OBJECTIVES: To estimate the efficacy of app-based interventions designed to support medication adherence and investigate which behaviour change techniques (BCTs) used by the apps are associated with efficacy. DESIGN: Systematic review of randomised controlled trials (RCTs), with meta-analysis. SETTING: Medline/PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Embase and Web of Science were searched from 1990 to November 2018 for RCTs conducted in any healthcare setting. PARTICIPANTS: Studies of participants of any age taking prescribed medication for any health condition and for any duration. INTERVENTION: An app-based intervention delivered through a smartphone, tablet computer or personal digital assistant to help, support or advise about medication adherence. COMPARATOR: One of (1) usual care, (2) a control app which did not use any BCTs to improve medication adherence or (3) a non-app-based comparator. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the pooled effect size of changes in medication adherence. The secondary outcome was the association between BCTs used by the apps and the effect size. RESULTS: The initial search identified 13 259 citations. After title and abstract screening, full-text articles of 83 studies were screened for eligibility. Nine RCTs with 1159 recruited participants were included. The mean age of participants was >50 years in all but one study. Health conditions of target populations included cardiovascular disease, depression, Parkinson's disease, psoriasis and multimorbidity. The meta-analysis indicated that patients who use mobile apps to support them in taking medications are more likely to self-report adherence to medications (OR 2.120, 95% CI 1.635 to 2.747, n=988) than those in the comparator groups. Meta-regression of the BCTs did not reveal any significant associations with effect size. CONCLUSIONS: App-based medication adherence interventions may have a positive effect on patient adherence. Larger scale studies are required to further evaluate this effect, including long-term sustainability, and intervention and participant characteristics that are associated with efficacy and app usage. PROSPERO REGISTRATION NUMBER: PROSPERO Protocol Registration Number: CRD42017080150.