Nonadherence with thiopurine immunomodulator and mesalamine medications in children with Crohn disease

Prevalence and predictors of medication non-adherence in children with inflammatory bowel disease in China: A cross-sectional study

Background: Non-adherence to physician-prescribed medications, especially oral medications, is common in children with inflammatory bowel disease (IBD), and medication non-adherence is associated with poorer outcomes in IBD. Therefore, understanding and improving medication adherence in children with IBD is critical for optimizing treatment and improving treatment outcomes. Despite the relatively high prevalence of IBD in children in China, to date, very little is known about medication adherence in these patients.

Objective: The aim of this study was to investigate the prevalence of medication non-adherence and its risk factors in children with IBD in China to provide a basis for developing adherence improvement strategies.

Methods: A cross-sectional design was employed. Children (aged <18 years) with IBD who visited the Children’s Hospital, Zhejiang University School of Medicine, from September 2020 to December 2021 were included. Data were collected by a general information questionnaire, the 4-item Medication Adherence Report Scale (MARS-4) and Crohn’s and Colitis Knowledge (CCKNOW) questionnaire. Subsequently, forward stepwise binary logistic regression analysis was performed to determine independent predictors of medication non-adherence.

Results: A total of 119children were included in this study. The results showed that 33 (27.73%) and 86 (72.27%) children had poor and good medication adherence, respectively. Of these, 83 (69.75%) had forgotten to take their medications sometimes, often, or always. On binary logistic regression, we found that the incidence of medication non-adherence in children with IBD course of 3 years and above [OR 4.82 (95%CI: 1.47-15.88); p = 0.01] was significantly higher than that in children with course of 3 months to 1 year, whereas children with higher parental CCKNOW scores [OR 0.77 (95%CI: 0.67-0.88); p = 0.00] had significantly lower incidence of medication non-adherence than those with lower parental CCKNOW scores, and the results of the correlation between parental knowledge scores of the four categories and children’s medication adherence showed that drug knowledge scores (r = 0.36, p < 0.00) and complication knowledge scores (r = 0.24, p = 0.01) were positively correlated with medication adherence.

Conclusion: Poor medication adherence in children with IBD in China was common, and forgetting to take medication was the main barrier. Longer disease duration (3 years and above) in children could act as a risk factor for medication adherence, whereas higher level of parental knowledge about IBD could act as a protective factor, and one interesting novel finding was that the level of parental knowledge about drug and complication were significantly correlated with medication adherence in children with IBD. Our results may inform on the design and implementation of medication adherence interventions for children with IBD.

Young age and shorter duration of Crohn's disease are associated with non-adherence to taking medication

Objective

The mainstay of Crohn's disease treatment is medical therapy. Failure to comply with medications causes disease activation, loss of response to treatment, and increased hospitalization rates. Drug non-adherence worsens the course of the disease, leading to fistula, stricture, and surgical interventions. The adherence rates to drug therapy in Crohn's disease patients and the risk factors vary considerably in the literature. The aim of the study was to investigate drug adherence rates and factors affecting adherence to Crohn's disease medications.

Methods

This study was conducted as prospective cohort study at the tertiary health care institution inflammatory bowel disease outpatient clinic within 1 year. Crohn's disease characteristics and pharmacy records of consecutive patients were evaluated. Medication adherence was assessed by calculating the medication possession ratio using the amount of medication purchased from the pharmacy.

Results

A total of 129 patients were included in the study. It was observed that 43.6% of the patients did not comply with their Crohn's disease medications. It was determined that the patients who did not adhere to the medication were significantly younger (41±12 vs. 48±13, p=0.039). The duration of the disease is shorter in patients who did not comply with the drugs (4.50 [IQR: 3.00-12.00] vs. 6.00 [IQR: 3.00-12.00, p=0.025]). Adherence with medication is lower in patients with higher education levels (35.7% vs. 64.3%, p=0.023).

Conclusion

Medication adherence is of critical importance for Crohn's disease outcomes. Nearly half of Crohn's disease patients do not comply with drugs. Young and highly educated patients with shorter disease duration should be targeted for measures to increase the rates of medication adherence.

Health-Related Social Needs Facing Youth with NonAlcoholic Fatty Liver Disease

Background

The objective of this study was to identify the prevalence of health-related social needs among youth with nonalcoholic fatty liver disease (NAFLD).

Methods

Retrospective review of prospectively administered health-related social needs questionnaires from Steatohepatitis Clinics.

Results

Patients with NAFLD (n=271) were predominantly male (72%), and non-Hispanic (68%). The most common unmet need was food insecurity (13%, n=36). Families who endorsed food insecurity at the first visit were 27-fold more likely to have unmet health-related social needs persist at subsequent visits than those who were food-secure at their first visit (95% CI: 6.7-111).

Conclusion

Screening for social, economic, and environmental needs may identify previously unrecognized family challenges and may enhance intervention delivery, inform resource allocation, and improve outcomes.

Budding Multi-matrix Technology-a Retrospective Approach, Deep Insights, and Future Perspectives

The human race is consistently striving for achieving good health and eliminate disease-causing factors. For the last few decades, scientists have been endeavoring to invent and innovate technologies that can substitute the conventional dosage forms and enable targeted and prolonged drug release at a particular site. The novel multi-matrix technology is a type of matrix formulation where the formulation is embraced to have a matrix system with multiple number of matrices. The MMX technology embraces with a combination of outer hydrophilic layer and amphiphilic/lipophilic core layer, within which drug is encapsulated followed by enteric coating for extended/targeted release at the required site. In comparison to conventional oral drug delivery systems and other drug delivery systems, multi-matrix (MMX) technology formulations afford many advantages. Additionally, it attributes for targeting strategy aimed at the colon and offers modified prolonged drug release. Thus, it has emerged rapidly as a potential alternative option in targeted oral drug delivery. However, the development of this MMX technology formulations is a exigent task and also has its own set of limitations. Due to its promising advantages and colon targeting strategy over the other colon targeted drug delivery systems, premier global companies are exploiting its potential. This article review deep insights into the formulation procedures, drug delivery mechanism, advantages, limitations, safety and efficacy studies of various marketed drug formulations of MMX technology including regulatory perspectives and future perspectives.

Initial Validation of IBD KNOW-IT: Measuring Patient and Caregiver Knowledge of a Child's Disease and Treatment Regimen

The present study describes the development and initial validation of a newly developed measure of child and caregiver knowledge of the child's own IBD and treatment, called IBD KNOW-IT. One hundred and fifty-five children and their caregivers completed the IBD KNOW-IT as well as a scale designed to compare each dyad's perceived knowledge to their actual knowledge. Initial psychometric evaluation of IBD KNOW-IT was completed by conducting factor analysis and determining internal consistency, convergent validity, and associations with demographic and medical characteristics. Results supported the validity of a 12-item measure with 4 subscales including Symptoms, Medication Regimen, Disease Monitoring, and Medical Team. Support for the internal consistency of IBD KNOW-IT was obtained. Evidence of validity was demonstrated by significant correlations between child and caregiver scales, and high congruence between perceived and actual knowledge across all subscales. The reliability of the measure was demonstrated by good internal consistency and test-retest reliability. Preliminary psychometric evaluation suggests that IBD KNOW-IT is reliable and valid.

Overview of Self-Management Skills and Associated Assessment Tools for Children with Inflammatory Bowel Disease

Self-management is a multi-modal approach for managing chronic conditions that encompasses a number of different elements; knowledge, adherence, self-regulation, communication, and cognitive factors. Self-management has been shown to be beneficial for adults with inflammatory bowel disease (IBD), and for children with IBD it may help them learn to take control of their complex treatment regimens and lead to positive disease outcomes. The development of self-management skills for children with IBD is vital in order to maximize their potential for health autonomy, but it is still an emergent field in this population. This review provides an over-arching view of the self-management elements specific to children with IBD, and highlights outcome measures that may be used to assess skills within each field as well as the efficacy of targeted interventions.

Thiopurine adherence: high prevalence with low impact in UC outcomes

Introduction Thiopurines are used as maintenance therapy in patients with ulcerative colitis (UC). There are contradictory results regarding the relationship between adherence to treatment and risk of relapse. Objectives To quantify and evaluate the trends in thiopurines prescription rates, and to determine the impact and risk factors of non-adherence. Methods Analytical, observational and retrospective study of UC patients, on thiopurines, included in the ENEIDA single-center registry from October 2017 to October 2019. We included adult patients under clinical remission at the beginning of the study on thiopurines maintenance treatment for at least 6 months before recruitment. Adherence was evaluated with an electronic pharmaceutical prescription system. Adherence was considered when 80% or more of the prescribed medication was dispensed at the pharmacy. Kaplan-Meier curves and a regression model were used to examine year-to-year treatment dispensation and identify factors associated to non-adherence. Results A total of 41 patients were included, of whom 71% were males with a mean age of 44 (14) and 26.8% were concomitantly managed with biological therapy. Overall, 22% were non-adherent to thiopurines. No predictive factors of non-adherence were identified. Adherence rate did not correlate with disease activity for two years follow-up (OR 1.6; 95CI =0.3-9.1). Left-sided colitis and concomitant biological treatment were related with disease relapses (p ≤0.01). Conclusion The adherence to thiopurines in UC patients is high (78%). Non-adherence is not related to clinical or pharmacological factors. Adherence rate was not associated with disease activity.

Refill Adherence Measures and Its Association with Economic, Clinical, and Humanistic Outcomes Among Pediatric Patients: A Systematic Review

Although refill adherence measures (RAMs) are widely reviewed on their use among adult patients, existing reviews on adherence among children have only focused on self-report measures and electronic monitoring. Hence, this systematic review aims to examine the use of RAMs and their association with economic, clinical, and humanistic outcomes (ECHO) among pediatric patients. A literature search was conducted in Pubmed, Embase, CINAHL, and PsycINFO. Studies published in English involving subjects aged ≤18 years were included if RAMs were analyzed with ECHO. Of the 35 included studies, the majority (n = 33) were conducted in high-income countries. Asthma was the most common condition (n = 9) studied. Overall, 60.6% of 33 clinical outcomes reported among 22 studies was positive (improved clinical outcomes with improved adherence), while 21.9% of 32 economic outcomes reported among 16 studies was positive (reduced healthcare utilization or cost outcomes with improved adherence). Only four studies evaluated the relationship of adherence with 11 humanistic outcomes, where the majority (72.7%) were considered unclear. RAMs are associated with ECHO and can be considered for use in the pediatric population. Future studies could explore the use of RAMs in low-income countries, and the association of RAMs with quality of life.

Longitudinal Barriers to Thiopurine Adherence in Adolescents With Inflammatory Bowel Diseases

Objectives

Cross-sectionally, more adherence barriers are associated with lower medication adherence. However, little is known about longitudinal associations between adherence barriers and adherence. Among adolescents with inflammatory bowel diseases (IBD), this study examined both (1) how time-varying self-reported adherence barriers affect daily thiopurine adherence and (2) how adherence barriers at baseline affect daily thiopurine adherence over a six-month period.

Methods

Eighty-one adolescents 11-18 years old prescribed a once-daily oral IBD maintenance medication participated in a six-month observational study. Adherence barriers were self-reported monthly via the Medication Adherence Measure (MAM): Medication Subscale. Daily adherence estimates were collected via Medication Event Monitoring System (MEMS) Track Caps.

Results

Generalized linear mixed modeling indicated that time alone did not significantly predict whether one was more likely to be adherent (p = .602). However, increasing adherence barriers lowered the likelihood that a participant would be adherent on a given day, and the interaction between time and barriers predicted likelihood of adherence on a given day (p < .01). Specifically, when participants reported no adherence barriers at baseline, adherence did not significantly change over time (p = .369). However, when barriers were endorsed, adherence decreased over time (p < .01).

Conclusions

Fewer adherence barriers over time predicted greater likelihood of adherence on a given day, which is consistent with previous cross-sectional research. Routine assessment of barriers to adherence over the course of adolescence is critical in addressing suboptimal adherence behavior in youth with IBD.

Adherence to Azathioprine/6-Mercaptopurine in Children and Adolescents with Inflammatory Bowel Diseases: A Multimethod Study

BACKGROUND

Measurement of the degree of adherence is a key element for the evaluation of treatment efficacy and safety; thus, adherence plays an important role in clinical research and practice. The aim of this study was to investigate medication adherence in children with inflammatory bowel disease (IBD) utilizing a multimethod assessment approach. A further aim was to examine factors that can influence adherence within this population.

METHODS

Medication adherence in 47 children (age range 3 to 17 years) with IBD in three centers in Northern Ireland and Jordan was assessed via subjective (parent and child versions of the Medication Adherence Report Scale (MARS) specific questionnaire) and objective methods, that is, high-performance liquid chromatography (HPLC) determination of the 6-mercaptopurine (6-MP) and azathioprine (AZA) metabolites in packed red blood cell samples taken during a clinic visit. Beliefs about prescribed medicines were also assessed in parents/guardians using the Beliefs about Medicines Questionnaire (BMQ).

RESULTS

An overall nonadherence to AZA/6-MP therapy in children with IBD was found to be 36.17% (17 out of 47 patients were classified as nonadherent using at least one of the assessment methods). A total of 41 patients (91.1%) were classified as adherent to AZA or 6-MP using the blood sampling, while adherence rates using the MARS questionnaire completed by children and parents/guardians were 60.6% and 72.7%, respectively. The latter provides a more longitudinal measure of adherence. Child self-reported nonadherence rates were significantly higher than parent/guardian reported rates (p=0.013). Binary logistic regression analysis identified age to be independently predictive of adherence, with adolescents (children aged ≥ 13 years old) more likely to be classified as nonadherent. Regarding the BMQ, when parental/guardian necessity beliefs outweighed concerns, that is, higher scores in the necessity-concern differential (NCD), adolescents were more likely to be classified as adherent.

CONCLUSION

Results provide evidence for ongoing adherence challenges in the paediatric population with IBD. It is recommended that parents/guardians (particularly of older children) and older children themselves, should receive enhanced counselling and education about their prescribed medicines.

Response pattern analysis of IBD-KID: A knowledge assessment tool for children with inflammatory bowel disease

AIM

Paediatric inflammatory bowel disease (IBD) is a chronic relapsing condition requiring adherence to complex treatment regimens to achieve best outcomes. Adherence is frequently low in this population but can be improved by increasing disease- and treatment-related knowledge. The IBD-knowledge inventory device (IBD-KID) is a knowledge assessment tool specifically developed and validated for children with IBD. To analyse IBD-KID participant response patterns in order to review the strength of the tool.

METHODS

A cohort of children with IBD completed IBD-KID, and their responses were used to assess the tool's validity and feasibility. Item response analysis assessed the item difficulty and the ability of items to discriminate between high/low scorers. The analysis considered item structure, readability and the effectiveness of multiple choice items.

RESULTS

A total of 105 completed IBD-KID assessments showed that 12 items (52%) had an acceptable difficulty level, and 17 (74%) were effective at discriminating between high/low scorers. Nine (61%) had good readability, but comprehension levels ranged from 5 to 18 years. Seven (30%) had elevated 'don't know' responses, highlighting the need for content and construction review. Of the 10 multiple choice items, 9 were complex and not functioning efficiently. Internal consistency was acceptable but could be improved by removing two items.

CONCLUSIONS

The response analysis metrics were reviewed by an expert panel and provided a framework for IBD-KID improvements with the aim of increasing discrimination and reducing difficulty without adversely affecting reliability. The proposed revisions will address components that may have caused children to answer incorrectly due to confusion rather than lack of knowledge.

Longitudinal non-adherence predicts treatment escalation in paediatric ulcerative colitis

BACKGROUND

Medication non-adherence in paediatric ulcerative colitis (UC) has been associated with negative health outcomes including flares in disease activity. However, no studies to date have examined longitudinal adherence to maintenance medication in a prospective controlled trial.

AIMS

To determine whether objectively measured adherence to standardised mesalazine (mesalamine) therapy over time was related to remission at 52 weeks and the need for treatment escalation in newly diagnosed paediatric patients with UC METHODS: PROTECT (NCT01536535) was a prospective, inception cohort, multi-site study of paediatric patients aged 4-17 years with newly diagnosed UC followed for 52 weeks. Patients received standardised mesalazine, with pre-established criteria for escalation to thiopurines or anti-TNFα inhibitors. Patients used pill bottles with electronic caps to monitor mesalazine adherence. We tested whether longitudinal adherence to mesalazine predicted steroid-free remission at week 52 (i.e. quiescent disease on mesalazine alone with no corticosteroids ≥4 weeks prior) and need for treatment escalation (i.e. introduction of immunomodulators, calcineurin-inhibitors or anti-TNFα inhibitors).

RESULTS

Among 268 patients, average mesalazine adherence trajectories did not predict week 52 steroid-free remission. Declining adherence over time strongly predicted treatment escalation (β = -.037, P = .001). By month 6, adherence rate ≤85.7% was associated with treatment escalation.

CONCLUSIONS

Non-adherence may have affected therapeutic efficacy of standardised mesalazine, thereby contributing to need for treatment escalation. Routine adherence monitoring for at least 6 months following treatment initiation and addressing adherence difficulties early in the disease course are recommended.

Young age and tobacco use are predictors of lower medication adherence in inflammatory bowel disease

BACKGROUND

Medication adherence is crucial in the management of patients with inflammatory bowel disease (IBD) because medication nonadherence in these patients is associated with an increased risk of flare-up, relapse, recurrence, loss of response to anti-tumour necrosis factor agents, morbidity and mortality, and poor quality of life. Data on risk factors are very controversial in the literature.

AIM

To assess the prevalence of medication nonadherence and to identify predictors of low medication adherence in Spanish patients with IBD.

PATIENTS AND METHODS

We carried out a cross-sectional study that included consecutive outpatients with IBD attending in our adult tertiary clinic in a 3-month period. Morisky 8-Item Medication Adherence Scale questionnaire as well as a survey of sociodemographic data were used.

RESULTS

A total of 181 patients were evaluated. Almost half of the patients (46.4%) had high medication adherence, 30.9% had medium adherence, and 22.7% had low adherence. In relation to predictive factors of medication adherence, multivariate analysis showed that age was associated with high adherence [odds ratio (OR): 1.04; 95% confidence interval (CI): 1.01-1.06; P=0.002]. However, being a smoker and presence of Crohn's disease were associated with low adherence (OR: 3.47; 95% CI: 1.36-8.90; P<0.01 and OR: 2.54; 95% CI: 1.12-5.79; P<0.05, respectively).

CONCLUSION

Only half of patients were high medication adherers. Young age, active smoking, and Crohn's disease seems to be predictors of low medication adherence. On the basis of these data, efforts for reinforce medication adherence should be especially directed to young patients and smokers.

Association of Autism Spectrum Disorders and Inflammatory Bowel Disease

Autism spectrum disorders (ASD) and inflammatory bowel disease (IBD) both have multifactorial pathogenesis with an increasing number of studies demonstrating gut-brain associations. We aim to examine the association between ASD and IBD using strict classification criteria for IBD. We conducted a retrospective case-cohort study using records from the Military Health System database with IBD defined as having one encounter with an ICD-9-CM diagnostic code for IBD and at least one outpatient prescription dispensed for a medication to treat IBD. Children with ASD were more likely to meet criteria for Crohn's disease (CD) and Ulcerative colitis (UC) compared to controls. This higher prevalence of CD and UC in children with ASD compared to controls confirms the association of ASD with IBD.

A Systematic Review of Self-Management Interventions for Children and Adolescents With Inflammatory Bowel Disease

BACKGROUND

Self-management of inflammatory bowel disease is complex. Children and adolescents (CA) with inflammatory bowel disease (IBD) often have difficulty with managing aspects of their condition, resulting in treatment nonadherence and impaired psychosocial function. Self-management interventions are developed to help support patients and their parents/carers to effectively self-manage. The aim of this systematic review was to evaluate the efficacy of self-management interventions in children and adolescents with IBD.

METHODS

The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic literature search of the following databases was conducted to identify controlled trials of interventions aiming to enhance IBD self-management in CA: Medline, Embase, Cochrane, CINAHL, and PsychINFO. Two reviewers screened articles for inclusion.

RESULTS

Nine trials (11 articles) met the inclusion criteria. Most were underpowered, with 7 recruiting fewer than 50 participants. The interventions aimed to enhance psychological well-being (n = 5), medication adherence (n = 3), or calcium intake (n = 1). There was considerable heterogeneity in intervention content and outcomes assessment. Some benefits were reported in disease activity, adherence, and psychological well-being, but findings were inconsistent.

CONCLUSIONS

Self-management is difficult for CA with IBD; however, this review identified only a small number of interventions to support self-management, most of which were underpowered and only 1 that was conducted outside the United States. Clinical consensus is required on which self-management activities should be recommended to patients and targeted in interventions and which core outcomes should be assessed. Adequately powered trials of interventions are required to identify how best to support self-management in CA with IBD.

Successful Transition from Pediatric to Adult Care in Inflammatory Bowel Disease: What is the Key?

The incidence of pediatric-onset inflammatory bowel disease (IBD) is on the rise, accounting for up to 25% of IBD cases. Pediatric IBD often has extensive bowel involvement with aggressive and rapidly progressing behavior compared to adult IBD. Because IBD has a high morbidity rate and can have a lifelong impact, successful transition from pediatric to adult care is important to maintain the continuity of care. Furthermore, successful transition facilitates appropriate development and psychosocial well-being among patients, as well as comprehensive and harmonious healthcare delivery amongst stakeholders. However, there are various obstacles related to patients, family, providers, and organizations that interfere with successful transition. Successful transition requires a flexible and tailored plan that is made according to the patient's developmental abilities and situation. This plan should be established through periodic interviews with the patient and family and through close collaboration with other care providers. Through a stepwise approach to the transition process, patients' knowledge and self-management skills can be improved. After preparation for the transition is completed and the obstacles are overcome, patients can be gradually moved to adult care. Finally, successful transition can increase patients' adherence to therapy, maintain the appropriate health status, improve patients' self-management, and promote self-reliance among patients.

Successful transition from pediatric to adult care in inflammatory bowel disease: what is the key?

The incidence of pediatric-onset inflammatory bowel disease (IBD) is on the rise, accounting for up to 25% of IBD cases. Pediatric IBD often has extensive bowel involvement with aggressive and rapidly progressing behavior compared to adult IBD. Because IBD has a high morbidity rate and can have a lifelong impact, successful transition from pediatric to adult care is important to maintain the continuity of care. Furthermore, successful transition facilitates appropriate development and psychosocial well-being among patients, as well as comprehensive and harmonious healthcare delivery amongst stakeholders. However, there are various obstacles related to patients, family, providers, and organizations that interfere with successful transition. Successful transition requires a flexible and tailored plan that is made according to the patient’s developmental abilities and situation. This plan should be established through periodic interviews with the patient and family and through close collaboration with other care providers. Through a stepwise approach to the transition process, patients’ knowledge and self-management skills can be improved. After preparation for the transition is completed and the obstacles are overcome, patients can be gradually moved to adult care. Finally, successful transition can increase patients’ adherence to therapy, maintain the appropriate health status, improve patients’ self-management, and promote self-reliance among patients.

Text Messaging Effect on Adherence in Children With Inflammatory Bowel Disease

BACKGROUND

Successful treatment of patients with inflammatory bowel disease (IBD) requires regular intake of medication. Nonadherence to treatment is associated with increased frequency of relapses, morbidity, and cost.

METHODS

Pediatric patients with IBD taking oral medication and with access to text messaging (TM) services were included. Children were randomized by age, sex, medication administration responsibility (self vs parent), and disease activity (Pediatric Crohn Disease Activity Index or Pediatric Ulcerative Colitis Activity Index) into TM intervention and standard of care. Prospectively, the interventional group received 2-way TM reminders about medication administration. Failure to confirm intake by the patient resulted in a TM alert to the caregiver and weekly compliance reports were sent to patients, caregivers, and healthcare providers. Patients' medical records were reviewed and an adherence Morisky questionnaire completed at recruitment, 6 and 12 months.

RESULTS

A total of 51 children were randomized (21 TM and 30 control). The age, sex, diagnosis (ulcerative colitis/Crohn), activity index, ethnicity, insurance, and Morisky score at baseline were similar in both groups. Morisky score improved by 1 and 0.8 points, respectively in the TM group at 6 and 12 months, whereas it did not change in the control group (P = 0.0131 and P = 0.1687, prospectively).

CONCLUSIONS

TM may be effective in promoting adherence in children with IBD. Larger and longer multicenter studies are required to confirm this finding.

Remission in Pediatric Inflammatory Bowel Disease Correlates With Prescription Refill Adherence Rates

OBJECTIVES

The aim of the study was to use pharmacy benefit management (PBM) prescription claims data to assess refill adherence in pediatric inflammatory bowel disease (IBD) and correlate adherence with clinical outcomes in pediatric IBD.

METHODS

We identified 362 pediatric patients with IBD seen at Washington University from 9/1/2012 to 8/31/2013 and matched them within Express Scripts' member eligibility files for clients allowing use of prescription drug data for research purposes. Maintenance IBD medication possession ratios (MPR) were determined through PBM prescription claims data and chart review. Demographic and prospectively captured physician global assessments (PGA) were retrospectively extracted from the medical record. MPR was analyzed as continuous data and also dichotomized as greater or less than 80%.

RESULTS

Among our 362 patients, we matched 228 (63%) within Express Scripts' eligibility data files. Of those, 78 patients were continuously eligible for benefits and had at least one outpatient prescription IBD medication prescribed. Their mean MPR was 0.63 ± 0.31 (standard deviation) and 40% had an MPR ≥80%. Patients in clinical remission had a higher mean MPR than those with an active PGA (0.72 ± 0.28 vs 0.51 ± 0.32, P = 0.002) and patients whose MPR were ≥80% were more likely to have a PGA of remission than those with whose MPR were <80% (84% vs 43%, P = <0.001).

CONCLUSIONS

We found a significant association between refill adherence and clinical remission. Nonadherence was common and was more common in adolescents. Use of PBM databases to identify and intervene on patients with poor adherence may improve outcomes in pediatric IBD.

Adherence to Oral Maintenance Treatment in Adolescents With Inflammatory Bowel Disease

OBJECTIVES

The aim of this study was to systematically review the rates of nonadherence to oral maintenance treatment in adolescents with inflammatory bowel disease (IBD), and to describe perceived barriers to adherence and psychosocial factors involved.

METHODS

The article considered studies published in MEDLINE, Embase, and PsycINFO up to March 2015. Studies that had collected data on adherence to thiopurines or aminosalicylates in a cohort of adolescents with IBD. Case reports and case series were excluded.

RESULTS

A total of 25 studies were included. Lack of uniformity of outcome measures made pooling of data impossible. Rates of medication nonadherence ranged from 2% to 93%. The most frequently reported barriers were "just forgot," "wasn't home," and "interferes with activity." Family dysfunction, peer victimization, poor health-related quality of life, poor child-coping strategies, anxiety, and depressive symptoms were associated with medication nonadherence.

CONCLUSIONS

Nonadherence to oral maintenance therapy in adolescents with IBD is a significant health care problem and can lead to unnecessary escalation in therapy. Difficulties in family and social interactions, and psychosocial dysfunction can jeopardize IBD treatment outcome and should receive attention early in the course of the disease.

Can You Teach a Teen New Tricks? Problem Solving Skills Training Improves Oral Medication Adherence in Pediatric Patients with Inflammatory Bowel Disease Participating in a Randomized Trial

BACKGROUND

Medication nonadherence is associated with higher disease activity, greater health care utilization, and lower health-related quality of life in pediatric inflammatory bowel diseases (IBD). Problem solving skills training (PSST) is a useful tool to improve adherence in patients with chronic diseases but has not been fully investigated in IBD. This study assessed feasibility, acceptability, and preliminary efficacy of PSST in pediatric IBD.

METHODS

Recruitment occurred during outpatient clinic appointments. After completion of baseline questionnaires, families were randomized to a treatment group or wait-list comparison group. The treatment group received either 2 or 4 PSST sessions. Youth health-related quality of life was assessed at 3 time points, and electronic monitoring of oral medication adherence occurred for the study duration.

RESULTS

Seventy-six youth (ages 11-18 years) on an oral IBD maintenance medication participated. High retention (86%) and treatment fidelity rates (95%) supported feasibility. High satisfaction ratings (mean values ≥4.2 on 1-5 scale) supported intervention acceptability. Modest increases in adherence occurred after 2 PSST sessions among those with imperfect baseline adherence (d = 0.41, P < 0.10). Significant increases in adherence after 2 PSST sessions were documented for participants aged 16 to 18 years (d = 0.95, P < 0.05). Improvements in health-related quality of life occurred after 2 PSST sessions. No added benefit of 4 sessions on adherence was documented (d = 0.05, P > 0.05).

CONCLUSIONS

Phone-delivered PSST was feasible and acceptable. Efficacy estimates were similar to those of lengthier interventions conducted in other chronic illness populations. Older adolescents benefited more from the intervention than their younger counterparts.

Thiopurine monitoring in children with inflammatory bowel disease: a systematic review

AIMS

The aim was to systematically review the evidence on the clinical usefulness of thiopurine metabolite and white blood count (WBC) monitoring in the assessment of clinical outcomes in children with inflammatory bowel disease (IBD).

METHODS

Medline, Embase, Cochrane Central Register of controlled trials and http://www.clinicaltrials.gov were screened in adherence to the PRISMA statement by two independent reviewers for identification of eligible studies. Eligible studies were randomized controlled trials (RCTs), cohort studies and large case series of children with inflammatory bowel disease (IBD) (<18 years) who underwent monitoring of thiopurine metabolites and/or WBC.

RESULTS

Fifteen papers were identified (n = 1026). None of the eligible studies were RCTs. High 6-thioguanine nucleotide (6TGN) concentrations were not consistently associated with leucopenia. Leucopenia was not associated with achievement of clinical remission. A positive but not consistent correlation between 6TGN and clinical remission was reported. Haematological toxicity could not be reliably assessed with 6TGN measurements only. A number of studies supported the use of high 6-methylmercaptopurine ribonucleotides (6MMPR) as an indicator of hepatotoxicity. Low thiopurine metabolite concentration may be indicative of non-compliance.

CONCLUSION

Thiopurine metabolite testing does not safely predict clinical outcome, but may facilitate toxicity surveillance and treatment optimization in poor responders. Current evidence favours the combination of thiopurine metabolite/WBC monitoring and clinic follow-up for prompt identification of haematologic/hepatic toxicity safe dose adjustment, and treatment modification in cases of suboptimal clinical outcome or non-compliance. Well designed RCTs for the identification of robust surrogate markers of thiopurine efficacy and toxicity are required.

Managing inflammatory bowel disease in adolescent patients

Increasing numbers of adolescents are being diagnosed with Crohn's disease or ulcerative colitis, the two main subtypes of inflammatory bowel disease. These young people face many short- and long-term challenges; one or more medical therapies may be required indefinitely; their disease may have great impact, in terms of their schooling and social activities. However, the management of adolescents with one of these incurable conditions needs to encompass more than just medical therapies. Growth, pubertal development, schooling, transition, adherence, and psychological well-being are all important aspects. A multidisciplinary team setting, catering to these components of care, is required to ensure optimal outcomes in adolescents with inflammatory bowel disease.

6-Thioguanine levels in pediatric IBD patients: adherence is more important than dose

BACKGROUND

Thiopurine immunosuppressants such as 6-mercaptopurine (6-MP) are widely used to maintain remission in children with both Crohn's disease and ulcerative colitis. Therapeutic efficacy is associated with higher red blood cell levels of the thiopurine metabolite 6-thioguanine (6-TGN). Studies in both children and adults have inexplicably failed to demonstrate a significant correlation between prescribed dose and level of 6-TGN. We aimed to quantify the relationship between 6-TGN levels and adherence.

METHODS

We used electronic monitoring devices to assess adherence in children and adolescents with inflammatory bowel diseases who were prescribed 6-MP.

RESULTS

During 3230 days of monitoring in 19 subjects, adherence to 6-MP was 74.2%. Due to the generally low adherence to the prescribed dose of 6-MP, the 6-TGN level was not correlated with the prescribed dose. The 6-TGN level was significantly correlated with the adherence-adjusted dose (R(2) = 0.395). It was also significantly correlated to adherence alone (R(2) = 0.478). Adherence to 5-aminosalicylic acid and 6-MP were significantly positively correlated (r(s)(9) = 0.82, P = 0.00), and a significant relationship was found between 5-aminosalicylic acid adherence and 6-TGN levels independent of 6-MP adherence. Furthermore, low adherence to 6-MP was associated with increased likelihood of escalation of medical therapy.

CONCLUSIONS

Red blood cell 6-TGN levels are strongly correlated with the dose, when the dose is actually taken. Lack of efficacy of thiopurines may often be the result of poor adherence. Novel ways of assessing and improving adherence are necessary. Future trials should assess adherence in study participants. Intake of 5-aminosalicylic acid positively influences 6-TGN levels.

Self-management in pediatric inflammatory bowel disease: A clinical report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

This clinical report aims to review key self-management and adherence issues in pediatric inflammatory bowel disease (IBD) and to provide recommendations for health care providers regarding evidence-based assessment and treatment approaches to promote optimal self-management. Self-management difficulties in the form of nonadherence to treatment regimens are common in pediatric IBD and are influenced by various disease-related, individual, family, and health professional relationship factors. To promote adaptive self-management, health care providers are encouraged to adopt a long-term preventive orientation, which includes routine screening of barriers to self-management and nonadherence in the context of routine clinic appointments. The use of a multimethod approach to assessment that incorporates objective measures (eg, pill counts or bioassays) may be particularly advantageous. Individualized treatment approaches that incorporate evidence-based practices, such as providing written treatment plans and offering opportunities to practice and receive feedback on skills, may help to ameliorate minor self-management concerns; however, more severe or chronic self-management problems may require a referral for behavioral health intervention. Additional research to broaden our understanding of self-management in domains beyond medication adherence and to evaluate the effect of clinic-based interventions is imperative.

Vitamin and mineral supplement adherence in pediatric inflammatory bowel disease

OBJECTIVE

Although vitamin and mineral supplementation for nutritional deficiencies is a common component of pediatric inflammatory bowel disease (IBD) management, little is known about supplement adherence in this group. This study described adherence to multivitamin, iron, and calcium supplements among 49 youth aged 11-18 years with IBD. Additionally, the study examined relationships between supplement knowledge and adherence.

METHODS

Participants completed supplement adherence ratings using a validated interview. Knowledge was assessed using an open-ended question from the same interview; responses were later categorized into 1 of 3 knowledge sophistication categories (low, moderate, or high).

RESULTS

Mean adherence rates ranged from 32 to 44% across supplements. Youth who did not know the reason for supplementation (approximately 25% of the sample) displayed substantially poorer adherence than did those with moderate or high levels of knowledge, across all supplements.

CONCLUSIONS

Findings highlight the importance of evaluating and addressing nonadherence to vitamin and mineral supplements in youth with pediatric IBD.

Development and reliability of a correction factor for family-reported medication adherence: pediatric inflammatory bowel disease as an exemplar

OBJECTIVES

To examine the issue of accurate adherence assessment and illustrate methodologies for correcting parent-reported medication adherence.

METHODS

40 children with inflammatory bowel disease provided medication adherence data using electronic monitoring. Parents provided subjective reports of medication adherence. Receiver operating characteristic analyses were used to examine the detection of non-adherence at several adherence cut-points. 2 methods for empirically deriving a correction factor for subjectively reported adherence were applied.

RESULTS

Although parent-report and EM adherence were significantly correlated, parent-reported adherence was significantly higher than EM adherence. A 90% cut-point provided the highest sensitivity and specificity. Both correction factors reliably adjusted parent-reported adherence based on EM adherence.

CONCLUSIONS

Application of an empirically derived correction factor for parent-reported adherence using methodologies, such as those illustrated in the current study, could yield more accurate adherence assessment. Obtaining more accurate adherence assessments based on parent-report will have implications for self-management interventions, clinician prescribing behavior, and medication safety.

Adherence to anti-TNF therapy in inflammatory bowel diseases: a systematic review

BACKGROUND

Nonadherence to medications may affect disease outcomes. The aim of this article was to review methods of assessment, prevalence, and predictors of nonadherence to anti-tumor necrosis factor therapy in inflammatory bowel diseases (IBD).

METHODS

Studies were identified through the electronic database of MEDLINE (up to January 2012) and the annual meetings of Digestive Disease Week, the American College of Gastroenterology, the United European Gastroenterology Week, and the European Crohn's and Colitis Organization.

RESULTS

Among 1783 citations identified, 13 studies evaluated adherence to biologics in IBD. Several methods were used to assess adherence to anti-tumor necrosis factor, including the medication possession ratio, the medication refill adherence, and the Morisky Medication Adherence Scale 8. Pooled adherence to anti-tumor necrosis factor therapy was 82.6%. Pooled adherence was 83.1% in adalimumab and 70.7% in infliximab-treated patients. Female gender, smoking, constraints related to treatment, anxiety, and moodiness were associated with nonadherence to both infliximab and adalimumab. Concomitant immunomodulator use and time since first infusion more than 18 weeks were predictors for nonadherence to infliximab . Regimen of 40 mg every other week, syringe use (versus pen), internal medicine center prescription (versus gastroenterology center prescription), retail pharmacy (versus speciality pharmacy) and new user (versus previous user) were predictors for adalimumab nonadherence.

CONCLUSIONS

More than three-quarters of patients with IBD adhere to biologics. Predictors of nonadherence include female gender, smoking, constraints related to treatment, anxiety, and moodiness. These data could be used to develop intervention studies aimed at improving adherence to biologics in IBD.

Practical strategies for enhancing adherence to treatment regimen in inflammatory bowel disease

Promoting adherence to treatment among pediatric and adult patients with inflammatory bowel disease (IBD) is a critical yet challenging task for health care providers. Several existing interventions to enhance adherence among individuals with IBD offer useful information about practical strategies to enhance adherence. The current review article has 3 goals. First, the review provides a context for understanding treatment regimen adherence in IBD by reviewing key definitional, measurement, and conceptual challenges in this area. Next, published studies focused on interventions to enhance adherence in IBD are briefly summarized, followed by a synthesis of practical adherence promotion strategies for use in IBD by health care providers. Strategies are distinguished by the level of evidence supporting their utility as well as by age group. Finally, recommendations for future research to facilitate the development and implementation of practical, evidence-based strategies for adherence promotion in IBD are provided. Findings from the literature review suggest that strategies including education, regimen simplification, and use of reminder systems and organizational strategies (e.g., pill boxes) are likely to be best suited for addressing accidental nonadherence. In contrast, addressing motivational issues, teaching problem-solving skills, and addressing problematic patterns of family functioning are more likely to benefit individuals displaying intentional nonadherence.

Identifying youth nonadherence in clinical settings: data-based recommendations for children and adolescents with inflammatory bowel disease

BACKGROUND

To examine the validity of patient self-report of thiopurine adherence in pediatric inflammatory bowel disease (IBD) against an objective electronic monitoring adherence measure, and to investigate the role of youth and maternal involvement in remembering to take daily medications as predictors of medication adherence.

METHODS

Fifty-one youths with IBD, ages 11-18 years, participated. Youths completed questionnaire assessments of their own and their maternal caregiver's involvement in remembering to take daily medications at baseline, completed monthly interviews assessing thiopurine adherence over the past week for a period of 6 months, and utilized a Medication Events Monitoring System (MEMS) electronic monitor for their thiopurine medication for 6 months. Participants were grouped into adherent (at least 80% of doses taken based on objective MEMS caps) or nonadherent for analyses.

RESULTS

Youths who were nonadherent based on electronic monitoring overestimated their adherence by 23%, whereas adherent youths overestimated their adherence by only 2%, and as such patient self-report offered little utility in identifying youths who were nonadherent. Youths who reported high levels of involvement in remembering to take their medications were nearly eight times less likely to be nonadherent.

CONCLUSIONS

The current findings provide evidence that clinicians who work with children and adolescents with IBD may benefit from modifying their approach to nonadherence screening. Asking about youth involvement in remembering daily medications may be more informative than asking them to recall their medication-taking behavior over the last week in identifying those at highest risk for nonadherence.

Pros and cons of medical management of ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory disease characterized by diffuse mucosal inflammation limited to the colon and rectum. Although a complete medical cure may not be possible, UC can be treated with medications that induce and maintain remission. The medical management of this disease continues to evolve with a goal to avoid colectomy and ultimately alter the natural history of UC. Emergence of antitumor necrosis factor-α (TNF-α) agents has expanded the medical armamentarium. 5-Aminosalicylates continue to be used in mild to moderate UC and corticosteroids are mainly used for induction of remission with immunomodulators (6-mercaptopurine/azathiopurine/methotrexate) being applied as steroid-sparing agents for maintenance therapy. Infliximab has been approved by the U.S. Food and Drug Administration and used in the treatment of moderate to severe UC; nevertheless, its use may be associated with significant adverse effects and have a negative impact on the postoperative course should the patients undergo restorative proctocolectomy. In addition, there is always a concern about patients' compliance to medical therapy, cost of medications, and risk for UC-associated dysplasia. The authors discuss the pros and cons of medications used in the treatment of UC.

Treatment adherence in adolescents with inflammatory bowel disease: the collective impact of barriers to adherence and anxiety/depressive symptoms

OBJECTIVE

Knowledge of factors impacting adolescents' ability to adhere to their inflammatory bowel disease (IBD) regimen is limited. The current study examines the collective impact of barriers to adherence and anxiety/depressive symptoms on adolescent adherence to the IBD regimen.

METHODS

Adolescents (n = 79) completed measures of barriers to adherence, adherence, and anxiety/depressive symptoms at one of two specialty pediatric IBD clinics.

RESULTS

Most adolescents reported barriers to adherence and 1 in 8 reported borderline or clinically elevated levels of anxiety/depressive symptoms. Anxiety/depressive symptoms moderated the relationship between barriers to adherence and adherence. Post hoc probing revealed a significant, additive effect of higher anxiety/depressive symptoms in the barriers-adherence relationship, with adherence significantly lower among adolescents with higher barriers and higher anxiety/depressive symptoms.

CONCLUSIONS

In order to optimize adherence in adolescents, interventions should target not only barriers to adherence but also any anxiety/depressive symptoms that may negatively impact efforts to adhere to recommended treatment.

Treatment adherence in paediatric inflammatory bowel disease: perceptions from adolescent patients and their families

The objective of this study was to examine patient- and parent-perceived factors that impact adherence to inflammatory bowel disease treatment using a qualitative descriptive individual interview approach. Sixteen adolescents and their parents were recruited from May through August 2007 and interviewed about medication adherence using an open-ended semi-structured interview format. Interviews were audio recorded, transcribed, and coded into themes. Parent-child dyads identified forgetting, interfering activities, parent-child conflict and oppositional behaviour and inadequate planning for treatment as challenges to adherence. Participants reported that family support and good parent-child relationships, routines, monitoring and reminding and organisational tools such as pill boxes facilitated treatment adherence. Other issues that emerged included immediacy of treatment effects and parent-adolescent responsibility for treatment. Patients and parents experience a number of challenges related to adherence within behavioural, educational, organisational and health belief domains. Behavioural interventions should focus on these issues, reduction of perceived barriers, and effective transition of responsibility for treatment adherence. Future research considerations are discussed.

Volitional and accidental nonadherence to pediatric inflammatory bowel disease treatment plans: initial investigation of associations with quality of life and disease activity

OBJECTIVE

To examine rates of volitional and accidental nonadherence, and explore potential differential associations of each with disease activity and quality of life (QOL), in pediatric patients with inflammatory bowel disease (IBD).

METHODS

One hundred families (100 parents, 78 adolescents) recruited from a large Midwestern children's hospital reported on the child's medication nonadherence and QOL. Healthcare providers supplied disease activity ratings.

RESULTS

Most adolescents (73.1%) and parents (70.1%) reported engaging in accidental nonadherence, whereas a smaller group (35 and 30%, respectively) reported engaging in volitional nonadherence to the child's prescribed medication regimen. Frequency of accidental nonadherence was unrelated to disease activity or any specific QOL area examined, whereas greater frequency of volitional nonadherence was associated with greater disease activity and poorer parent reported psychosocial QOL.

CONCLUSIONS

Nonadherence and the relationship with disease severity and QOL may be more complex for children with IBD than understood through previous work.

Predictors of medication adherence in pediatric inflammatory bowel disease patients at the Stollery Children's Hospital

BACKGROUND

Patients with inflammatory bowel disease (IBD) often do not take their medications as prescribed.

OBJECTIVE

To examine self-reported adherence rates in IBD patients at the Stollery Children's Hospital (Edmonton, Alberta) and to determine predictors of medication adherence.

METHODS

A survey was mailed to 212 pediatric IBD patients of the Stollery Children's Hospital. A chart review was completed for those who returned the survey.

RESULTS

A total of 119 patients completed the survey. The nonresponders were significantly older than responders (14.5 years versus 13.2 years; P=0.032). The overall adherence rate was 80%. Nonadherence was associated with older age (14.6 years versus 13.0 years; P=0.04), longer disease duration (5.0 years versus 3.1 years; P=0.004) and reported use of herbal medications (40.0% versus 13.6%; P=0.029). The most common reasons reported for missing medications were forgetfulness, feeling better and too many medications. In addition, patients reported being more likely to take anti-inflammatory medications and less likely to take herbal medicines.

CONCLUSION

Identified predictors of nonadherence such as age, disease duration and use of herbal treatments may enable the development of specific strategies to improve adherence in adolescents with IBD.

Barriers to adherence among adolescents with inflammatory bowel disease

BACKGROUND

The purpose of this study was to describe barriers to adherence among adolescents with inflammatory bowel disease (IBD) and to examine demographic, disease-related, and treatment regimen-related correlates of adherence barriers using a multimethod reporting strategy. A final goal was to examine relationships between the frequencies of barriers and levels of nonadherence.

METHODS

In all, 64 adolescents (ages 11-18) participated, along with 61 mothers and 25 fathers. Barriers to adherence and ratings of medication adherence were assessed via patient and parent reports. Disease activity ratings were provided by pediatric gastroenterologists.

RESULTS

Lack of time and medication side effects were commonly reported barriers across adolescent, mother, and father reports. Other adolescent-reported barriers included missing medication due to feeling well or discontinuing medication based on the belief that the medication was not working. The prevalence of adherence barriers was not consistently associated with adolescent age, sex, time since diagnosis, or disease activity. Adolescents whose regimen involved more than 1 daily medication administration had more adherence barriers based on adolescent and maternal report than did those whose regimen involved 1 or less than 1 daily medication administration. Finally, adherence barriers were significantly higher among families reporting imperfect adherence as compared to those reporting perfect adherence.

CONCLUSIONS

Barriers to medication adherence do exist among adolescents with IBD and may have negative implications for medication adherence. Systematic assessment of barriers during routine medical appointments may help to identify and modify these barriers and ultimately improve adherence.

Brief report: Barriers to treatment adherence in pediatric inflammatory bowel disease

OBJECTIVE

To examine perceived barriers to medication adherence in inflammatory bowel disease (IBD) treatment and their relationship with adherence using a combined forced choice and semi-structured interview assessment approach.

METHODS

Sixteen adolescents with IBD and their parents participated in an open-ended interview regarding adherence barriers and completed quantitative measures of adherence, barriers to treatment, and disease severity.

RESULTS

The most commonly identified barriers to adherence were forgetting, interference with other activities, difficulty swallowing pills, and not being at home. Number of reported barriers was positively correlated with objective nonadherence for 6-MP/azathioprine. Nonadherence frequency was 42% for 6-MP/azathoprine and 50% for 5-ASA medications.

CONCLUSIONS

Using a combined assessment approach, patients and parents reported several barriers to treatment adherence that are appropriate for clinical intervention. This is critical given the significant medication nonadherence observed in this sample and the relationship between total number of barriers and disease management problems.

Symposium 6: Young people, artificial nutrition and transitional care: Nutrition, growth and puberty in children and adolescents with Crohn's disease

Of the individuals who present with Crohn's disease 25% are <18 years of age, mostly adolescent. Nutritional impairment and delayed growth are common at diagnosis and remain an issue during the disease course. Treatment has the primary aim to control symptoms, induce disease remission and achieve normal growth in the long term and includes nutritional support and early use of immunomodulation. Puberty may be discordant and is generally late and final adult height may not be achieved until the late teenage years. Chronic ill health and delayed growth may be accompanied by emotional and intellectual immaturity. These factors, including the varying rates of physical and emotional development, need to be considered during adolescence with multidisciplinary input to ensure that the young patient is appropriately supported. Transition to adult care requires close collaboration between paediatric and healthcare teams with careful attention to nutritional, emotional and educational issues, all of which are relevant in the progression from childhood, through adolescence and to adult life.

Barriers to oral medication adherence for adolescents with inflammatory bowel disease

OBJECTIVE

To identify family-reported, adherence-related barriers for adolescents with inflammatory bowel disease (IBD) and examine their relationship to 6-MP/azathioprine and 5-ASA medication adherence.

METHODS

Participants included 74 adolescents, aged 13-17 years, diagnosed with IBD and their caregivers. Adolescents and caregivers jointly completed a measure of barriers to medication adherence. Adherence to medication was measured by family-report, pill-count, and serum assay.

RESULTS

Families endorsed one to seven total barriers to medication adherence. The most commonly reported barriers included forgetting, being away from home, and interference with an activity. Neither demographic nor disease severity variables were related to the total number of reported barriers. Fewer total reported barriers was related to better adherence by adolescent and maternal report.

CONCLUSION

Most families experience at least one barrier to treatment adherence. Effective problem-solving around these barriers and its integration into future treatment protocols may help improve medication adherence in the pediatric IBD population.

Prevalence, predictors, and clinical consequences of medical adherence in IBD: How to improve it?

Inflammatory bowel diseases (IBD) are chronic diseases with a relapsing-remitting disease course necessitating lifelong treatment. However, non-adherence has been reported in over 40% of patients, especially those in remission taking maintenance therapies for IBD. The economical impact of non-adherence to medical therapy including absenteeism, hospitalization risk, and the health care costs in chronic conditions, is enormous. The causes of medication non-adherence are complex, where the patient-doctor relationship, treatment regimen, and other disease-related factors play key roles. Moreover, subjective assessment might underestimate adherence. Poor adherence may result in more frequent relapses, a disabling disease course, in ulcerative colitis, and an increased risk for colorectal cancer. Improving medication adherence in patients is an important challenge for physicians. Understanding the different patient types, the reasons given by patients for non-adherence, simpler and more convenient dosage regimens, dynamic communication within the health care team, a self-management package incorporating enhanced patient education and physician-patient interaction, and identifying the predictors of non-adherence will help devise suitable plans to optimize patient adherence. This editorial summarizes the available literature on frequency, predictors, clinical consequences, and strategies for improving medical adherence in patients with IBD.

Objective versus subjective assessment of oral medication adherence in pediatric inflammatory bowel disease

BACKGROUND

The objective was to examine the prevalence and frequency of oral medication nonadherence using a multimethod assessment approach consisting of objective, subjective, and biological data in adolescents with inflammatory bowel disease (IBD).

METHODS

Medication adherence was assessed via pill counts, patient/parent interview, and 6-thioguanine nucleotide (6-TGN)/6-methylmercaptopurine nucleotide (6-MMPN) metabolite bioassay in 42 adolescents with IBD. Pediatric gastroenterologists provided disease severity assessments.

RESULTS

The objective nonadherence prevalence was 64% for 6-MP/azathioprine (AZA) and 88% for 5-aminosalicylate (5-ASA) medications, whereas subjective nonadherence prevalence was 10% for 6-MP/AZA and 2% for 5-ASA. The objective nonadherence frequency was 38% for 6-MP/AZA and 49% for 5-ASA medications, and subjective nonadherence frequency was 6% for 6-MP/AZA and 3% for 5-ASA. The bioassay data revealed that only 14% of patients had therapeutic 6-TGN levels.

CONCLUSIONS

The results indicate that objectively measured medication nonadherence prevalence is consistent with that observed in other pediatric chronic illness populations, and that objective nonadherence frequency is considerable, with 40%-50% of doses missed by patients. Subjective assessments appeared to overestimate adherence. Bioassay adherence data, while compromised by pharmacokinetic variation, might be useful as a cursory screener for nonadherence with follow-up objective assessment. Nonadherence in 1 medication might also indicate nonadherence in other medications. Clinical implications and future research directions are provided.

Systematic review: impact of non-adherence to 5-aminosalicylic acid products on the frequency and cost of ulcerative colitis flares

BACKGROUND

Ulcerative colitis (UC) can be maintained in remission with 5-aminosalicylic acid (5-ASA) medications, but frequent non-adherence by patients who are feeling well has been associated with more frequent flares of colitis.

AIM

To perform a systematic review of the published literature and unpublished randomized clinical trials (RCTs) regarding the impact of non-adherence with 5-ASA medications on the incidence of UC flares and costs of care.

METHODS

A search of MEDLINE, EMBASE and the Cochrane databases was performed. Prospective studies of UC maintenance with 5-ASAs in adults were selected if they included data on adherence and disease flares. Studies using insurance claims data to estimate the impact of non-adherence on cost of care were included. Data from unpublished RCTs were obtained from the FDA with a request under the Freedom of Information Act.

RESULTS

The relative risk for flare in non-adherent vs. adherent patients ranged from 3.65 to infinity. Data were obtained from six unpublished 5-ASA RCTs, but none measured the impact of adherence on disease activity. The comorbidity-adjusted annual costs of care in adherent patients were 12.5% less than in non-adherent patients, despite increased medication expenditures.

CONCLUSIONS

A substantial proportion of UC flares and medical costs of UC are attributable to 5-ASA non-adherence. As non-adherence to 5-ASA medications is common, cost-effective strategies to improve adherence are needed. The impact of adherence on disease activity should be measured in RCTs of all inflammatory bowel disease treatments.

Treatment regimen adherence in pediatric gastroenterology

OBJECTIVE

To review and critically evaluate the extant research pertaining to adherence in pediatric gastroenterological diseases, particularly inflammatory bowel disease and celiac disease, and to provide recommendations for future research development.

MATERIALS AND METHODS

A literature search with no date restriction was conducted using PubMed and PsychInfo electronic databases and bibliographies of relevant articles.

RESULTS

Adherence rates in inflammatory bowel disease and celiac disease range considerably from 16% to 62% and 5% to 70%, respectively, across treatments and assessment method; nonadherence frequency was generally not reported. Measures used to assess adherence included self-report, interview, diet record, and bioassay methods, and each measure demonstrated strengths and limitations. Limited evidence suggests that adherence in both disease populations is related to patient and family behavioral factors and that nonadherence is related to poor disease outcome. Treatment outcome research for nonadherence is scant in the current literature.

CONCLUSIONS

Future research should focus on refining assessment method, examining adherence and concomitant behavioral factors longitudinally, testing theoretical models of adherence, and developing efficacious treatments for nonadherence.

Medication adherence and quality of life in pediatric inflammatory bowel disease

OBJECTIVE

To examine the relationship between medication adherence and quality of life (QOL) in adolescent patients with inflammatory bowel disease (IBD) utilizing a multimethod adherence assessment approach.

METHODS

Medication adherence in 36 adolescents with IBD was assessed via interviews, pill counts, and biological assays. QOL was assessed via patient and parent report. Pediatric gastroenterologists provided disease severity assessments.

RESULTS

Hierarchical multiple regression analyses revealed that adherence contributed significant variance to patient-reported QOL but not parent-reported QOL. Nonadherence to 6-MP/azathioprine was related to poorer patient-reported physical health QOL. Greater self-reported 5-ASA adherence was related to poorer overall psychological health QOL, and particularly social functioning QOL.

CONCLUSIONS

Results provide preliminary support for the negative effects of 6-MP/azathioprine nonadherence on QOL and an inverse relationship between 5-ASA adherence and QOL in this population. Adherence burden in patients and the utility of multimethod adherence assessment in research are discussed.

Adherence to thiopurine treatment in out-patients with Crohn's disease

BACKGROUND

High frequency of incomplete or non-response to azathioprine (AZA) and/or mercaptopurine (MP) limit their use in Crohn's disease (CD). Non-adherence is considered to be of relevance for ineffectiveness.

AIM

To assess adherence to thiopurines in CD out-patients treated in a single gastroenterology practice.

METHODS

Patients were eligible for inclusion if they received AZA/MP for at least 3 months. After follow-up of 3 months, adherence to AZA/MP was assessed by quantitation of relevant thiopurine metabolite levels in red blood cells as well as by patients' self-report using standardized questionnaire.

RESULTS

Sixty-five patients were prospectively included. Six patients (9.2%) had metabolite profiles indicative of non-adherence. Self-assessed questionnaire revealed non-adherence in four of 56 patients (7.1%). Therapeutic drug monitoring (TDM) and self-assessment as two independent methods had a concordance rate of 75%. Metabolite levels and self-assessed adherence were not significantly different between patients in remission compared with those with active disease.

CONCLUSIONS

Out-patients with CD treated in a single gastroenterology practice had a satisfactory adherence (>90%) to thiopurine therapy. Different measures of adherence (TDM and self-report) applied to the same patient suggest comparable levels. TDM appears to be a reliable tool to assess adherence to thiopurines in clinical practice.