ADAPTING TO NEW INTERNATIONAL TB TREATMENT STANDARDS WITH MEDICATION MONITORS AND DOT GIVEN SELECTIVELY

THOMAS MOULDING M.D.

Tropical Medicine and International Health Volume 12, No. 11, pp 1302-1308, November 2007 .
The definitive version is available in the journal or at www.blackwell-synergy.com

Summary:  In contrast to previous recommendations New International Standards no longer require directly observed therapy (DOT) for all TB patients, but state practitioners must be capable of assessing adherence and addressing poor adherence when it occurs. This removes much of the burden that DOT imposes on both patients and treatment delivery systems. However, the new recommendations may lead to treatment failures and drug resistance because consistent accurate assessment of adherence is at best problematic. Electronic medication monitors, devices that determine when medication is removed from a container may significantly help overcome this problem even in poor developing countries, if they were mass-produced to reduce cost. Both health facilities and community workers could dispense drugs for self-administered treatment (SAT) in medication monitors and retrieve the adherence record with inexpensive built-in displays. These devices could keep the adherence record from the beginning of therapy for managing patients who move. Pharmacists using medication monitors could provide surveillance of SAT prescribed by private physicians with less adherent patients referred to health departments. Health departments could oversee Family Member DOT with these devices. Less adherent patients could be managed with focused counseling, DOT when necessary, and extensions in treatment duration. Removal of the DOT burden would encourage patients to seek free high quality supervised pubic care and help expand effective TB treatment services.  If the resources saved by giving less DOT were focused on poorly adherent patients and defaulters, medication monitor based programs could create less acquired drug resistance than overwhelmed treatment programs that attempt but fail to give uninterrupted DOT to all patients.
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I. INTRODUCTION

II. THE SUCCESS AND PROBLEMS WITH DOT

III. RELIABLE PATIENTS - A POTENTIAL RESOURCE FOR REDUCING THE ADHERENCE PROBLEM

IV. DETERMINING THE ADHERENCE OF PATIENTS

V. EXPERIENCE WITH SELF ADMINISTERED TREATMENT GIVEN IN MEDICATION MONITORS (MONITORED SAT)

VI. PROPOSED SUPERVISION OF TREATMENT BASED ON MONITORED SAT AND DOT GIVEN SELECTIVELY

VII. USE OF MONITORED SAT TO IMPROVE TREATMENT OUTCOMES AND EXPAND SERVICES IN VARIOUS SETTINGS

VIII. CAN MEDICATION MONITORS HELP PREVENT DRUG RESISTANT DISEASE

IX) USE OF MEDICATION MONITORS WHEN MANAGING HIV/AIDS and HIV/AIDS/TB

X) EXPENSE AND PRACTICALITY OF USING MEDICATION MONITORS

XI. EVALUATION

XII. IN SUM

REFERENCES:

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