Medication adherence and formulation challenges — branching viva

Opening (warm-up)

Examiner: "You are the general paediatric registrar in the transplant clinic. A six-year-old renal transplant recipient has had erratic tacrolimus levels for three months despite a correct weight-based dose. I've just asked the mother how he takes it, and she tells me he spits out the bitter liquid and the half-tablets crumble. Reframe this for me — is this a pharmacology problem?" ^[2]

Model answer: No — this is a formulation-and-adherence problem wearing a pharmacology disguise. The dose is correct but the child cannot take the formulation he has been given, so the level bounces. Before I touch the dose I would treat the erratic level as adherence-until-proven-otherwise, ask openly how he actually takes the medicine, and fix the formulation. Adherence is a property of the prescribing, not of the child. ^{[1] [2]}