Compliance, or adherence, as it relates to health care is the extent to which a person's behavior coincides with medical or health advice. Medication compliance is critical for all aspects of pediatrics, specifically in successful treatment, disease prevention, and health promotion. Compliance depends on the patient's and physician's committing to the same objectives. It is unfortunate that numerous studies and physician accounts reveal difficulties in achieving compliance with pediatric medication therapy. Medication compliance in pediatric patients ranges from 11% to 93%. At least one third of all patients fail to complete relatively short-term treatment regimens. Poor compliance places children at risk for problems such as continued disease, complicates the physician-patient relationship, and prevents accurate assessment of the quality of care provided. This article presents the issue in the context of its incidence of and barriers to compliance and provides general principles to improve compliance in pediatrics by improving communication and characteristics of the practice setting. A one-on-one relationship between physician and patient is needed for communication and improved compliance.

How Do You Improve Compliance

Drug compliance in pediatrics. Clinical and research issues.

The calcium channel blockers (CCBs) are a diverse group of antihypertensive medications with variable pharmacokinetics and clinical effects. Although CCBs have been widely applied to the treatment of hypertensive children, data regarding the pharmacokinetics, efficacy and safety of these agents in children are extremely limited. In this review we briefly summarize the mechanism of action of CCBs and then summarize pertinent pharmacokinetic information on each of the CCBs commonly used in children, including amlodipine, diltiazem, felodipine, isradipine, intravenous nicardipine, nifedipine and verapamil. Clinically important drug interactions and adverse effects are discussed, as well as the potential role of CCBs in renal protection. Available pediatric efficacy and safety data are summarized, and recommendations made regarding the rational use of CCBs in the management of pediatric hypertension.

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Calcium channel blockers: pharmacology and place in therapy of pediatric hypertension

With the recent emphasis on investigating the efficacy of medication in children, it is also important to assess what determines whether pediatric patients do or do not take their medication. In general, children are no better at adhering to drug therapy than older individuals. Dealing with medication nonadherence is essential given its association with a failure to achieve the desired treatment goal. In addition to the many factors that influence adherence in adults, there are some unique challenges faced in the pediatric age group including the role of family (and its dysfunction), the changes of adolescence, and the lack of appropriate drug formulations. Intervention strategies to improve adherence include behavioral and educational strategies. Although there is no consensus as to what is the best approach to promote adherence with therapy, attention should be given to determining what barriers exist and trying to overcome them by involving children and their parents in the treatment planning process. If possible, the medication regimen, taking into account the frequency and timing of administration, should be tailored to the child and family's lifestyle and daily routine. Consideration should be given to the palatability and formulations of medications prescribed for young children. The use of simplified regimens of better tasting medications and age-appropriate delivery mechanisms may enhance the ability of pediatric patients to adhere to their drug therapy.

Current issues in pediatric medication adherence.

Essential hypertension in pediatric patients may require pharmacological treatment. There is a need for efficacious, safe, and well-tolerated antihypertensive agents with a once-a-day dosing regimen in children and adolescents. The aim of the trial was to evaluate the dose-response and tolerability of the dihydropyridine calcium channel blocker, felodipine extended-release tablets (felodipine ER), given once daily to pediatric patients with essential hypertension. A randomized double-blind, parallel-group, multi-center clinical study comparing felodipine ER (2.5, 5, or 10 mg once daily) and placebo was performed on pediatric patients with a baseline systolic (SBP) or diastolic blood pressure (DBP) above the 95th percentile for age, sex, and height. Of 133 randomized patients, 128 (96.2%) completed the 3 weeks of double-blind treatment. The study population included 50% children 6–12 years of age or Tanner stage ≤3, 39% black, and 40% female patients. All doses of felodipine ER and placebo decreased both SBP and DBP. The 5-mg dose of felodipine ER resulted in a significant decline in trough sitting, standing, and supine DBP (placebo-adjusted, −4.6, −5.06, and −5.05 mmHg, respectively, P<0.05) compared with placebo. However, there was no significant decline in SBP. The 2.5- and 10-mg doses showed no significant differences compared with placebo in lowering BP. The effect of felodipine ER was comparable in patient subgroups by age, race, and gender. The drug was well tolerated. The study failed to show a dose response of felodipine ER in pediatric patients with essential hypertension. This finding might be explained in part by the limitations of study design. The spectrum of side effects in pediatric patients was comparable with that in adults, except for a lower incidence of peripheral edema. Further studies are needed to clarify the role of felodipine ER in the management of children and adolescents with essential hypertension.

Clinical trial of extended-release felodipine in pediatric essential hypertension

In a crossover design, control of blood pressure by extended release felodipine was compared with control by prolonged action nifedipine in 21 children with renal hypertension. Compliance with once daily felodipine was higher than with nifedipine, at 95.6 (SEM 2.7)% v 78.9 (6.0)% (p = 0.02). Mean diastolic blood pressure was lower during the day with felodipine than with nifedipine, at 77.6 (2.4) v 84.4 (2.8) mm Hg (p = 0.05). Similarly, blood pressure load (the percentage of the day during which the child had blood pressure exceeding the upper limits of normal for age) was lower for felodipine than for nifedipine: 43.5 (5.5)% v 61.3 (6.3)%. There was an opposite trend during the night, though this did not reach statistical significance. These data suggest that once a day felodipine is effective in children with hypertension. This may be because of improved compliance.

https://adc.bmj.com/content/archdischild/73/2/154.full.pdf

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Papers

A crossover comparison of extended release felodipine with prolonged action nifedipine in hypertension.