On The Perils of Pill-Boxes...

Despite the rather arresting title, anyone expecting an exciting cautionary tale about the dangers of World War 2 fortifications and over-adventurous offspring will, I’m afraid, be disappointed....

The Pill-boxes I refer to are those clever little inventions many of us now use to ensure we remember to take our medications at the right time on the right day.

Younger readers might think this is a task that should be easy enough for anyone of sound mind; they may even scoff at the need for anything to aid in something so pedestrian, given their only medication they ever need is the occasional paracetamol or ibuprofen for a headache.

What we need to remember, though, is that the average age of our UK population is increasing rapidly, and its general health is continuing to decline in the face of a failing health service which is forced to ration its care by availability, poor diet and a sedentary lifestyle. 

As a result, more and more people are being prescribed medication to keep them alive and out of hospital for a bit longer, and go some way to maintaining their quality of life…. this doesn’t just apply to the elderly – the working age population is also becoming progressively more and more dependent on pharmaceutical aid of one sort or another, with many now permanently signed-off work sick. Rest assured, the ageing process happens to all of us (if we survive long enough!) and short term memory normally declines steadily into the bargain.

The invention of the weekly pill-dispenser (see Figure 1for a typical and well-used example) was a simple but ingenious way of helping with the problem of ‘dose non-compliance’, as the medics would put it. Even if you’re only taking a single daily dose of a prescribed medication, the very fact that you do it every day, and usually under the same circumstances, makes it challenging enough to remember whether you’ve actually done it that particular day or not. (How many of us have had to cut short our journey to work because we can’t remember whether we switched off the gas, or indeed locked the back door, before we left ?).

This ‘déjà vu conundrum', as I call it, becomes much more acute if you’re prescribed 3 or more separate drugs, some of which may need to be dosed twice or more per day and at different times. Almost an impossibility to keep proper track of for anyone with a ‘normal’memory, let alone for someone in their 80s or 90s living alone and with mild to moderate cognitive impairment…

Thus I would contend that the common-or-garden pill box was, and still is, an example of an ‘SB’ product, and is a real boon for many. However, it can have hidden snags, as we’ll see shortly, and these can actually cause harm if they continue unnoticed.

But what can possibly go wrong with something so simple ? I hear you ask. The problem lies in the fact that, although the compartments usually do have protective lids, the individual enclosures designed to hold each dose of your medication(s) are not airtight. Why is this an issue ?

Most medications nowadays are supplied in ‘blister’ packs, rather than bottles as in ‘days of old’. There is a good reason for this. Some drugs are actually hygroscopic (i.e. attract water), and even those that aren’t can be susceptible to water damage caused by the ‘filler’. This is the substance which manufacturers use to turn what is normally only a few milligrams of the active substance into a manageable tablet which can weigh as much as several grams. These fillers often absorb water themselves in damp environments, and in doing so generate an acidic environment which in turn can promote degradation of the drug product.

Blister packs are designed to be airtight, such that there is no risk of moist external air being allowed to make contact with the tablet during storage. Once the blister is opened, however, the tablet or capsule is immediately exposed to the outside air, where it can sit waiting to be consumed for up to a week in your pill-box. Normally in a centrally heated home in the winter the moisture content (i.e. humidity) of the air is relatively low (generally in the ‘comfort’ zone of 40-60%. It may even go lower than this if the heating is turned up high and there are no humidifier trays on the radiators.)

In present day UK, however, a warm house throughout the winter has sadly become an unattainable luxury for many, due to our ill-adapted housing stock, the excessively high cost of electricity and gas and the high cost of living generally. The result of this is that many lower-income households are forced to choose between ‘heating and eating’, at least to some extent during the winter months. Single pensioner households are particularly at risk here, with the UK’s meagre pension provision (still one of the lowest in Europe) and the removal for many of the winter Fuel Payment in 2024-5. Many pensioners were brought up in the 50s and 60s, with thrift as a way of life, and realise that they will receive little if any help with their residential care costs (currently ca £5000/month on average) from the state at the end of their lives. They therefore feel obliged for the sake of their relatives to save every penny they can to avoid losing their funds, and their house if they have one, before they pass on. What this means is that their living accommodation will often be significantly colder, often to the detriment of their respiratory health.

It's a physical fact that cold air holds less water (air at 5oC can hold ca 3.5 times less water than air at 25oC), and thus has a tendency to release its moisture as condensation, and promote the growth of mould. This happens particularly if ventilation is poor, due to attempts of the householder to conserve what little heat there is by keeping widows and doors firmly shut at all times. Under these conditions, humidities can then easily remain in the range 90-100%, especially in prone areas like un-heated bedrooms, and in kitchen areas due to the moisture generated by the cooking process. 

If tablet medications are stored in pill boxes under such conditions, they are likely to take on water and may be rendered much less effective if the tablet contents undergo significant chemical degradation as a result. This can in turn have serious health effects, and even missed diagnoses, if the problem isn’t spotted by a busy GP.

A good example of this effect in action is Bisoprolol, a commonly prescribed cardio-selective beta-blocker regularly prescribed by GPs to treat cardiac arrhythmias. This generic and highly effective drug is normally prescribed in 5 or 10 mg tablet form as the fumarate salt with a binder containing phosphates and supplied in blister packs as individual scored tablets weighing ca 0.5g. The drug itself is hygroscopic; the phosphate-containing filler that makes up the majority of the tablet’s bulk, will also absorb water in high humidity conditions and becomes acidic as a result, hastening the degradation of the active drug (only ca 1/50 of the tablet’s weight). This change may not be apparent to the user until the tablet starts to crumble visibly (see Figure 2 for a 7-day stored example), by which time the tablet is unusable and should not be taken.

Bisoprolol is by no means the only drug that behaves in this way, and phosphate fillers are commonly used in tablet formulations. Thus any drug could potentially be adversely affected by damp conditions, thus reducing its effectiveness significantly. A remedy is clearly necessary, but preferably one which solves the problem without re-instating the original one (i.e. how to avoid forgetting to take your medicine in the first place!)

The simplest solution by far (as you may well have guesed for yourself by now) is to retain the pill dispenser, but leave the individual tablets in their blister packaging (Figure 3). You can do this by cutting out the individual tablets from the pack, taking care not to puncture the tablet’s foil enclosure. Most pill boxes have compartments large enough to accommodate at least two or three of these cut-outs. The only problem with this strategy comes when it’s necessary to split tablets to get the right dose – the best way of avoiding this is to request a smaller or larger tablet size which accommodates your dosing requirement without the need to split tablets. You’ll thus retain the all-important ‘aide memoire’ function of the pill box while ensuring your tablets don’t degrade as a result of damp conditions. Some with poor eyesight and/or manual deterity may need help with this, but by and large, with a bit of extra effort...it works.

The ideal solution, of course, which would tackle the ‘root cause’ of the problem, would be to ensure that all our pensioners are entitled to, and get, a warm home in their final years without the need to eating into their residential care emergency funds…not a lot to ask, most would  agree, after a lifetime of contributions to society (and NI!). 

Sadly, I suspect that, under this government at least, that’s just not going to happen…

First published 18.2.26

Figure 1: A typical 7-day, 4-Dose Matrix Pill Dispenser

 Figure 2: Degradation in Action - The 'Remains' of a 7-day stored Bisporolol 10 mg tablet

Figure 3: A Possible Remedy...Keep the Blister !