Treatment adherence to disease-modifying antirheumatic drugs in patients with rheumatoid arthritis and systemic lupus erythematosus

High Degree of Nonadherence to Disease-modifying Antirheumatic Drugs in Patients with Rheumatoid Arthritis

Objective.

To test medication adherence using the Compliance-Questionnaire-Rheumatology (CQR).

Methods.

Invitation letter and CQR were sent to 240 patients with rheumatoid arthritis. Followup CQR was sent 3 months later. Adherence was evaluated using CQR 80% cutoff scores.

Results.

Seventy-eight patients who were being treated with disease-modifying antirheumatic drugs provided full information on the CQR at both points in time. Eleven patients (14.1%) were classified as adherent based on taking compliance (TC), with only 3 patients (3.8%) adherent in regard to correct dosing (CD) [followup: 13 (16.7%) and 3 (3.8%) for TC and CD, respectively]. Nonadherence was not related to disease activity or side effects.

Conclusion.

We demonstrated low adherence, suggesting differences between doctors’ records and patients’ practice of antirheumatic drug therapy.

Facilitators and barriers to adherence in the initiation phase of Disease-modifying Antirheumatic Drug (DMARD) use in patients with arthritis who recently started their first DMARD treatment

OBJECTIVE

To explore themes associated with adherence in the initiation phase for first-time use of disease-modifying antirheumatic drugs (DMARD) in patients with inflammatory arthritis using focus groups and individual interviews.

METHODS

Thirty-three patients were interviewed in focus groups and individual interviews. Interviews were transcribed verbatim and imported into ATLAS.ti software (Scientific Software Development GmbH). Responses that included reasons for adherence or nonadherence in the initiation phase were extracted and coded by 2 coders separately. The 2 coders conferred until consensus on the codes was achieved. Codes were classified into overarching themes.

RESULTS

Five themes emerged: (1) symptom severity, (2) experiences with medication, (3) perceptions about medication and the illness, (4) information about medication, and (5) communication style and trust in the rheumatologist.

CONCLUSION

Perceptions about medication and the communication style with, and trust in, the rheumatologist were mentioned the most in relation to starting DMARD. The rheumatologist plays a crucial role in influencing adherence behavior by addressing perceptions about medication, providing information, and establishing trust in the treatment plan.

Individual patient monitoring in daily clinical practice: a critical evaluation of minimal important change

PURPOSE

In daily practice, physicians translate knowledge from clinical trials to practice, to improve health in individual patients. To help interpret meaningful change on disease outcome measures, the concept of minimal important change (MIC) was conceived. The objective of this study was to investigate whether MIC values are suited for individual patient monitoring.

METHODS

Three main elements of the MIC concept were evaluated: (1) MIC values for improvement and deterioration were determined, and the amount of misclassification present in quantifying minimal change was analyzed. (2) Discordance between change categories (improved, unchanged, deteriorated), defined by the MIC values, and patients' satisfaction with their health was inspected. (3) Discordance between change categories, defined by MIC values, and patients' willingness to alter therapy was inspected.

RESULTS

MIC value analysis was based on 469 patients with RA seen in daily practice. The chance of falsely classifying health change of an individual patient was high (false-positive range 19-30 % and false-negative range 43-72 %). Of patients classified as improved, 24 % were not satisfied with their health and 69 % were not willing to change therapy. Of patients classified as deteriorated, 54 % were satisfied with their health and 57 % were not willing to change therapy.

CONCLUSIONS

The misclassification in the quantification of change and high proportions of discordance between change categories defined by MIC cutoff values and patients' satisfaction and willingness to alter therapy indicate that MIC values as such are not suited for individual patient monitoring.

Lupus nephritis flare in young patients: relapse or nonadherence to treatment?

Purpose

Adherence is a challenging issue in the treatment of systemic lupus erythematosus. Nonadherence has been widely addressed in patients with lupus and must be detected quickly to prevent severe complications. The cases we present illustrate the importance of adherence in young adults.

Case 1

A 23-year-old Spanish woman diagnosed with severe lupus nephritis 8 years previously achieved renal remission after immunosuppressive treatment with corticosteroids and cyclophosphamide. Three years later, she developed a renal flare. Her treatment was intensified, and rituximab and mycophenolate mofetil were added. One year later, she was readmitted for a new renal flare. A blood test revealed no detectable levels of mycophenolic acid, and the patient admitted she had not taken her treatment correctly. Treatment was resumed. Four years later, the patient remains in remission.

Case 2

A 19-year-old Spanish woman was diagnosed with nephrotic syndrome due to lupus nephritis. She achieved complete remission after treatment with corticosteroids and cyclophosphamide followed by mycophenolate mofetil. Two years later, she developed a severe renal relapse that was treated with corticosteroids, cyclophosphamide, and rituximab. The response to treatment was good. Mycophenolic acid was undetectable in blood. The patient admitted that she had often missed doses before this relapse. The renal response has been maintained since she resumed her previous medications 2 years ago.

Conclusion

We conclude that the frequent and severe relapses of lupus nephritis observed in young patients may actually be due to nonadherence rather than to refractory disease. Our cases are typical examples of nonadherence that were discovered after a detailed interview with the patients and their families. We emphasize the need for clinical suspicion of nonadherence when caring for young adults with lupus.

Utilization and adherence patterns of subcutaneously administered anti-tumor necrosis factor treatment among rheumatoid arthritis patients

BACKGROUND

Adherence to therapy is a key requirement underlying achievement of clinical outcomes in randomized controlled drug registration trials. In postmarketing studies, comparison of adherence among therapies can become more complicated when drug dosing and administration schedules differ or when methods used to measure adherence are not consistently applied.

OBJECTIVE

The objective of this exploratory study was to investigate a broad range of utilization and adherence outcomes associated with subcutaneous biologic treatments for rheumatoid arthritis (RA).

METHODS

Adult patients (aged ≥18 years) exhibiting ≥2 claims with an RA diagnosis (code 714.x), at least 24 months of continuous medical and pharmacy eligibility, and 30-day supplies of adalimumab, etanercept, or golimumab were selected from the Optum Insight Clinformatics database. Adherence and utilization measures were calculated and compared across treatment groups.

RESULTS

A total of 1532 adalimumab, 2099 etanercept, and 261 golimumab patients met inclusion criteria. Compared with both adalimumab and etanercept patients, golimumab patients were significantly more likely to have a medication possession ratio of ≥0.80 (82% vs 71% vs 62%; P < 0.001) and significantly less likely to have ≥4 late medication refills (6.9% vs 17.7% vs 26.1%; P < 0.001 for all). Etanercept patients had significantly greater refill intervals (37.7 vs 34.9 and 35.1 days) and had the lowest proportion of adherent fills (70% vs 77% and 75%) compared with both golimumab and adalimumab patients (P < 0.001 for all). Bivariate effects were reproduced in multivariate models that controlled for treatment duration.

CONCLUSIONS

A number of statistically significant medication adherence differences were observed among golimumab, adalimumab, and etanercept patients in treatment for RA. Overall, golimumab patients appeared to be the most adherent group. Findings may be partially attributable to golimumab patients' likely increased disease severity, their prior experience with biologic medication, or golimumab's once-monthly dosing schedule, which requires fewer administrations than both adalimumab and etanercept.

Patient-reported adherence to coprescribed proton pump inhibitor gastroprotection in osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis patients using nonsteroidal anti-inflammatory drugs

BACKGROUND

Patients with osteoarthritis (OA), rheumatoid arthritis (RA), or ankylosing spondylitis (AS) are commonly treated with nonsteroidal anti-inflammatory drugs (NSAIDs), sometimes with a concomitant gastroprotective proton pump inhibitor (PPI). The present study examines real-life patient adherence to PPIs when coprescribed with NSAIDs.

METHODS

This retrospective medical record survey identified patients diagnosed with OA, RA, or AS who had PPIs coprescribed with NSAIDs for prevention of NSAID-associated gastrointestinal ulcers. Actual NSAID and PPI intake was retrospectively recorded using a self-reported questionnaire. Adherence to PPI treatment was assessed using descriptive statistics.

RESULTS

In total, 96 patients (69% female, mean age 67 years, 72% OA, 16% RA, 12% AS) were included. The mean patient-reported adherence to coprescribed PPIs was 73%-81%. The percentage of patients with a self-reported adherence of ≤80% was 26%. No predictive factors for low adherence could be identified.

CONCLUSION

Despite doctors' instructions to use PPIs concomitantly with NSAIDs, the mean patient-reported adherence to coprescribed PPIs in this population indicates a risk of a "gastroprotective treatment gap". The patients' adherence to gastroprotective PPIs for the prevention of NSAID-associated upper gastrointestinal ulcers can be improved.

Electronic monitoring of oral therapies in ethnically diverse and economically disadvantaged patients with rheumatoid arthritis: consequences of low adherence

OBJECTIVE

To quantify adherence to oral therapies in ethnically diverse and economically disadvantaged patients with rheumatoid arthritis (RA), using electronic medication monitoring, and to evaluate the clinical consequences of low adherence.

METHODS

A total of 107 patients with RA enrolled in a 2-year prospective cohort study agreed to have their oral RA drug therapy intake electronically monitored using the Medication Event Monitoring System. Adherence to disease-modifying antirheumatic drugs (DMARDs) and prednisone was determined as the percentage of days (or weeks for methotrexate) on which the patient took the correct dose as prescribed by the physician. Patient outcomes were assessed, including function measured by the modified Health Assessment Questionnaire, disease activity measured by the Disease Activity Score in 28 joints (DAS28), health-related quality of life, and radiographic damage measured using the modified Sharp/van der Heijde scoring method.

RESULTS

Adherence to the treatment regimen as determined by the percentage of correct doses was 64% for DMARDs and 70% for prednisone. Patients who had better mental health were statistically more likely to be adherent. Only 23 of the patients (21%) had an average adherence to DMARDs ≥80%. These patients showed significantly better mean DAS28 values across 2 years of followup than those who were less adherent (3.28 versus 4.09; P = 0.02). Radiographic scores were also worse in nonadherent patients at baseline and at 12 months.

CONCLUSION

Only one-fifth of RA patients had an overall adherence to DMARDs of at least 80%. Less than two-thirds of the prescribed DMARD doses were correctly taken. Adherent patients had lower disease activity across the 2 years of followup.

Nanogel-based delivery of mycophenolic acid ameliorates systemic lupus erythematosus in mice

The ability to selectively inactivate immune cells with immunosuppressants is a much sought-after modality for the treatment of systemic lupus erythematosus and autoimmunity in general. Here, we designed and tested a novel nanogel drug delivery vehicle for the immunosuppressant mycophenolic acid (MPA). Treatment with MPA-loaded nanogels increased the median survival time (MST) of lupus-prone NZB/W F1 mice by 3 months with prophylactic use (MST was 50 weeks versus 38 weeks without treatment), and by 2 months when administered after the development of severe renal damage (MST after proteinuria onset was 12.5 weeks versus 4 weeks without treatment). Equivalent and greater doses of MPA administered in buffer were not efficacious. Nanogels had enhanced biodistribution to organs and association with immune cells. CD4-targeted nanogels yielded similar therapeutic results compared with nontargeted formulations, with protection from glomerulonephritis and decreases in IFN-γ-positive CD4 T cells. DCs that internalized nanogels helped mediate immunosuppression, as they had reduced production of inflammatory cytokines such as IFN-γ and IL-12. Our results demonstrate efficacy of nanogel-based lupus therapy and implicate a mechanism by which immunosuppression is enhanced, in part, by the targeting of antigen-presenting cells.

Lifestyle- and behaviour-change interventions in musculoskeletal conditions

This review discusses several health behaviours associated with the progression and impact of osteoarthritis (OA) and rheumatoid arthritis (RA), including weight management, physical activity, medication adherence and smoking. An overview of current theories of behaviour-change is provided in terms of principles that can guide medical practice. Finally, evaluation studies of interventions targeting weight loss, physical activity and medication adherence in patients with OA or RA are presented and discussed. Of existing behaviour-change interventions in this population, few have taken a comprehensive theory-based approach to behaviour-change. Practitioners who provide lifestyle or behavioural advice to patients would do well to adopt a less prescriptive and more patient-centred approach in which they, or other health professionals to whom they refer the patient, assist the patient in formulating personal change goals, in translating good intentions into specific action plans and in closely monitoring their progress towards self-chosen goals.

Factors associated with adherence to pharmaceutical treatment for rheumatoid arthritis patients: a systematic review

OBJECTIVES

To identify factors associated with adherence to medication for rheumatoid arthritis or undifferentiated inflammatory arthritis using a systematic literature search.

METHODS

PubMed, PsycINFO, EMbase and CINAHL databases were systematically searched from inception to February 2011. Articles were included if they addressed medication adherence, used a reproducible definition, determinants and its statistical relationship. Methodological quality was assessed using a quality assessment list for observational studies derived from recommendations from Sanderson et al. (2007) [12]. Resulting factors were interpreted using the Health Belief Model (HBM).

RESULTS

18 out of 1479 identified studies fulfilled the inclusion criteria. 64 factors were identified and grouped according to the HBM into demographic and psychosocial characteristics, cues to action and perceived benefits versus perceived barriers. The belief that the medication is necessary and DMARD use prior to the use of anti-TNF had strong evidence for a positive association with adherence. There is limited evidence for positive associations between adherence and race other than White, general cognition, satisfactory contact with the healthcare provider and the provision of adequate information from the healthcare provider. There is limited evidence for negative associations between adherence and having HMO insurance, weekly costs of TNF-I, having a busy lifestyle, receiving contradictory information or delivery of information in an insensitive manner by the rheumatologist. 18 factors were unrelated to adherence.

CONCLUSIONS

The strongest relation with adherence is found to be prior use of DMARDs before using anti-TNF and beliefs about the necessity of the medication. Because the last one is modifiable, this provides hope to improve adherence.

The role of trust in health decision making among African American men recruited from urban barbershops

OBJECTIVE

To examine factors within the patient-provider relationship that influence which role African American men aged 40-70 years prefer when making health care decisions.

METHODS

We recruited 40 African American men from barbershops in the Richmond, Virginia, metropolitan area to participate in semistructured interviews. At the completion of each interview, participants completed a brief self-administered demographic survey. The semistructured interviews were audiotaped and transcribed verbatim and then imported into a qualitative software program for organizing, sorting, and coding data. The principles of thematic analysis and template approach were used in this study. The survey data were analyzed using descriptive statistics.

RESULTS

Trust was a major theme that emerged from the semistructured interviews. The men listed trust in the health care provider as the primary reason for choosing a collaborative or active role in the decision-making process. Within the theme of trust, 4 subthemes emerged: expertise, information sharing, active listening, and relationship length. Thirty-five out of the 40 men interviewed preferred an active or collaborative role in the decision-making process; only 5 preferred passive decision making.

CONCLUSIONS

Trust emerged as an important factor that influenced role preference for African American men when making health care decisions in the context of the patient-provider relationship. Future studies that help identify which other factors influence health care decision-making roles among African American men may have implications for addressing health disparities among this population and improve the quality of their health care.

Measuring therapeutic adherence in systemic lupus erythematosus with electronic monitoring

Objective: We used an electronic monitoring system to quantify adherence to prescribed oral therapies by patients with systemic lupus erythematosus (SLE). Methods: Participants were included from a larger longitudinal study cohort of 110 patients recruited from publicly-funded rheumatology clinics, 78 of whom agreed to have their SLE drug therapy electronically monitored for two years with the Medication Events Monitoring System (MEMS®, AARDEX Group). Adherence was determined as the percentage of days (weeks for methotrexate) the patient took the medication as prescribed by the physician. Collected data included SLEDAI; SLICC damage index for SLE (SDI); medical outcome study social support survey (MOS-SSS); Center for Epidemiologic Studies depression scale (CESD); and quality of life (SF-12). Results: Ninety percent of the cohort was female, 45% were Hispanic, and 49% were African-American. Mean age was 36.3 years, disease duration was 5.9 years, SLEDAI score was 3.2, and SDI score was 0.9. Adherence was 62% for all drugs combined and did not differ significantly for individual medications. Patients with more depression ( p < 0.02), and higher number of pills taken daily ( p < 0.02) were more likely to be non-adherent. Only one-fourth of the patients had an average adherence of ≥80%; these patients had a better mental component score (SF-12) at 24 months than non-adherent patients ( p < 0.01). Conclusions: Electronic monitoring demonstrated that only one-fourth of the patients had an adherence rate ≥80%. Polypharmacy and depression were associated with non-adherence.

Each type of cause that initiates rheumatoid arthritis or RA flares differentially affects the response to therapy

The autoimmune disease rheumatoid arthritis (RA) presents difficulty in diagnosis, commonly observed flare ups, polycyclical nature of RA progression, and variable response to therapies. Congruent with multiple causes, literature has documented various infectious agents, environmental factors, physical trauma, silica and food sensitivities as potential causes of RA or RA flares in different populations. We propose that these>36 events can initiate RA or RA flares which complicates treatment decisions. Each pharmaceutical medicine benefits 15-82% of RA patients. Predictive factors are needed. Because the initiating cause of RA or RA flare affects the type of joint damage, initial inflammatory response, adaptive immune response, and potential molecular mimicry, we propose the "RA cause affects response to therapy" (RACART) theory. The potential cause combined with confounding factors such as genetic risk factors, nutritional status, epigenetic status, inflammatory levels, and detoxification ability may help predict responses to various therapies.

Compliance with treatment of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, progressive, debilitating disease that demands continuous therapy with multiple medications. Noncompliance with disease-modifying drugs may cause disease flares, preventable functional impairment, unnecessary treatment changes, and loss of health care resources. The aim of the current study was to explore self-reported compliance with treatment and the factors contributing to this compliance using a representative sample of an RA patient population in Estonia. Two thousand patients diagnosed with RA were randomly selected from the Estonian Health Insurance Fund database. The eligible response rate of the study was 60%. Using prestructured questionnaires, the following information about the disease and treatment was evaluated: self-reported compliance with treatment, reasons for noncompliance, disease history, sociodemographic variables, health care utilization, and satisfaction with health care providers. The self-reported compliance rate was 80.3%, reflecting the percentage of patients who reported that they always took their medications exactly as described. The most often reported reasons for noncompliance were side effects and fear of side effects. Compliance was found to be the lowest in a group of younger and active patients with higher income. Higher frequency of visits to the rheumatologist, satisfaction with health care providers, and sufficient information about RA treatment correlated with better compliance.

Improving treatment adherence in patients with rheumatologic disease

Further evaluation of reasons for treatment nonadherence in patients with rheumatologic disease is key in the development of successful interventions. Patient education efforts alone are not sufficient to improve adherence; complex interventions are most effective. Because most rheumatologic diseases require lifetime therapy, the consequences of nonadherence can be deleterious. Several direct and indirect methods have been proposed to measure adherence. Pharmacy claims data have been used frequently in studying rheumatologic disease; electronic monitoring provides an accurate measure. Adherence is mediated through constructs of the patient-physician relationship.