A large group of patients have no explanations, and apparently
fail to take their medicine due to forgetfulness or through indolence.
In this last group of patients unless the irregularities had been
specially looked for, their occurrence would not have been suspected
as great majority of them keep up the social side of the relationship
with the clinic and attend regularly.
Unfortunately very little is known of the motives,
which impel a patient to take medicine and the best way to get him
to do so. In essence, in order to make a patient to take medicine
regularly morning and night for a year it is necessary to establish
a new pattern of behaviour; and this many of the patients find difficult.
If the irregularity in self medication is small and does not influence
the outcome it does not matter but if the evidence suggest that
the irregularity carries serious consequences then i) Find a way
to make patient regular in taking their medicine. ii) To alter our
out look on the ideal form of home treatment. iii) To study regimen
given daily or intermittently under direct observation.
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