Adherence to treatment in patients with Behçet's disease

A systematic review of sex and gender differences in treatment outcome of inflammatory skin diseases: Is it time for new guidelines?

BACKGROUND

Gender- and sex-specific differences in medicine were long-time disregarded. Despite numerous indications of gender- and sex-specific influences on the treatment of dermatological conditions, these have not yet been systematically investigated.

OBJECTIVES

To meet this unmet need, we conducted the present systematic review on the topic of gender and sex differences in the treatement outcome of skin diseases.

METHODS

Embase (via Ovid), PubMed Medline and Web of Science were searched, in between January 2001 and December 2022. English and german randomized controlled trials, prospective and retrospective cohorts and case-control studies that examined differences between men and women in treatment outcomes of skin diseases were included.

RESULTS

Two authors independently screened the reports for eligibility, one extracted all data (the second double-checked) and critically appraised the quality and risk of bias of the studies. Eighty-three reports were included. The largest share of the identified publications focused on gender differences in psoriasis and psoriatic arthritis (n = 49), followed by melanoma (n = 8) and sporadic studies (n < 5) of inflammatory, infectious and autoimmune skin diseases. The main topics in which gender differences could be identified were choice of treatment, time to initiation of treatment, therapy response, adverse events, adherence and treatment satisfaction. For psoriasis, gender differences could be found in all aspects, while for the other skin diseases specific publications on gender differences are still missing.

CONCLUSIONS

This systematic review shows numerous gender differences but also reveals major gaps in gender-specific care in dermatology which should be narrowed in the upcoming years to optimize a patient-centred, individualized, gender-equal healthcare. PROSPERO Registration: CRD42022306626.

Epidemiology and treatment of Adamantiades-Behçet's disease in Germany: A healthcare claims database study

BACKGROUND

Adamantiades-Behçet's disease (ABD) is a rare, chronic, relapsing, multisystem vasculitis, with a reported prevalence of 0.9 out of 100,000 population in Germany in 2012. However, more recent epidemiological data are lacking.

OBJECTIVES

To estimate the prevalence and incidence of ABD in Germany and assess associated comorbidities and current treatment patterns.

METHODS

This retrospective cohort study used claims data from the anonymized Institute for Applied Health Research Berlin (InGef) research database. Cohorts were formed for the observation years 2016, 2017 and 2018, using data from 2013 to 2018 (allowing for a 3-year baseline period for incidence data). The study population included patients ≥18 years old with a diagnosis of ABD (ICD-10 diagnostic code M35.2), covered under the statutory health insurance system and in the InGef research database, with continuous insurance in the observation year and baseline period. We descriptively evaluated prevalence (≥2 outpatient ABD diagnoses in different quarters/≥1 main inpatient diagnosis in the observation year), incidence (no confirmed outpatient/inpatient diagnosis in the baseline period), comorbidities reported during the study and ABD-related medications.

RESULTS

We identified 300, 303 and 329 patients diagnosed with ABD in 2016, 2017 and 2018, respectively, with fewer than half (122/300 [40.7%], 127/303 [41.9%] and 150/329 [45.6%]) prescribed ≥1 disease-related medication. In the treated population, ABD prevalence was 3.9 (2016), 4.1 (2017) and 4.7 (2018) per 100,000 population; annual ABD incidence was 0.5 per 100,000 population in 2016 and 2017 and 0.6 per 100,000 population in 2018. The most commonly reported comorbidities in patients diagnosed with ABD were dorsalgia (an indicator of possible misdiagnosis), disorders of refraction and accommodation, and essential (primary) hypertension. Prednisolone, colchicine and azathioprine were the most commonly prescribed treatments for ABD, with approximately 15% of patients taking >1 medication for ABD.

CONCLUSIONS

The reported data provide evidence that ABD remains a rare disease in Germany.

Treatment Adherence Effect on the Visual Acuity of Behçet's Uveitis Patients

PURPOSE

This study aimed to explore the relationship between treatment adherence, visual acuity, quality of life (QoL), depression, and anxiety levels in individuals with Behçet's uveitis (BU).

METHODS

A total of 55 BU patients and 55 healthy controls completed sociodemographic questionnaires, the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), World Health Organization Quality of Life Questionnaire-BREF version (WHOQOL-BREF), Self-reported Questionnaire About Treatment Compliance, and the Morisky Medication Adherence Scale (MMAS). The scores obtained from these scales were analyzed to assess the relationship between treatment adherence, visual acuity, QoL, depression, and anxiety levels.

RESULTS

The results revealed that 36 (65.4%) of the 55 BU patients exhibited depressive symptoms, while 45 (81.8%) of them experienced symptoms of anxiety. Patients with BU demonstrated significantly higher BAI and BDI scores compared to the healthy control group (p < 0.001). Furthermore, the patient group reported lower mean scores across multiple domains of the WHOQOL-BREF questionnaire, including general health, psychological health, social relationships, and environment (p < 0.05). Moreover, a significant association was observed between low treatment adherence and lower values of best-corrected visual acuity (BCVA) (p < 0.05), as well as a higher frequency of uveitis attacks (p = 0.005).

CONCLUSION

Poor treatment adherence in BU patients has a negative effect on final visual acuity outcomes. Moreover, BU patients experience lower QoL and higher rates of depression and anxiety compared to the healthy control group. These findings highlight the importance of addressing treatment adherence and psychological well-being in the management of BU.

A patient-driven registry on Behçet's disease: the AIDA for patients pilot project

Introduction

This paper describes the creation and preliminary results of a patient-driven registry for the collection of patient-reported outcomes (PROs) and patient-reported experiences (PREs) in Behçet's disease (BD).

Methods

The project was coordinated by the University of Siena and the Italian patient advocacy organization SIMBA (Associazione Italiana Sindrome e Malattia di Behçet), in the context of the AIDA (AutoInflammatory Diseases Alliance) Network programme. Quality of life, fatigue, socioeconomic impact of the disease and therapeutic adherence were selected as core domains to include in the registry.

Results

Respondents were reached via SIMBA communication channels in 167 cases (83.5%) and the AIDA Network affiliated clinical centers in 33 cases (16.5%). The median value of the Behçet's Disease Quality of Life (BDQoL) score was 14 (IQR 11, range 0-30), indicating a medium quality of life, and the median Global Fatigue Index (GFI) was 38.7 (IQR 10.9, range 1-50), expressing a significant level of fatigue. The mean Beliefs about Medicines Questionnaire (BMQ) necessity-concern differential was 0.9 ± 1.1 (range - 1.8-4), showing that the registry participants prioritized necessity belief over concerns to a limited extent. As for the socioeconomic impact of BD, in 104 out of 187 cases (55.6%), patients had to pay from their own pocket for medical exams required to reach the diagnosis. The low family socioeconomic status (p < 0.001), the presence of any major organ involvement (p < 0.031), the presence of gastro-intestinal (p < 0.001), neurological (p = 0.012) and musculoskeletal (p = 0.022) symptoms, recurrent fever (p = 0.002), and headache (p < 0.001) were associated to a higher number of accesses to the healthcare system. Multiple linear regression showed that the BDQoL score could significantly predict the global socioeconomic impact of BD (F = 14.519, OR 1.162 [CI 0.557-1.766], p < 0.001).

Discussion

Preliminary results from the AIDA for Patients BD registry were consistent with data available in the literature, confirming that PROs and PREs could be easily provided by the patient remotely to integrate physician-driven registries with complementary and reliable information.

Consequences of COVID-19 on Uveitis Patients from Their Own Perspective: A Questionnaire-based Study

PURPOSE

Given their immunocompromised status, uveitis patients should be particularly careful during the COVID-19 pandemic. Treatment compliance and adherence are among the most important patient-related determinants of treatment success.To assess the effect of the COVID-19 pandemic on the management of uveitis patients from their own perspective.

METHODS

A questionnaire was performed on uveitis patients at Cairo University Hospital in the period between June and August 2020.

RESULTS

Overall, 150 responses were received. Almost 20% patients stopped their medications. A total of 61.7% patients reported no fears regarding getting infected with the novel coronavirus. In addition, 54% patients found medical services easily, 26% patients received them through telemedicine, and 34% patients reported worsening of their ocular condition.

CONCLUSIONS

COVID-19 has caused a decrease in uveitis patient compliance with follow-ups, leading to worsening of their ocular condition. Economic and psychological effects of COVID-19 pandemic on any chronic patient should be addressed to prevent further deterioration as the pandemic continues.

Emergence of New Manifestations During Infliximab Treatment in Behçet Syndrome

OBJECTIVES

Infliximab (IFX) is being increasingly used for the treatment of severe manifestations of Behçet syndrome (BS). However, emergence of new manifestations has also been occasionally reported during IFX treatment. We aimed to assess the frequency of new manifestations in our BS patients treated with IFX.

METHODS

A chart review was conducted to identify all BS patients treated with IFX in our clinic between 2004 and 2020. Demographic data, indications for IFX initiation, concomitant treatments, and outcomes were recorded. A new manifestation was defined as the emergence of a new organ involvement or mucocutaneous manifestation developing for the first time during IFX treatment or within 12 weeks after the last infusion of IFX.

RESULTS

Among our 282 patients who used IFX, 19 (7%) patients had developed a total of 23 new manifestations during a mean follow up of 20.0 ± 15.3 months. Patients with vascular involvement were more likely to develop a new manifestation (12/19, 63%). Initial manifestations that required IFX were in remission at the time of new manifestation in 14/19 patients. IFX treatment was intensified (n = 6) and/or glucocorticoids, immunosuppressives, or colchicine were added to IFX (n = 21). IFX was switched to another agent for the remaining manifestations (n = 8). These treatment modifications led to remission in 17/19 patients.

CONCLUSION

New manifestations developed during IFX treatment in 7% of our patients with BS. They could be managed by intensifying IFX treatment or adding other agents in majority of these manifestations.

A systematic literature review of existing tools used to assess medication adherence in connective tissue diseases: the state of the art for the future development of co-designed measurement tools

Lack of medication adherence is frequent in chronic connective tissue diseases and is associated with poorer health outcomes, low quality of life and economic loss. This research is based on a systematic literature search and aims to identify the surveys and tools used for the assessment of medication adherence in patients with connective tissue diseases (CTDs) and in particular the tools co-designed with patients. A systematic literature review was performed in PubMed and Embase databases searching for studies concerning the application of surveys or tools designed for medication adherence assessment. A specific analysis was also performed to identify which of these existing tools were developed in co-design with patients affected by CTDs. 1958 references were identified, and 31 studies were finally included. Systemic lupus erythematosus was the most investigated disease, followed by the Behçet's disease. The tools used to assess adherence in CTDs were, in most cases, valid and useful. However, the results showed a certain degree of heterogeneity among the studies and the medication adherence assessment and measurement tools adopted, which were mostly based on selfreported questionnaire. No co-designed tools with patients were found. Low- and non-adherence were explored in some CTDs with valid and useful tools, while other CTDs still need to be assessed. Therefore, more efforts should be made to better understand the specific reasons for the low- and non-adherence in CTDs patients.

Experiences of the Patients with Behcet's Syndrom from Adherence to Treatment: A Qualitative Content Analysis

Background

Adherence to treatment plays an important role in the effectiveness of treatment in patients with Behcet's Syndrome (BS). An in-depth understanding of the experiences of patients with BS will help to improve the patients' management. The present qualitative study aimed to explore the experiences of patients with BS from adherence to treatment.

Methods

This qualitative study was conducted during February-September 2019 at Shahid Motahari Behcet's Clinic in Shiraz, Iran. Data were collected through eight unstructured observations and 22 individual in-depth semi-structured interviews with 20 participants (15 patients with BS, three family members, and two rheumatologists). Data analysis was performed simultaneously with data collection, using the conventional content analysis as proposed by Graneheim and Lundman. Data were managed using MAXQDA 10 software.

Results

Data analysis resulted in 21 sub-categories, seven categories, and three themes. The themes included barriers to treatment adherence (inability to cope with treatment and challenges in access to health care), facilitators of treatment adherence (incentives, receiving support, and striving to adapt to illness), and missing aspects of the treatment program (inadequate patient education and the neglect of lifestyle modification).

Conclusion

The barriers to and facilitators of treatment adherence as well as the missing aspects of the treatment program of patients with BS were identified. Adherence to treatment is not only determined by the patients, but also affected by the support system and relies upon the existing context and the nature of the treatment plan. These parameters should be considered during patient management to effectively promote treatment adherence.

Long-term outcome and predictors of remission in Behçet's disease in daily practice

BACKGROUND

Many factors can influence the response to treatment and prognosis of Behçet's disease (BD). Identifying the predictors of response to treatment can improve the quality and decrease the cost of medical care. This analytical study was performed to identify factors affecting the remission and outcome in BD patients with long-term follow-up.

METHODS

A total of 245 BD patients aged over 16 years were followed for at least 12 months and visited at least three times a year were included. The outcome was assessed by the number of patients who were in sustained and long-term remission, had lost the primary criteria of BD for at least 12 months, were asymptomatic, and developed the sequela of disease or deceased. Sustained remission was defined as being in remission for at least six months. Long-term remission was defined as remission for ≥ 5 years.

RESULTS

Mean age and mean duration of follow-up were 35.1 ± 10.7 years and 92.3 months, respectively. At the end of follow-up, 63.2% of the patients lost the criteria of BD, 51.8% of the cases were in sustained remission, and 36.2% of them were asymptomatic. Predictors of sustained remission were adherence to therapy and treatment for more than six years. Having genital ulcers and treatment with methotrexate were associated with non-remission. Predictor of long-term remission was remission induction in the first two years of the treatment. Treatment with methotrexate was associated with non-remission. Poor outcome was observed in 31.8% of patients. Male sex, obesity, and having severe disease were the risk factors of poor outcome.

CONCLUSION

Achieving remission in BD is not inaccessible. Treatment with conventional and biologic disease-modifying antirheumatic drugs may cause sustained and long-term remission. Adherence to treatment, remission induction during the two years after the diagnosis and treatment for at least six years have significant role.

Comparability of European League Against Rheumatology-Recommended Pharmacological Treatments of Oral Ulcers Associated with Behçet's Disease: A Systematic Literature Review of Randomized Controlled Trials

Objective

Oral ulcers are the cardinal manifestation in Behçet's disease (BD). The 2018 European League Against Rheumatism (EULAR) recommendations describe treatments for BD-associated oral ulcers with mucocutaneous involvement; however, little comparative effectiveness information for these agents is available. In the absence of head-to-head trials, an indirect treatment comparison (ITC) could provide useful evidence regarding comparative effectiveness of BD treatments. The purpose of this study was to conduct a comparative systematic literature review (SLR) and similarity assessment of randomized controlled trials (RCTs) investigating the oral ulcer-related efficacy outcomes of EULAR-recommended treatments for BD-associated oral ulcers to determine the feasibility of an ITC.

Methods

An SLR was performed to identify relevant RCTs indexed in MEDLINE/Embase before May 29, 2019. RCT similarities for the ITC were assessed based on a step-wise process recommended by the International Society for Pharmacoeconomics and Outcomes Research.

Results

In total, 317 articles were identified, of which 14 RCTs, reflecting 11 EULAR-recommended treatments, were evaluated in a similarity assessment. Number of oral ulcers, resolution of oral ulcers, and healing time for oral ulcers were identified as the possible oral ulcer-related outcomes. After completing the similarity assessment of these outcomes, it was determined that a robust ITC was infeasible for the three oral ulcer-related outcomes due to heterogeneity in outcomes reporting, study design, and/or patient characteristics. More broadly, the results underscore the need for and consistent use of standardized measures for oral ulcer outcomes to facilitate comparative research.

Conclusion

In the absence of head-to-head RCTs and infeasibility of quantitative ITC, comparative assessments for BD-associated oral ulcers are limited, including comparative effectiveness and cost-effectiveness evaluations. Healthcare decision-makers must continue to base treatment decisions on the extent and strength of available evidence (eg, robust RCTs), clinical guidelines, real-world experience, and patient considerations.

Evaluation of treatment adherence in patients with Behçet's disease: its relation to disease manifestations, patients' beliefs about medications, and quality of life

INTRODUCTION/OBJECTIVES

Despite its importance, adherence to treatment has not been sufficiently studied in Behçet's disease (BD). The aim of this study was to evaluate medication adherence in BD using the Compliance Questionnaire of Rheumatology (CQR) and factors potentially affecting it.

METHOD

This cross-sectional study included 67 consecutive BD patients including 57 (85%) males with a mean age of 35.1 ± 9.27 years and mean disease duration of 129 ± 91 months. The cumulative clinical manifestations, the Behçet's Disease Current Activity Form (BDCAF) score, and the Vasculitis Damage Index (VDI) were recorded. The CQR, Socioeconomic Status Questionnaire for Health Research in Egypt (SES), the Beliefs about Medication Questionnaire (BMQ), and the Short Form 36 (SF-36) quality of life assessment questionnaire were administered to the patients. Linear regression analysis was done to determine independent predictors of CQR.

RESULTS

The mean BDCAF score was 3.27 ± 3.54 and the VDI was 3.36 ± 2.21. The mean CQR score was 69.2 ± 11.79. The CQR score varied significantly among different health sources (p = 0.02), with no relationship detected with other sociodemographic characteristics, nor with clinical characteristics or the SF-36. Among the investigated medications' complexities, severity of side effects showed significantly different CQR scores (p = 0.004), and a weak positive correlation between medications' numbers and the CQR was detected. Predictors for higher CQR scores included the necessity beliefs score of the BMQ (β = 1.1, p < 0.001); whereas, predictors for lower CQR scores were the harm and concern BMQ subscales ((β = - 1.5, p = 0.004) and (β = - 0.72, p = 0.032), respectively).

CONCLUSIONS

Beliefs about medications were the only predictor for adherence in our cohort.