title: Variations in pill appearance of antiepileptic drugs and the risk of nonadherence.
abstract: BACKGROUND
  Generic prescription drugs are bioequivalent to brand-name versions but may not have consistent color or shape, which can cause confusion and lead to interruptions in medication use. We sought to determine whether switching among different-appearing antiepileptic drugs (AEDs) is associated with increased rates of medication nonpersistence, which can have serious medical, financial, and social consequences.
  
  
  METHODS
  We designed a nested case-control study of commercially insured patients in the United States who initiated an AED. Cases were patients who became nonpersistent, defined as failure to fill a prescription within 5 days of the elapsed days supplied. Controls had no delay in refilling and were matched by sex, age, number of refills, and the presence of a seizure disorder diagnosis. We evaluated the 2 refills preceding nonpersistence and determined whether pill color and/or shape matched ("concordant") or did not match ("discordant"). We compared the odds of discordance among cases and controls using multivariate conditional logistic regression, adjusting for baseline characteristics, and drug type. We repeated our analysis among patients with a seizure diagnosis.
  
  
  RESULTS
  The AEDs dispensed had 37 colors and 4 shapes. A total of 11,472 patients with nonpersistence were linked to 50,050 controls. Color discordance preceded 136 cases (1.20%) but only 480 controls (0.97%) (adjusted odds ratio [OR], 1.27 [95% CI, 1.04-1.55]). Shape discordance preceded 18 cases (0.16%) and 54 controls (0.11%) (OR, 1.47 [95% CI, 0.85-2.54]). Within the seizure disorder diagnosis subgroup, the risk of nonpersistence after changes in pill color was also significantly elevated (OR, 1.53 [95%, CI 1.07-2.18]).
  
  
  CONCLUSIONS
  Changes in pill color significantly increase the odds of nonpersistence; this may have important clinical implications. Our study supports a reconsideration of current regulatory policy that permits wide variation in the appearance of bioequivalent drugs.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA. akesselheim@partners.org
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Kesselheim
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Misono
authors.forename: William H
authors.initials: WH
authors.lastname: Shrank
authors.forename: Jeremy A
authors.initials: JA
authors.lastname: Greene
authors.forename: Michael
authors.initials: M
authors.lastname: Doherty
authors.forename: Jerry
authors.initials: J
authors.lastname: Avorn
authors.forename: Niteesh K
authors.initials: NK
authors.lastname: Choudhry
mesh_terms: D000328:Adult; D000927:Anticonvulsants / Q000008:administration & dosage / Q000592:standards*; D016022:Case-Control Studies; D003116:Color; D004304:Dosage Forms; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016903:Drug Monitoring
chemical_list: D000927:Anticonvulsants; D004304:Dosage Forms