Barriers to medication adherence and degree of nonadherence in a systemic lupus erythematosus (SLE) outpatient population

Systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease characterised by the presence of autoantibodies towards nuclear antigens, immune complex deposition, and chronic inflammation at classic target organs such as skin, joints, and kidneys. Despite substantial advances in the diagnosis and management of SLE, the burden of disease remains high. It is important to appreciate the typical presentations and the diagnostic process to facilitate early referral and diagnosis for patients. In most patients, constitutional, mucocutaneous, and musculoskeletal symptoms represent the earliest complaints; these symptoms can include fatigue, lupus-specific rash, mouth ulcers, alopecia, joint pain, and myalgia. In this Seminar we will discuss a diagnostic approach to symptoms in light of the latest classification criteria, which include a systematic evaluation of clinical manifestations (weighted within each domain) and autoantibody profiles (such as anti-double-stranded DNA, anti-Sm, hypocomplementaemia, or antiphospholipid antibodies). Non-pharmacotherapy management is tailored to the individual, with specific lifestyle interventions and patient education to improve quality of life and medication (such as hydroxychloroquine or immunosuppressant) adherence. In the last decade, there have been a few major breakthroughs in approved treatments for SLE and lupus nephritis, such as belimumab, anifrolumab, and voclosporin. However the disease course remains variable and mortality unacceptably high. Access to these expensive medications has also been restricted across different regions of the world. Nonetheless, understanding of treatment goals and strategies has improved. We recognise that the main goal of treatment is the achievement of remission or low disease activity. Comorbidities due to both disease activity and treatment adverse effects, especially infections, osteoporosis, and cardiovascular disease, necessitate vigilant prevention and management strategies. Tailoring treatment options to achieve remission, while balancing treatment-related comorbidities, are priority areas of SLE management.

Adherence patterns to medications and their association with subsequent hospitalization in adult Egyptian patients with systemic lupus erythematosus

OBJECTIVE

The aim of this study was to evaluate the adherence pattern to medications and the influence of non-adherence on hospitalization rate among Egyptian patients who were diagnosed with systemic lupus erythematosus (SLE).

METHODS

This cross-sectional interview-based study was conducted in an Egyptian rheumatology outpatient clinic. Individuals with SLE who were prescribed oral medications were included in the study. The 19-item Compliance Questionnaire of Rheumatology (CQR) was employed to evaluate drug adherence. Patients were classified as non-adherent and adherent group based on their CQR score Sociodemographic variables, clinical and therapeutic data, and the frequency of outpatient visits and hospitalization were collected and compared between the two groups.

RESULTS

In total, there were 161 SLE patients who participated in the study with mean age 30.70 ± 9.62 years, 129 females and 32 males (F:M 5.4:1). Of them, 93 patients were assigned to the non-adherent group, whereas 68 patients were assigned to the adherent group. There was a statistically significant difference in terms of marital status (p = 0.009), employment (p = 0.032), and the frequency of physical activity (p = 0.045) between the two groups. The adherents had a higher rate of administration of antimalarials (88.2% vs 75.3%, p = 0.039). The frequency of recurrent fever was lower in adherents (23.5% vs 38.7%, p = 0.042), lymphadenopathy (11.8% vs 31.2%, p = 0.004), recurring oral ulcers (25% vs 50.5%, p = 0.001), and substantial hair loss (87.1% vs 98.5%, p = 0.009) in comparison to non-adherents. The number of yearly outpatient visits was considerably greater in adherents (p = 0.007), while the number of prior hospitalizations was higher in non-adherents (p < 0.001). Non-adherents believed that taking medicines disrupt patients' daily routine (p < 0.001) and were more afraid of the occurrence of an adverse drug reaction (p < 0.001).

CONCLUSIONS

Egyptian SLE patients have an alarmingly high percentage of medication non-adherence. There is a strong association between medication non-adherence and frequency of hospitalization and cumulative clinical manifestations.

Flares in Lupus Nephritis: Risk Factors and Strategies for Their Prevention

PURPOSE OF REVIEW

Discuss the prognostic significance of kidney flares in patients with lupus nephritis, associated risk factors, and possible preventative strategies.

RECENT FINDINGS

Recently performed clinical trials and observational cohort studies underscore the high frequency of relapses of kidney disease, following initial response, in patients with proliferative and/or membranous lupus nephritis. Analysis of hard disease outcomes such as progression to chronic kidney disease or end-stage kidney disease, coupled with histological findings from repeat kidney biopsy studies, have drawn attention to the importance of renal function preservation that should be pursued as early as lupus nephritis is diagnosed. In this respect, non-randomized and randomized evidence have suggested a number of factors associated with reduced risk of renal flares such as attaining a very low level of proteinuria (< 700-800 mg/24 h by 12 months), using mycophenolate over azathioprine, adding belimumab to standard therapy, maintaining immunosuppressive/biological treatment for at least 3 to 5 years, and using hydroxychloroquine. Other factors that warrant further clarification include serological activity and the use of repeat kidney biopsy to guide the intensity and duration of treatment in selected cases. The results from ongoing innovative studies integrating kidney histological and clinical outcomes, together with an expanding spectrum of therapies in lupus nephritis, are expected to facilitate individual medical care and long-term disease and patient prognosis.

Cost-related prescription non-adherence and patient-reported outcomes in systemic lupus erythematosus: The Michigan Lupus Epidemiology & Surveillance program

OBJECTIVES

Medication access and adherence play key roles in determining patient outcomes. We investigated whether cost-related non-adherence (CRNA) to prescription medications was associated with worse patient-reported outcomes in a population-based systemic lupus erythematosus (SLE) cohort.

METHODS

Sociodemographic and prescription data were collected by structured interviews in 2014-2015 from patients meeting SLE criteria in the established Michigan Lupus Epidemiology & Surveillance (MILES) Cohort. We examined the associations between CRNA and potential confounders such as sociodemographics and health insurance coverage, and outcome measures of SLE activity and damage using multivariable linear regression.

RESULTS

462 SLE participants completed the study visit: 430 (93.1%) female, 208 (45%) Black, and mean age 53.3 years. 100 (21.6%) participants with SLE reported CRNA in the preceding 12 months. After adjusting for covariates, CRNA was associated with both higher levels of current SLE disease activity [SLAQ: β coeff 2.7 (95% CI 1.3, 4.1), p < 0.001] and damage [LDIQ β coeff 1.4 (95% CI 0.5, 2.4), p = 0.003]. Race, health insurance status, and fulfilling Fibromyalgia (FM) Survey Criteria were independently associated with both higher (worse) SLAQ and LDIQ scores; female sex was further associated with higher SLAQ scores.

CONCLUSION

Patients with SLE who reported CRNA in the previous 12 months had significantly worse self-reported current disease activity and damage scores compared to those not reporting CRNA. Raising awareness and addressing barriers or concerns related to financial implications and accessibility issues in care plans may help to improve these outcomes.

Uncertainty and its related coping strategies in systemic lupus erythematosus. Life in the fog

BACKGROUND

One of the most prevalent problems of patients with systemic lupus erythematosus (SLE) is the uncertainty over an indefinite future. Uncertainty has significant effects on quality of life. The aim of this study was to explore uncertainty and personal strategies to cope with it among patients with SLE.

MATERIALS AND METHODS

This qualitative study was conducted in 2020-2021 using conventional content analysis. Participants were 21 patients with SLE who were purposefully selected from rheumatology clinics in Kashan, Kerman, and Bandar Abbass in Iran. Data collection was performed using face-to-face, in-depth, semi-structured interviews and was continued up to data saturation. Data were analyzed concurrently with data collection through conventional content analysis approach proposed by Graneheim and Lundman.

RESULTS

Two main themes, namely, "life in the fog" and "attempt to find peace" emerged from patients' experiences of illness uncertainty of SLE. Life in the fog included three main categories of "perception of threat to health", "challenge of doubt and certainty," and "indefinite future." Attempt to find peace included three main categories of "spirituality," "reflection," and "attempt to acquire SLE-related knowledge.

CONCLUSIONS

Uncertainty is a major psychological stress for patients with SLE. Healthcare providers should therefore consider the challenges and concerns faced by patients and, through utilizing appropriate training and communicational practices, plan interventions and strategies to empower patients for coping with uncertainty.

An online survey of the Spanish Lupus Patient Association (FELUPUS): patient perceptions and experiences

OBJECTIVES

A survey conducted by the Spanish Lupus Federation (FELUPUS) shows the results on perceptions and experiences of the people who live with lupus in Spain. The information was gathered anonymously from May 21st to June 30th, 2020. The aim of the study was to monitor the impact of the disease on quality of life, as well as to measure the impact of organ damage in lupus patients.

METHODS

A national survey was conducted among people with lupus living in Spain who belong to the Spanish Lupus Patient Association (FELUPUS). Online interviews of approximately 25 min were completed. The information was gathered anonymously from May 21st to June 30th, 2020.

RESULTS

One thousand two hundred sixty-three interviews were completed. 92% had a diagnosis of Systemic Lupus Erythematosus (SLE) and 8% of Cutaneous Lupus Erythematosus (CLE); 95% of the patients surveyed were female. Most of the patients claimed they stay up late, exercising and work/study were the most limited actions due to the disease. 73% of patients considered that there was little knowledge of the disease by society and at the time of diagnosis, the patient's level of knowledge about lupus was low in 92% of them. Regarding organ damage, many patients did not understand the concept of chronicity and irreversibility of the term, relating it erroneously to acute symptoms like fatigue (38%), joint pain (47%) and even to the presence of cutaneous symptoms such as the presence of oral ulcers (17%).

CONCLUSIONS

The survey highlighted the need for disease awareness campaigns, greater involvement of healthcare professionals and the need to provide more information to lupus patients from the time of diagnosis. Nationally and to our knowledge, this is the survey with the largest number of participants (N = 1263) conducted in patients with lupus. Key Points •A national survey was conducted among people with lupus living in Spain and belonging to patient associations in Spain (FELUPUS). •Nationally and to our knowledge, this is the survey with the largest number of participants (N = 1263) conducted in patients with lupus. •Most of the patients claimed they stay up late, exercising and work/study were the most limited actions due to the disease. •73% of patients considered that there is little knowledge of the disease by society and at the time of diagnosis, the patient's level of knowledge about lupus was low in 92% of them.

Adherence to antimalarials and glucocorticoids treatment and its association with self-reported disease activity in systemic lupus erythematosus patients

OBJECTIVES

We aimed to investigate the rate of non-adherence to antimalarials and glucocorticoids (GCs) and to analyze their potential relationships with sociodemographic characteristics, disease activity and accumulate damage in a cohort of Systemic lupus erythematosus (SLE) patients.

METHODS

A cross-sectional study was conducted among 670 patients. The Systemic Lupus Erythematosus Activity Questionnaire (SLAQ) and the Lupus Damage Index Questionnaire (LDIQ) were used to assess disease activity and accumulated damage.

RESULTS

The prevalence of non-adherence to antimalarials and GCs were 10.67% and 39.61%. 86.9% of participants indicated that the reason for stopping therapy was the presence of side effects. SLE patients with non-adherence to antimalarials and GCs had significantly higher scores in disease severity (SLAQ) compared to adherence patients (5.03 (2.12) vs 4.39 (2.61); p = .004 and (4.75 (2.29) vs 4.05 (2.78); p ≤ .001).

CONCLUSION

Adherence to the treatment indicated in SLE differs from drug to drug. Findings highlight the importance of developing interventions to support adherence and improve outcomes among patients.

Post-traumatic growth in adult patients with systemic lupus erythematosus: a cross-sectional study in China

This cross-sectional study aims to evaluate the post-traumatic growth (PTG) level and explores its predictors among adult patients with SLE in China. From April 2020 to April 2021, 135 hospitalized adult SLE patients completed the questionnaire including sociodemographic and disease-related data, Post-traumatic Growth Inventory (PTGI), Medical Coping Modes Questionnaire (MCMQ), Social Support Rating Scale (SSRS), Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS), and Self-Perceived Burden Scale (SPBS). Descriptive analysis, pearson's correlation analysis, and forward multiple line regression analysis were used for analysis by SPSS 22.0. Results showed that, the mean PTGI score was 57.52 ± 20.82. Pearson correlation analysis showed that, complicated autoimmune hemolytic anemia (r = - 0.185), CD4 +/CD8 + (r = - 0.383), acceptance-resignation (r = - 0.185), poor PSQI (r = - 0.215), and depression (r = - 0.322) were negatively associated with total PTGI score; while the relationship with lupus nephritis (r = 0.247), confrontation (r = 0.313), avoidance (r = 0.379), and SSRS (r = 0.242) were positive (all P < 0.05). The total score of PTGI and its five sub-dimensions were not correlated with anxiety and self-perceived burden. Further, CD4 +/CD8 +, confrontation of MCMQ, and SSRS could explain 30.3% of the variance in total PTGI (F = 6.646, P < 0.01). In summary, Chinese adults with SLE experience moderate levels of PTG. Clinical nurses need pay attention to the current disease status and individual characteristics of patients, as well as their mental health, to promote their growth experience, so that they can cope with the future life in a better state and coexist well with SLE.

Health disparities in systemic lupus erythematosus-a narrative review

PURPOSE OF REVIEW

To describe root causes of health disparities by reviewing studies on incidence and outcomes of systemic lupus erythematosus (SLE) related to ethnic, race, gender, or socioeconomic differences and to propose solutions.

RECENT FINDINGS

SLE outcomes have steadily improved over the past 40 years but are not uniformly distributed across various racial and ethnic groups. Belonging to racial and ethnic minority has been cited as a risk factor for more severe disease and poor outcome in SLE. Population-based registries have demonstrated that Black patients with SLE have significantly lower life expectancy compared to White patients. Lower socioeconomic status has been shown to be one of the strongest predictors of progression to end stage renal disease in lupus nephritis. An association between patient experiences of racial discrimination, increased SLE activity, and damage has also been described. The lack of representation of marginalized communities in lupus clinical trials further perpetuates these disparities. To that end, the goal of a rheumatology workforce that resembles the patients it treats has emerged as one of many solutions to current shortfalls in care. Disparities in SLE incidence, treatment, and outcomes have now been well established. The root causes of these disparities are multifactorial including genetic, epigenetic, and socioeconomic. The underrepresentation of marginalized communities in lupus clinical trials further worsen these disparities. Efforts have been made recently to address disparities in a more comprehensive manner, but systemic causes of disparities must be acknowledged and political will is required for a sustained positive change.

Real-world data on vitamin D supplementation and its impacts in systemic lupus erythematosus: Cross-sectional analysis of a lupus registry of nationwide institutions (LUNA)

Background

Although vitamin D concentration is reportedly associated with the pathogenesis and pathology of systemic lupus erythematosus (SLE), benefits of vitamin D supplementation in SLE patients have not been elucidated, to our knowledge. We investigated the clinical impacts of vitamin D supplementation in SLE.

Methods

A cross-sectional analysis was performed using data from a lupus registry of nationwide institutions. We evaluated vitamin D supplementation status associated with disease-related Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) as a parameter of long-term disease activity control.

Results

Of the enrolled 870 patients (mean age: 45 years, mean disease duration: 153 months), 426 (49%) received vitamin D supplementation. Patients with vitamin D supplementation were younger (43.2 vs 47.5 years, P < 0.0001), received higher doses of prednisolone (7.6 vs 6.8 mg/day, P = 0.002), and showed higher estimated glomerular filtration rates (79.3 vs 75.3 mL/min/1.73m², P = 0.02) than those without supplementation. Disease-related SDI (0.73 ± 1.12 vs 0.73 ± 1.10, P = 0.75), total SDI, and SLE Disease Activity Index (SLEDAI) did not significantly differ between patients receiving and not receiving vitamin D supplementation. Even after excluding 136 patients who were highly recommended vitamin D supplementation (with age ≥ 75 years, history of bone fracture or avascular necrosis, denosumab use, and end-stage renal failure), disease-related SDI, total SDI, and SLEDAI did not significantly differ between the two groups.

Conclusions

Even with a possible Vitamin D deficiency and a high risk of bone fractures in SLE patients, only half of our cohort received its supplementation. The effect of vitamin D supplementation for disease activity control was not observed.

Outcomes following antimalarial withdrawal in patients with quiescent systemic lupus erythematosus

OBJECTIVE

Antimalarial medications (AMs) are central to the management of SLE. We investigated the rate of flare in lupus patients who withdrew AM after achieving clinical remission for at least one year, compared to those who continued therapy and compared flare rates in cases who tapered AM versus abruptly withdrew.

METHODS

Cases achieved clinical remission for at least one year then ceased their AM. Index date was defined as the date of complete AM cessation. Controls achieved clinical remission for at least one year and continued AM. Controls were matched according to the duration of AM before remission and the duration of therapy from remission date to case index date. All patients had ≥ 2 years of follow up.

RESULTS

Of 1573 patients on AM, 165 achieved a one-year remission and then ceased their AM. 96 had adequate follow-up, 88 were successfully matched to one control and 85 to 2 controls for a total of 173 controls. Flare occurred in 61.4% of cases and 45.1% of controls (p = 0.002). 52.3% patients who withdrew AM later restarted it due to disease flare. 88% recaptured control or improved, while 12% did not. Patients who tapered had significantly fewer flares (45.9% vs. 72.6%; p = 0.01).

CONCLUSION

AMs aid in preventing disease flare even in patients who have achieved prolonged clinical remission. Tapering AM results in lower flare rates. Hence, except in the setting of toxicity, cessation of antimalarial therapy in patients with prolonged disease quiescence is feasible using a slow taper.

COVID-19 in patients with systemic lupus erythematosus: A systematic review

The objectives of the study were to review the articles to identify (a) the epidemiology of systemic lupus erythematosus (SLE) and coronavirus disease 2019 (COVID-19); (b) the clinical characteristics of SLE patients with COVID-19; (c) the treatment of COVID-19 in SLE patients; and (d) the impact of COVID-19 pandemic on SLE patients. PubMed was systematically reviewed for literature published from December 2019 to June 2021. Our search was limited to human studies, with language restriction of English. Studies were included if they reported COVID-19 in SLE patients. Our systematic review included 52 studies. The prevalence of COVID-19 infection ranged from 0.0% to 18.1% in SLE patients, and the hospitalisation rates ranged from 0.24% to 10.6%. COVID-19 infection is likely to mimic SLE flare. Hydroxychloroquine (HCQ) was ineffective in prevention of COVID-19, and SLE patients with COVID-19 faced difficulty in healthcare access, had financial constraints and suffered from psychological distress during the pandemic. The pandemic had a significant effect on mental and physical health. Adequate healthcare access, along with containment policies, social distancing measures and psychological nursing was required.

Barriers to medication adherence and degree of nonadherence in a systemic lupus erythematosus (SLE) outpatient population

To estimate the level of medication adherence and barriers to adherence among systemic lupus erythematosus (SLE) patients. Patients taking antimalarials, immunosuppressives, and/or steroids to treat SLE were included. Adherence was measured using the Medication Adherence Self Report Inventory (MASRI) and adherence rates < 80% were considered nonadherent while rates ≥ 80% sufficiently adherent. Pill counts were conducted in a proportion of participants. Barriers to adherence were identified using the Identification of Medication Adherence Barriers Questionnaire 30 (IMAB-Q 30). Associations between adherence and patient demographics and disease-specific characteristics were explored. A total of 94 patients were studied and 28 pill counts conducted. 10 patients were classified as nonadherent and 84 patients as sufficiently adherent. 46% of patients were taking steroids, 77.7% antimalarials, and 55.3% immunosuppressives. 88% of patients were taking ≥ 1 medication for non-SLE conditions. The mean medication adherence rate for the SLE patients was 90.7%. Important barriers to adherence reported by nonadherent patients were: concern about harmful side effects (50%), being easily distracted (50%), life getting in the way (50%), being unsure or disagreeing that their condition will worsen without medications (50%), and having personal reasons for not taking medications (50%). Non-adherent patients reported significantly more barriers than sufficiently adherent patients (p < 0.001). The adherence rate in our population was higher than expected, reaching 90%. Barriers to medication adherence were identified and should be addressed on a population and individualized basis to improve patient outcomes.