Investigating barriers to immunosuppressant medication adherence in renal transplant patients

The Gut Microbiome and Symptom Burden After Kidney Transplantation: An Overview and Research Opportunities

Many kidney transplant recipients continue to experience high symptom burden despite restoration of kidney function. High symptom burden is a significant driver of quality of life. In the post-transplant setting, high symptom burden has been linked to negative outcomes including medication non-adherence, allograft rejection, graft loss, and even mortality. Symbiotic bacteria (microbiota) in the human gastrointestinal tract critically interact with the immune, endocrine, and neurological systems to maintain homeostasis of the host. The gut microbiome has been proposed as an underlying mechanism mediating symptoms in several chronic medical conditions including irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, and psychoneurological disorders via the gut-brain-microbiota axis, a bidirectional signaling pathway between the enteric and central nervous system. Post-transplant exposure to antibiotics, antivirals, and immunosuppressant medications results in significant alterations in gut microbiota community composition and function, which in turn alter these commensal microorganisms' protective effects. This overview will discuss the current state of the science on the effects of the gut microbiome on symptom burden in kidney transplantation and future directions to guide this field of study.

Development and Internal Validation of a Questionnaire Assessing Predisposition to Nonadherence to Immunosuppressive Medication in Kidney Pretransplant Patients

BACKGROUND

After kidney transplant, nonadherence to immunosuppressive therapy is the main cause of impaired kidney function and graft loss. The objective of this study was the development and internal validation of a clinical questionnaire for assessing the predisposition to adherence to immunosuppressive therapy in kidney pretransplant patients.

METHODS

Multicenter prospective study conducted in 7 kidney hemodialysis and 6 kidney transplant centers of 3 Brazilian state capitals. Kidney transplant candidate patients of both sexes and >18-y-old were included. Retransplanted patients were excluded. A 72-item pilot version of the questionnaire, created through literature review complemented with a focus group of 8 kidney pretransplant patients, was administered to 541 kidney transplant candidate patients. Factor analysis with varimax rotation was used for questionnaire development. Internal validity evaluation used Cronbach's alpha and test-retest reliability. Construct validity was assessed by differentiation by known groups.

RESULTS

The final questionnaire, named Kidney AlloTransplant Immunosuppressive Therapy Adherence (KATITA) Questionnaire, consisting of 25 items in 3 dimensions, presented good internal consistency reliability (Cronbach's alpha 0.81). The 3 dimensions and respective Cronbach's alpha were "Carelessness" (14 items, 0.81), "Skepticism" (6 items, 0.57), and "Concern" (5 items, 0.62). The interdimension correlation matrix showed low correlation coefficients (<0.35). Test-retest reliability, evaluated with 154 patients, showed an intraclass correlation coefficient of 0.62 (moderate agreement). The scale showed construct validity.

CONCLUSIONS

The KATITA-25 questionnaire is the first psychometric instrument for evaluation of predisposition to nonadherence to immunosuppressive medication in candidate patients for kidney transplant in the pretransplant setting.

Implementing a self-reported immunosuppression adherence questionnaire to screen for non-adherence in routine care of kidney transplant recipients

INTRODUCTION

Self-reported measures of immunosuppression adherence have been largely examined in research settings.

METHODS

In this single center study of 610 kidney transplant recipients, we examined if a voluntary, non-anonymous self-report measure could identify non-adherence in a routine clinic setting and how patients perceived such a measure. Non-adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) and patient perception was elicited using a customized questionnaire.

RESULTS

Non-responders to the survey (15%) were younger, more likely to be black, and less likely to have had a pre-emptive transplant. Among complete responders (n = 485), 38% reported non-adherence with non-adherent patients being younger (54 y vs. 60 y; p = .01), less likely to have been on dialysis pre-transplant (59% vs. 68%; p = .04), further out from transplant (37 vs. 22 months; p < .001) and had more rejections in the preceding year (8% vs. 3%; p = .02). Self-reported non-adherence was associated with higher calcineurin inhibitor intra-patient variability (27.4% vs. 24.5%; p = .02), but not with donor-specific antibody detection (27.8% vs. 21.2%, p = .15). Of patients providing feedback (n = 500), the majority of patients felt comfortable reporting adherence (92%), that the survey was relevant to their visit (71%), and that the survey did not interfere with their clinic visit (88%).

CONCLUSION

In summary, a self-reported questionnaire during clinic visits identified immunosuppression non-adherence in a significant proportion of patients and was well received by patients. Integrating self-report measures into routine post-transplant care may enable early identification of non-adherence.

The association between tacrolimus exposure and tremor, headache and insomnia in adult kidney transplant recipients: A systematic review

PURPOSE

Tremor, headache and insomnia have been linked to the immunosuppressant, tacrolimus. The aim of this systematic review was to determine if there is a correlation between tacrolimus exposure and new-onset tremor, headache and insomnia experienced by adult kidney transplant recipients.

METHODS

PubMed, Embase, Cochrane Library and CINAHL databases were searched up to 11 April 2023 for published studies which reported on tacrolimus exposure in adult kidney transplant recipients, alongside information on treatment-emergent neurologic manifestations, including tremor, headache and insomnia. Review articles, case studies, conference abstracts and articles not published in English in peer-reviewed journals were excluded. The Physiotherapy Evidence Database and Newcastle-Ottawa Quality Assessment Scales were used to assess risk of bias. Extracted data was analysed via a narrative synthesis.

RESULTS

Eighteen studies involving 4030 patients in total were included in the final analysis. These comprised five randomised control trials and thirteen observational studies. Studies failed to find significant association between tacrolimus trough concentrations in whole blood and the incidence of neurologic side effects such as tremor, headache and insomnia; however, in one study the incidence of toxicity requiring a dose reduction increased with increasing, supratherapeutic targeted levels. Females, especially Black females, and older age were positively associated with the prevalence of neurologic adverse effects. Results were conflicting regarding whether extended-release formulations were associated with fewer neurologic complications than immediate-release formulations.

CONCLUSION

The varied study designs and criteria for reporting tremor, headache and insomnia impacted on the quality of the data for exploring the relationship between tacrolimus exposure and the onset of neurologic manifestations experienced after kidney transplantation. Studies that examine defined neurologic complications as the primary outcome, and that consider novel markers of tacrolimus exposure while assessing the potential contribution of multiple covariate factors, are required.

Reciprocal associations between beliefs about medicines, health locus of control and adherence to immunosuppressive medication in allogeneic hematopoietic cell transplant patients: Findings from the ADE-TRAM study

PURPOSE

Patients undergoing allogenic hematopoietic stem cell transplantation (allo-HSCT) are required to strictly adhere to immunosuppressive medications to avoid rejection and infective complications. Since medication adherence is among the most important modifiable behaviors to achieve better outcomes, the aims of this study were to measure the baseline and longitudinal trends of medication adherence and investigate the psychological factors associated with medication adherence in allo-HSCT patients.

METHODS

This was a single-center, longitudinal study of patients who underwent allo-HSCT to treat hematological malignancies at the University hospital of Florence (Italy). Adherence was measured with the Immunosuppressive Medication Self-Management Scale; psychological factors (i.e., beliefs about medicines and health locus of control) were measured with the Beliefs About Medicines Questionnaire and Multidimensional Health locus of Control Scale. Data were collected 1, 3, 6 and 12 months after discharge. A mixed effects model was performed after adjusting for demographic characteristics.

RESULTS

50 adult patients were included in this study. Adherence to immunosuppressant was optimal and increased significantly 3 months after bone marrow transplantation (B = 0.23, p = 0.041). Patients with lower concerns about immunosuppressive medications were more likely to be adherent (B = 0.02, p = 0.040), while those having beliefs that their disease was due to external factors were less likely to be adherent (B = -0.02, p = 0.026) than their counterparts.

CONCLUSIONS

These results underline the importance of psychological factors in affecting adherence to immunosuppressants of allo-HSCT patients. Healthcare providers and researchers should target medication beliefs and reorient locus of control with appropriate interventions, in order to improve adherence.

Prevalence and Patient-Level Correlates of Intentional Non-Adherence to Immunosuppressive Medication After Heart-Transplantation-Findings From the International BRIGHT Study

After heart transplantation (HTx), non-adherence to immunosuppressants (IS) is associated with poor outcomes; however, intentional non-adherence (INA) is poorly understood regarding its international variability in prevalence, contributing factors and impact on outcomes. We investigated (1) the prevalence and international variability of INA, (2) patient-level correlates of INA, and (3) relation of INA with clinical outcomes. Secondary analysis of data from the BRIGHT study-an international multi-center, cross-sectional survey examining multi-level factors of adherence in 1,397 adult HTx recipients. INA during the implementation phase, i.e., drug holiday and dose alteration, was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale© (BAASIS©). Descriptive and inferential analysis was performed with data retrieved through patient interview, patient self-report and in clinical records. INA prevalence was 3.3% (n = 46/1,397)-drug holidays: 1.7% (n = 24); dose alteration: 1.4% (n = 20); both: 0.1% (n = 2). University-level education (OR = 2.46, CI = 1.04-5.83), insurance not covering IS costs (OR = 2.21, CI = 1.01-4.87) and barriers (OR = 4.90, CI = 2.73-8.80) were significantly associated with INA; however, clinical outcomes were not. Compared to other single-center studies, this sample's INA prevalence was low. More than accessibility or financial concerns, our analyses identified patient-level barriers as INA drivers. Addressing patients' IS-related barriers, should decrease INA.

Immunosuppressive Medication Adherence in Patients With Hepatocellular Cancer Who Have Undergo Liver Transplantation: A Case Control Study

BACKGROUND

We aimed to compare the adherence to immunosuppressive medication use in patients who underwent liver transplantation (LT) due to hepatocellular carcinoma (HCC) and non-HCC reasons.

METHODS

The study population was determined as 242 patients with HCC and 1290 patients with non-HCC who had LT performed in our institute between March 2002 and November 2021; all these patients were contacted by phone in March 2022. The sample size was calculated using the MedCalc software program, and the number of patients required in each group was determined as 111 patients. Furthermore, we used the sample.int function, a random integer generator in the R (version 4.1.2) software program. Whereas demographic and clinical parameters were determined as independent variables, the immunosuppressive medication adherence scale (IMAS) score was determined as a dependent variable. Patients were evaluated by the IMAS. This 11-item IMAS scale evaluates the lowest compliance score as 11 and the highest as 55.

RESULTS

Out of a total number of 221 patients, 161 (72%) were men and 60 (27.1%) were women, with a median age of 58 years (IQR: 14); one patient in the non-HCC group was excluded due to lack of data. Among the HCC and non-HCC groups, significant differences were found in terms of the variables of age (P = .003), IMAS score (P < .001), sex (P = .001), working status (P = .004), chronic diseases (P = .008), tacrolimus alone (P < .001), tacrolimus plus everolimus (P < .001), and often medication changes (P < .001). A statistically significant correlation was found between the IMAS score and whether the patients had HCC (P < .001) and frequently changing immunosuppressive drugs (P = .023).

CONCLUSION

This study showed that patients with frequent drug changes or non-HCC etiology had better adherence to immunosuppressive drug use.

Reliability and Validity of the Japanese Version of the Basel Assessment of Adherence to Immunosuppressive Medications Scale in Kidney Transplant Recipients

A valid and reliable instrument that can measure adherence is needed to identify nonadherent patients and to improve adherence. However, there is no validated Japanese self-report instrument to evaluate adherence to immunosuppressive medications for transplant patients. The purpose of this study was to determine the reliability and validity of the Japanese version of the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS).

Methods

We translated the BAASIS into Japanese and developed the Japanese version of the BAASIS (J-BAASIS) according to the International Society of Pharmacoeconomics and Outcomes Research task force guidelines. We analyzed the reliability (test-retest reliability and measurement error) and validity of the J-BAASIS (concurrent validity with the medication event monitoring system and the 12-item Medication Adherence Scale) referring to the COSMIN Risk of Bias checklist.

Results

A total of 106 kidney transplant recipients were included in this study. In the analysis of test-retest reliability, Cohen's kappa coefficient was found to be 0.62. In the analysis of measurement error, the positive and negative agreement were 0.78 and 0.84, respectively. In the analysis of concurrent validity with the medication event monitoring system, sensitivity and specificity were 0.84 and 0.90, respectively. In the analysis of concurrent validity with the 12-item Medication Adherence Scale, the point-biserial correlation coefficient for the "medication compliance" subscale was 0.38 (P < 0.001).

Conclusions

The J-BAASIS was determined to have good reliability and validity. Using the J-BAASIS to evaluate adherence can help clinicians to identify medication nonadherence and institute appropriate corrective measures to improve transplant outcomes.

Quality of life associated with immunosuppressant treatment adherence in liver transplant recipients: A cross-sectional study

Purpose: Transplanted organ survival after solid organ transplantation highly correlates with the adherence levels of the patients to their immunosuppressive drugs. On the other hand, one of the main goals of liver transplantation is to increase the overall quality of life (QOL) for the patient. This study is aimed to analyze the relationship between adherence and QOL in adult liver transplant recipients of the biggest liver transplant center in Asia. Methods: All of the included patients were older than 18 years and at least 6 months had passed from their liver transplantation. The adherence level was measured with BAASIS method and the QOL was assessed by SF-36 questionnaire in real-time interviews. The relationship between adherence and different aspects of QOL in addition to qualitative and quantitative influential factors on these two outcomes was calculated with statistical analysis. Results: Among the 122 included patients, 41% of the were categorized in the non-adherent group. The most important reasons for non-adherence in these patients included forgetfulness (62%), lack of medication (12%), financial problems for drug supply (9%), and side effects (2%). According to the results of the multivariate linear regression model, rejection was the only influential factor in the occurrence of non-adherence among patients (OR = 8.226 CI (1.404-48.196)). The overall mean QOL score of patients was reported 51.09 ± 21.86. The lowest is given to social functioning, while mental health has achieved the highest score. The mean QOL scores in different dimensions in patients with adherence were higher than non-adherents, which was only significant in mental health (p-value = 0.01). Additionally, in total scores related to Physical Composite Score (PSC) and Mental Composite Score (MCS), the mean MSC scores in adherent patients were significantly higher than non-adherent patients (p-value: 0.02). Although adherent patients have an overall greater QOL, the only meaningful effect on QOL total score was from income level. Conclusion: The overall QoL score has been in all parameters higher in the adherent group compared with non-adherent patients. The difference in QoL was most meaningfully significant in mental composite score among other parameters of QoL.

Exploring Transplant Medication-Taking Behaviours in Older Adult Kidney Transplant Recipients: A Qualitative Study of Semi-Structured Interviews

Background

Today, older adult patients routinely undergo kidney transplantation. To support graft survival, patients must take immunosuppressant medicines for the rest of their lives. The post-transplant medication regimen is complex, and barriers to medication taking are likely confounded by both functional and intrinsic changes associated with advancing age. To develop diverse and innovative approaches to support best health outcomes in this vulnerable age group, it is imperative that the degree to which patients’ needs are currently being met, be identified.

Aim

The aim of this study was to examine medication-taking behaviours of kidney transplant recipients transplanted at 60 years of age or older.

Methods

This qualitative study used semi-structured patient interviews to explore how kidney transplant recipients currently manage their immunosuppressant regimen and how they cope after transplantation with the complex routine. Data were themed using the principles of Grounded Theory methodology; with interviews conducted until data saturation was reached.

Results

Quantitative information was collected from 14 participants who ranged in age from 66 to 77 years (at time of interview), and were prescribed a median of 13 (min: 10, max: 26) medicines. The main themes that emerged from the interview were variability in health literacy toward medicines, the importance of support networks, the need to adjust health expectations, factors that were motivators for self-care, different approaches to medication management, and different approaches to medication taking. Overall, it was found that patients prioritised medication taking above all else, and gratitude to their donor was a powerful motivator to adhere. However, strategies to support medication taking were sometimes ineffective when patients’ routine changed.

Conclusions

Future interventions should consider approaches to foster adaptable medication taking behaviours that stand up to changes in the day-to-day routine.

Medication taking is complicated in transplant recipients, due to the number of medicines that need to be taken and the complex nature of the treatment regimen. Challenges in older transplant recipients may be more pronounced and varied compared with younger adults. There are multiple factors that may impact medication taking in older adults and each requires consideration, including level of dependence, living arrangements, level of mobility and manual dexterity, vision and memory, and social situation. To better identify the gaps in support, patients’ current perspectives around medication taking and how they cope after transplantation must be explored. Therefore, this study aimed to identify how older adult transplant recipients currently manage their anti-rejection medicine regimen. Participants described several strategies around how they manage a complex medication regimen. These included cues such as an alarm and linking the time they should take their medication to already established habits such as eating meals. Most participants discussed at length their relationships, and it seems that these relationships are often crucial to post-transplant positivity. Additionally, extreme gratitude to the donor, relative improvement in their life quality (compared with the rapid deterioration in their health when on dialysis), and fear of consequences (particularly graft failure) were important facilitators of self-care and served as timely reminders to prioritise one’s own health. To foster more robust medication-taking habits, future education needs to be tailored to each individual patient and include details about how to link medication taking to already established routines (coined ‘habit stacking’).

Locus of control, self-efficacy perception and treatment adherence in kidney transplant patients

OBJECTIVE

Among the factors forming the health behavior are the concept of locus of control and the perception of health self-efficacy. Studies investigating self-efficacy beliefs and the impact of health locus of control on immunosuppressive drugs are not adequate in number. Therefore the study sought to determine locus of control, self-efficacy perception and treatment adherence in kidney transplant patients.

METHODS

The sample of the study comprised 276 kidney transplant patients who applied to a university hospital. We collected the data using the Personal Information Form, the Multidimensional Health Locus of Control Scale, the Health Self-efficacy Perception Scale and the Compliance to Immunosuppressive Treatment Scale.

RESULTS

The study found the patients' mean Multidimensional Health Locus of Control scale external locus of control score to be 21.51 ± 3.74, mean Internal locus of control score to be 21.36 ± 3.92 and mean chance/fate score to be 15.48 ± 5.43. This result in the study demonstrates that kidney transplant individuals tend to believe in external forces in the disease management. The study determined the mean Health Self-efficacy Perception scale score of the kidney transplant patients to be 25.34 ± 3.89 and the patients had moderate level of self-efficacy perception. The study found that the patients' mean Compliance to Immunosuppressive Treatment Scale score was 11.26 ± 0.96 and their immunosuppressive treatment adherence was high but not adequate. The study found a significant negative weak correlation between the Health Self-efficacy Perception scale and the Multidimensional Health Locus of Control scale chance/fate subscale (p < 0.01). The study found no significant correlation between the Health Self-efficacy Perception scale and the Compliance to Immunosuppressive Treatment Scale (p > 0.05).

CONCLUSION

In order to increase drug adherence, we recommend that patients be supported to reinforce their self-efficacy perception. It is necessary to develop internal locus of control in kidney transplant patients in terms of treatment adherence and positive health behaviors.

Exploration of Adherence to the Immunosuppressive Medication in Kidney Transplant Recipients Based on Theory of Planned Behavior

To investigate adherence to immunosuppressive medication (IM) in kidney transplant recipients (KTRs) and analyze the associated factors using the Theory of Planned Behavior (TPB). Data were collected at Time1 (T1) and 3 months later (T2). T1: the elements of the TPB, past behavior, beliefs about medicines, perceived social support were measured. T2: IM adherence was measured. Structural equation modeling was applied to analyze the associated factors of medication adherence. A total of 246 KTRs were included. The average IM adherence score of KTRs' was 4.86 (SD = 1.63). Of the recipients, 39.43% had one aspect of non-adherence to IM. The model could explain 28.7% of the variance in adherence to IM (R² = .287, p = .006). TPB is a useful tool for understanding adherence to IM in KTRs. Caregivers can provide effective interventions during follow-up, which should focus on improving medication beliefs as well as provision of other external support especially from outside.

A Multifaceted Intervention to Improve Medication Adherence in Kidney Transplant Recipients: An Exploratory Analysis of the Fidelity of the TAKE IT Trial

BACKGROUND

Inadequate adherence to prescribed immunosuppressive medication regimens among kidney transplant recipients is common, yet interventions are needed to support patients in sustaining adequate adherence to prescribed regimens and achieving optimal transplant outcomes.

OBJECTIVE

We examined the preliminary fidelity of a transplant center-based, multifaceted adherence monitoring strategy known as TAKE IT.

METHODS

The TAKE IT strategy includes: (1) routine, online, monthly patient self-report adherence assessments; (2) care alerts directed to nurses; (3) quarterly reports monitoring tacrolimus values and adherence trends; (4) support tools tailored to specific adherence concerns. A 2-arm, patient-randomized trial is underway at two large transplant centers (N=449). To evaluate the initial fidelity of TAKE IT, we investigated patient uptake of monthly adherence assessments during the course of a 3-month period, whether any disparities emerged, and the nature of any reported adherence concerns.

RESULTS

Among 202 patients randomized and exposed to TAKE IT for 3-months or more, 81% (164/202) completed an adherence assessment, 73% (148/202) completed at least two, and 57% (116/202) completed all monthly assessments. Overall, 50% (82/164) of kidney transplant recipients reported at least one adherence concern over the 3-month assessment period. The most common barriers were classified as regimen-related (eg, regimen complexity), cognitive (eg, forgetfulness), and medical (eg, side effects). Higher-income participants were more likely to complete all surveys compared to lower-income participants (P=.01).

CONCLUSIONS

TAKE IT demonstrated 81% (164/202) completion of an adherence assessment, 73% (148/202) completion of at least two, and 57% (116/202) completion of all monthly assessments during this brief, initial observation period. Among those that did respond to the online assessments, the majority demonstrated sustained engagement. Additional monitoring modalities could also be offered to meet patient preferences to ensure all patients' medication use can be properly monitored.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03104868; https://clinicaltrials.gov/ct2/show/NCT03104868.

A qualitative exploration of the facilitators and barriers to self-management in kidney transplant recipients

Background

Understanding the behaviours that facilitate or impede one’s ability to self-manage is important to improve health-related outcomes in kidney transplant recipients (KTRs). Previous studies exploring the self-management experiences of KTRs have focused on specific tasks (e.g., medication adherence), age groups (e.g., adolescent or older recipients), or have been conducted outside of the UK where transferability of findings is unknown. Our study aimed to explore the perceptions and experiences of self-management in UK KTRs to identify facilitators and barriers associated with self-management tasks.

Methods

Semi-structured interviews were conducted with eleven KTRs. Topics explored included experiences of self-management tasks (diet, exercise, medications, stress management), perceived healthcare role, and future interventional approaches. Thematic analysis was used to identify and report themes.

Results

Eight themes were identified which were mapped onto the three self-management tasks described by Corbin and Strauss: medical, role and emotional management. Perceived facilitators to self-management were: gathering health-related knowledge, building relationships with healthcare professionals, creating routines within daily life, setting goals and identifying motivators, establishing support networks, and support from family and friends. Complexity of required treatment and adjusting to a new health status were perceived barriers to self-management.

Conclusions

Participants described the importance of collaborative consultations and continuity of care. Tailored interventions should identify individualised goals and motivators for participating in self-management. Education on effective strategies to manage symptoms and comorbidities could help alleviate KTRs’ perceived treatment burden. Family and peer support could emotionally support KTRs; however, managing the emotional burden of transplantation warrants more attention.

Graphic abstract

Development and testing of a framework for defining a strategy to address medication adherence during patient encounters in community pharmacies

Background

Counseling patients on medication adherence could be ameliorated in pharmacy practice. There is a lack of simple and practical strategies to address medication adherence with patients in daily practice. The goal was to develop and test a framework that allows pharmacy teams to define and apply a strategy to address medication adherence in community pharmacies.

Methods

A framework based on the principles of social marketing was developed. It consisted of 3 items: the target patient (“Who”), the target plan (“How”), and the target goal (“How many”). To test the framework, each participating pharmacy team developed their strategy by defining the 3 items and applied them during one pilot day. A master student observed the encounters between patients and pharmacy team members and used a structured checklist to document the patient's characteristics, counseling content, and strategy use. Pharmacy teams answered a feedback questionnaire at the end of the pilot day.

Results

Ten pharmacy teams were included. During a brainstorming session that lasted on average 31 ± 8 min, unique strategies comprised 18 different target patients and 20 different target plans. The planned target goal was a mean of 31 patients (range: 1 to “all”). A total of 325 encounters were observed, of which 208 patients (64%) corresponded to the predefined target patients. Medication adherence was addressed with 73 patients (22.5%), and adherence counseling was performed with 50 patients (15%). The pharmacy teams accepted the framework and judged it feasible and adaptable to their needs.

Conclusion

The proposed framework represents a simple tool that enables pharmacy teams to develop a strategy for addressing medication adherence in community pharmacies. Its adoption by pharmacy teams occurred without additional training and its integration into daily practice without difficulties. A further study is now needed to investigate if pharmacy teams can successfully engage patients in discussion on medication adherence and ultimately propose targeted adherence interventions.

•

A 3-item framework to address medication adherence in pharmacies was introduced.

•

The three framework was well received by the pharmacy teams.

•

The adoption of the 3-item framework by the pharmacy teams was simple and quick.

•

The teams chose target patient not according to known factors for poor adherence

•

Patients reacted mainly positively when asked about medication adherence

Illness Perceptions and Medication Nonadherence to Immunosuppressants After Successful Kidney Transplantation: A Cross-Sectional Study

Background: Medication nonadherence to immunosuppressants is a well-known risk factor for suboptimal health outcomes in kidney transplant recipients (KTRs). This study examined the relationship between illness perceptions and medication nonadherence in prevalent Dutch KTRs and whether this relationship depended on post-transplant time.

Methods: Eligible KTRs transplanted in Leiden University Medical Center were invited for this cross-sectional study. The illness perceptions and medication nonadherence were measured via validated questionnaires. Associations between illness perceptions and medication nonadherence were investigated using multivariable logistic regression models.

Results: For the study, 627 participating KTRs were analyzed. 203 (32.4%) KTRs were considered nonadherent to their immunosuppressants with “taking medication more than 2 h from the prescribed dosing time” as the most prevalent nonadherent behaviour (n = 171; 27.3%). Three illness perceptions were significantly associated with medication nonadherence: illness identity (adjusted odds ratio [OR_adj] = 1.07; 95% confidence interval [CI], 1.00–1.14), concern (OR_adj = 1.07; 95%CI,1.00–1.14), and illness coherence (OR_adj = 1.11; 95%CI,1.01–1.22). The relationships between illness perceptions and medication nonadherence did not differ depending on post-transplant time (p-values ranged from 0.48 to 0.96).

Conclusion: Stronger negative illness perceptions are associated with medication nonadherence to immunosuppressants. Targeting negative illness perceptions by means of psychoeducational interventions could optimize medication adherence and consequently improve health outcomes in KTRs.

Benefits, challenges and contributors to the introduction of new hospital-based outpatient clinic pharmacist positions

Background

Pharmacists working within interprofessional teams in the outpatient setting are well placed to address medication-related problems before and after hospital admission. Therefore, exploration of these roles is warranted.

Objective(s)

To explore pharmacists' and other health professionals' perspectives of the impact of pharmacists working within interprofessional teams in outpatient clinics. Furthermore, we endeavoured to identify both the challenges and contributors to success with the introduction of pharmacists into these settings.

Methods

This qualitative study involved semi-structured interviews with both hospital outpatient clinic pharmacists and other clinic health professionals to gain an in-depth understanding of how the introduction of pharmacists into clinics impacted clinic processes, patient care, and relationships with other health professionals. Participants were recruited from the outpatient clinics who had recently added a pharmacist to their service. Participants involved in setting up the roles were invited to participate in a voluntary interview, the transcripts from which were analysed into themes and sub-themes using an inductive and deductive approach.

Results

A total of 34 staff were interviewed of which 68% were female and 74% were aged between 31 and 50 years. The cohort included 16 outpatient pharmacists, nine pharmacist team leaders, five clinic nurses and four clinic doctors (specialist consultant or registrar). Three overall themes were identified: the benefits, the contributors, and the challenges of introducing clinical pharmacy services to outpatient clinics. When establishing a clinic role, pharmacists' awareness, adaptability, and strong communication were shown to be key traits to building rapport and trustworthiness with the established clinic team.

Conclusions

When pharmacists are integrated into multidisciplinary outpatient clinics they and their colleagues believe that they provide benefits to the patients and the clinics. Decision makers need to be cognizant of factors that contribute to, as well as those that impede, the successful implementation of outpatient pharmacist roles.

Immunosuppressive Medication Adherence in Kidney Transplant Recipients During the COVID-19 Pandemic: A Cross-Sectional Study in Hong Kong

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has put an enormous burden on health care systems worldwide. Limited access to medical care and fear of increased infective risks due to the use of immunosuppressive medication (IM) have increased concerns about IM adherence in kidney transplant recipients (KTRs). The aim of this study was to determine the various dimensions of IM nonadherence in KTRs during the COVID-19 pandemic.

METHODS

This was a single-center, cross-sectional study using a convenient sampling approach. KTRs with follow-up in Queen Elizabeth Hospital, Hong Kong between May 1, 2020 and September 30, 2020, were invited to complete a self-reported questionnaire on IM adherence. The sociodemographic factors associated with IM adherence were extracted from medical records.

RESULTS

Overall, 210 patients completed the questionnaires. The overall IM nonadherence rate was 35.2% in the 4 weeks before survey completion. None of the patients stopped taking IMs without instructions from their health care providers. The most common pattern of IM nonadherence was timing adherence (n = 63; 30.1%), followed by dose-skipping item. Among the different sociodemographic factors studied, only marital status was an independent risk factor of IM nonadherence (odds ratio, 1.97; 95% confidence interval, 1.04-3.72; P = .03).

CONCLUSIONS

The impact of COVID-19 on IM adherence in KTRs was not significant. All the patients continued their IM despite of the pandemic. Good family support can have a positive influence on treatment adherence in KTRs during the COVID-19 pandemic.

Mirabegron has longer treatment persistence than antimuscarinics: Real-world data from a Korean national cohort database

AIMS

To descriptively evaluate treatment persistence among adults who received mirabegron or antimuscarinics in South Korea.

METHODS

This study involved a retrospective analysis of the Health Insurance Review and Assessment (HIRA) database. Patients (≥18 years) who had a new prescription for an overactive bladder (OAB) target medication (mirabegron/antimuscarinic) within an 8-month index period (July 1, 2015-February 29, 2016) were included. The date when the target (index) medication was dispensed was the index date. The 6-month period before the index date was used to assess patient eligibility. A 12-month post-index period was used to assess medication persistence, which was defined as the time to discontinuation. Overall data were analyzed and the results were also stratified by age group (≤65, >65 years), sex, or prior OAB medication experience. Persistence rates were calculated after the 1st, 3rd, 6th, 9th, and 12th months.

RESULTS

A data set of 52 722 cases was obtained (mirabegron: 11 424, antimuscarinics: 41 298). The mean age was 60.9 ± 16.1 years and the majority of the patients were female (30 862 [58.5%] patients). Median persistence was longer with mirabegron (51 days) versus antimuscarinics (25 days). The persistence rate with mirabegron was higher throughout the study compared with all the antimuscarinics (12-month data: 13.5% and 4.9%, respectively). Longer treatment persistence was noted in older, male, and treatment-experienced patients.

CONCLUSION

The results from the HIRA database showed that persistence was longer with mirabegron than with antimuscarinics in South Korea. This finding may help inform clinical decision-making within the South Korean healthcare system.

Pharmacokinetic and Pharmacodynamic Considerations in Relation to Calcineurin Usage in Elderly Kidney Transplant Recipients

This review summarizes how possible age-related changes in tacrolimus and cyclosporine pharmacokinetics and pharmacodynamics may influence drug dosing and monitoring in the elderly, and highlights how micro-sampling may be useful in this cohort in the future. Advancing biological age leads to physiological changes that can affect drug absorption, distribution, metabolism and excretion, as well as immune system responsiveness. Some studies have shown that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors, suggesting that doses may need to be lowered in elderly recipients. Only one study has examined how aging effects drug target enzyme activity and demonstrated that age does not correlate with the calcineurin inhibitor half-maximal inhibitory concentration. Several studies have shown elderly kidney transplant recipients have increased risk of both morbidity and mortality, compared to younger adults due to increased susceptibility to immunosuppressant side effects, particularly cardiovascular disease, infection and malignancy. Current immunosuppressant dosing and monitoring protocols often make no adjustments for age. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established. Blood draw by micro-sampling may be useful for drug monitoring in this cohort in the future, as blood collection is minimally invasive and less painful than venepuncture. Micro-sampling could also make further pharmacokinetic, pharmacodynamics and outcome studies in the elderly more feasible.

Prevalence of Non-Adherence to Immunosuppressive Medications in Kidney Transplant Recipients: Barriers and Predictors

Background

Non-adherence to immunosuppressant therapy (IST) is a major risk factor for graft rejection. Limited reports are available regarding the prevalence of non-adherence to IST in kidney transplant recipients (KTRs) as well as the predictors and barriers of non-adherence.

Material/Methods

The study included ambulatory KTRs, ≥18 years of age, with a functional kidney, from January 2017 to November 2018. The primary outcome was the prevalence of non-adherence, assessed with: 1) A telephone interview to complete the Arabic-translated and validated Immunosuppressant Therapy Adherence Instrument Scale (ITAS) and 2) IST serum blood levels within therapeutic levels. The secondary outcomes were the barriers to adherence using the validated Immunosuppressant Therapy Barriers of Adherence Scale (ITBS).

Results

We enrolled 102 of 141 patients screened. The mean±SD for age, body mass index, and the baseline of the estimated glomerular filtration rate were 45.5±15.6 years, 29.1±6 kg/m², and 72.7±21.9 ml/min/1.73 m², respectively. The prevalence of non-adherence was 5.9%, 95% CI (2.19–12.36%) and 14.7%, 95% CI (8.47–23.09%) using the ITAS and the average blood serum drug levels, respectively. The concordance of the 2 methods demonstrated an agreement of 81.3%, kappa of 0.01, and 95% CI (−0.16 to 0.18). The median, interquartile range (IQR) for ITBS, and uncontrollable and controllable barriers for adherence were 21, (18–25), 15, (12–18), and 6, (5–8), respectively.

Conclusions

The current study demonstrated a low to moderate prevalence of non-adherence to IST in KTRs. The barriers for adherence with IST necessitate additional targeted interventions to manage and optimize therapeutic and clinical outcomes.

Health Literacy, Medication Adherence, and Quality of Life in Patients With Uveitis

Purpose: To evaluate health literacy, medication adherence, and quality of life (QOL) in uveitis patients.Methods: Cross-sectional quality improvement study using questionnaires of health literacy (Short Assessment of Health Literacy), adherence (Beliefs about Medicine Questionnaire), and QOL (12-item Short Form Health Survey).Results: Sixty patients were surveyed: 57% women, 80% identified as Black, and 42% with schooling beyond high school. Forty-three percent of the patients had poor health literacy, with lower scores among those with less schooling (p < .01). Necessity scores were higher for multiple providers (p = .02). Necessity (p = .03) and Concerns (p < .01) scores were higher for patients seeing a rheumatologist. Patients had lower physical (p < .01) and mental QOL (p < .01) than the general US population.Conclusions: Uveitis patients reported many barriers to care. Despite strong perceptions of treatment necessity, there were significant concerns, especially among patients seeing a rheumatologist. We recommend multidisciplinary care, individualized education, and counseling regarding medication safety and the necessity to improve adherence.

Association Between Regulatory Emotional Self-Efficacy and Immunosuppressive Medication Adherence in Renal Transplant Recipients:Does Medication Belief Act as a Mediator?

Background: Few studies have investigated the association between regulatory emotional self-efficacy (RESE) and immunosuppressive medication adherence or the mechanisms underlying this relationship. Considering that previous evidence of immunosuppressive medication adherence depended on the level of immunosuppressive medication beliefs, a model of multiple mediation was tested in which immunosuppressive medication beliefs acted as mediators of the relationship between RESE and immunosuppressive medication adherence. Methods: A retrospective cross-sectional study was performed in 293 renal transplant patients during outpatient follow-ups from November 2019 to February 2020 in China. All participants completed a general demographic questionnaire, the Chinese version of the RESE, the Beliefs about Medication Questionnaire, and the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS). Spearson correlation analysis was carried out to identify the correlation between RESE and immunosuppressive medication adherence. Binary logistic regression analysis was performed to confirm factors associated with immunosuppressive medication adherence in renal transplant recipients. Mediating effect analysis was used to explore the internal interaction between RESE and immunosuppressive medication adherence. Results: A total of 293 renal transplant patients were recruited, including 111 women and 182 men with a mean age of 42.5 years (SD = 10.0). A total of 23.21% of patients exhibited immunosuppressive medication none-adherence behavior, and 12.97% reported altering the prescribed amount of immunosuppressive medication without physician permission, which was most popular behavior among patients. The mean RESE score was 45.78 ± 6.12; the positive (POS) score was the highest, and the anger-irritation (ANG) score was the lowest. The correlation analysis results showed that RESE (r = -0.642, p < 0.01) and immunosuppressive medication beliefs (r = -0.534, p < 0.01) were significantly associated with immunosuppressive medication adherence. Binary logistic regression analysis indicated that marital status, fertility status, rejection, immunosuppressive medication beliefs, and RESE were found to be independent predictors of immunosuppressive medication adherence [R 2 = 0.803, p < 0.05]. The results of the mediating effect analysis showed that immunosuppressive medication necessity had a partial mediating effect, RESE directly and indirectly affected immunosuppressive medication adherence via immunosuppressive medication necessity, and immunosuppressive medication concerns were not a mediator between RESE and immunosuppressive medication adherence. Conclusion: The levels of immunosuppressive medication adherence in renal transplant patients need to be improved in China. Marital status, fertility status, rejection, immunosuppressive medication beliefs, and RESE were major factors affecting immunosuppressive medication adherence. RESE could affect immunosuppressive medication adherence indirectly through immunosuppressive medication necessity.

Renal Function and Patient-Reported Outcomes in Stable Kidney Transplant Patients Following Conversion From Twice-Daily Immediate-Release Tacrolimus to Once-Daily Prolonged-Release Tacrolimus: A 12-Month Observational Study in Routine Clinical Practice in Germany (ADAGIO)

INTRODUCTION

This 12-month, noninterventional study on routine clinical practice in Germany evaluated renal function in stable kidney transplant recipients converted from immediate-release tacrolimus (IR-T) to prolonged-release tacrolimus (PR-T).

METHODS

Renal function was assessed in 183 patients by estimated glomerular filtration rate using the modification of diet in renal disease-4 formula. Self-reported gastrointestinal health-related quality of life, adherence, satisfaction with PR-T, suspected rejection episodes, and safety were also assessed at conversion and at 3, 6, and 12 months.

RESULTS

Conversion from IR-T to PR-T resulted in stable kidney function over 12 months, with a difference in estimated glomerular filtration rate between the first and final visits of 0.1 mL/min/1.73 m² (95% confidence interval, -1.6, 1.8). Eight patients experienced an acute rejection episode (4.4%). At each assessment, gastrointestinal health-related quality of life was low and adherence was high. Most patients reported that they were very satisfied (69.8%) or satisfied (28.1%) with PR-T at the final visit. Among patients reporting a preference, 78.4% preferred PR-T, 2.2% preferred IR-T, and 19.4% reported no preference. The safety profile of PR-T was consistent with that previously described.

CONCLUSION

Conversion of stable kidney transplant recipients from IR-T to PR-T provided stable kidney and graft function over 12 months (Verband Forschender Arzneimittelhersteller--registered study: NIS ADV-02).

Nonadherence to Immunosuppressive Medications Following Pediatric Kidney Transplantation Within Full Cost Coverage Health System: Prevalence and Correlates

OBJECTIVES

Pediatric patients are at higher risk of nonadherence to immunosuppressive medication after kidney transplant and the resulting adverse outcomes. Factors associated with nonadherence vary, which follow an epidemiological framework and according to health system patterns. The Brazilian public health system covers all costs of kidney transplant, including immunosuppressive medications. We aimed to assess the prevalence and correlates of nonadherence to immunosuppressive medications in a pediatric kidney transplant population who received free access to immunosuppressive medications within the health care system.

MATERIALS AND METHODS

In this single-center crosssectional study, we studied a convenience sample of 156 outpatients (< 18 years old) who were a minimum of 4 weeks posttransplant. Implementation nonadherence to immunosuppressive medications was measured by the 4 questions of the Basel Assessment of Adherence to Immunosuppressive Medications Scale. Multilevel correlates to non - adherence (patient, micro, and macro levels) were assessed.

RESULTS

In our patient population, 61% were males, mean age was 13.6 ± 3.1 years, 77% were adolescents, and 84% received organs from deceased donors. We found that 33% were nonadherent to immuno - suppressive medications, mainly in timing (25%) and taking (10.9%) dimensions. Being an adolescent (odds ratio: 2.66; CI, 1.02-6.96), religion other than Catholic or Protestant (odds ratio: 4.33; CI, 1.13-16.67), and family income higher than 4 reference wages (odds ratio: 3.50; CI, 1.14-10.75) were factors associated with nonadherence.

CONCLUSIONS

In our patient population of mostly adolescents, one-third displayed nonadherence to immunosuppressants. Unexpectedly, a higher economic profile, potentially representing better previous access to health care, was independently associated with nonadherence. This result highlights the need for identifying specific correlates to non - adherence before designing interventions.

An E-Learning Program Improves Patients' Knowledge After Lung Transplantation

Background: Adherence to immunosuppressive medicine in lung transplant recipients is associated with improved long-term survival. Patient education and support from health care providers are key components. We investigated e-learning as a tool to improve lung transplant recipients' knowledge of post-transplant care such as hygiene, self-monitoring, travel precautions, vaccinations, and the importance of adherence to medication. Objective: To compare the effect of e-learning and conventional patient education with respect to level of knowledge and drug adherence. A single-center open randomized controlled trial design was used. Methods: Lung transplant recipients were randomized to an e-learning program or standard care. One month before a scheduled follow-up visit, the intervention group received a link by e-mail to a 15-min e-learning program. At the follow-up visit, all lung transplant recipients completed two drug adherence questionnaires (Basel Assessment of Adherence with Immunosuppressive medication Scales [BAASIS] and Transplant Adherence Questionnaire [TAQ]) and a questionnaire testing their knowledge of post-transplant care. Results: Fifty lung transplant recipients were randomized with 24 recipients in each group completing the study. Recipient adherence measured by BAASIS showed a tendency toward improved drug adherence in the intervention group compared with the control group (71% vs. 55%, p = 0.23). TAQ showed no difference between the two groups (p = 1.0). Recipients in the intervention group had a significantly higher number of correct answers to questions about transplant-friendly lifestyle (median 11 vs. 10, p = 0.02). Conclusion: A 15-min e-learning program is a simple and effective tool to improve lung transplant recipients' knowledge of post-transplant care.

Beliefs about immunosuppressant medication and correlates in a German kidney transplant population

OBJECTIVE

A common reason for organ rejection after transplantation is the lack of adherence regarding immunosuppressive medication (ISM). A variety of different aspects can promote non-adherent behavior, including the relationship between perceived benefits and concerns regarding ISM ("necessity-concerns-framework"). Little is known about the variables associated with this framework.

METHODS

As part of this cross-sectional study, 570 patients after kidney transplantation who participated in a structured multimodal follow-up program (KTx360°) were examined in two transplant centers in Lower Saxony. We used the Beliefs about Medicines Questionnaire (BMQ) to evaluate the patients' believes and concerns regarding their ISM.

RESULTS

The mean age of the participants was 51.9 (SD 14.17) years, 58.4% were men, and 25.8% had ≥12 years of school attendance. The mean time since transplantation was 65.9 months. In patients undergoing kidney transplantation, the perceived benefit of ISM mostly exceeded the concerns. We found an association between lower perceived benefits and greater concerns and lower adherence. Also, a higher perceived necessity was significantly associated with higher age and lower levels of depression and anxiety. Greater concerns were significantly associated with more symptoms of depression and anxiety, lower perceived social support, and lower kidney functioning (eGFR).

CONCLUSION

Even though patients after kidney transplantation usually acknowledge the importance of their ISM, they still have considerable concerns that are associated with less adherence and various psychosocial risk factors. Further longitudinal studies are needed to assess the extent to which beliefs about medication are variable and can be individually addressed to improve adherence.

Factors Associated With Adherence To Immunosuppressive Therapy And Barriers In Asian Kidney Transplant Recipients

Background

Medication non-adherence is the major risk factor for rejection episodes. The aim of this study was to determine the risk factors associated with adherence to immunosuppressive regimen and its barriers among kidney transplant (KT) recipients.

Methods

A cross-sectional study was performed in two outpatient post-transplant clinics in Mashhad, northeast of Iran. All patients who attended the clinics from August to October 2017 were included. Patients’s knowledge, adherence to immunosuppressive regimen, and quality of life were measured using the Kidney Transplant Understanding Tool, Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS), and SF-12V2 questionnaire, respectively. The barriers in adhering immunosuppressive regimen were investigated by Immunosuppressive Therapy Barriers Scale. Logistic regression was used to screen the significant risk factors of medication non-adherence.

Results

In this study, 244 KT recipients were included with a mean age of 39.6±12.5 years. Based on the BAASIS score, 111 (45.5%) patients were adherent to immunosuppressive regimen. Female patients were more likely to be adherent (OR=0.48, p<0.01). The patients with higher level of quality of life were more likely to follow immunosuppressive medications (OR=1.078, p<0.05). The main barriers were as follows: concurrent use of many immunosuppressants, lack of knowledge about the usefulness of immunosuppressive medications, confusion in medication taking, and difficulty in remembering medication taking.

Conclusion

More than half of the KT recipients were non-adherence to immunosuppressive regimen. These findings highlight the need for designing interventions in order to reduce or eliminate these barriers and consequently increase medication adherence among KT recipients.

Prevalence and Risk Factors of Immunosuppressant Nonadherence in Heart Transplant Recipients: A Single-Center Cross-Sectional Study

BACKGROUND

Immunosuppressant nonadherence (INA) has been shown to affect outcomes after solid organ transplantation. The aim of the present study was to determine the prevalence of INA in heart transplant recipients and the associated risk factors of INA.

METHODS

Adult heart transplant recipients who firstly received heart transplantation (discharged for at least 3 months) were consecutively enrolled. Immunosuppressant adherence was assessed using the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS). INA was categorized into five domains of contributing factors (socio-demographic factors, transplant-related factors, healthcare system access factors, post-transplant treatment-related factors, and patient-related psychosocial factors). These factors were compared between adherent and nonadherent patients. The risk factors of INA were investigated by logistic regression analysis.

RESULTS

A total of 168 heart recipients were ultimately included. Among them, 69 (41.1%) recipients were revealed to be nonadherent. Logistic regression analysis indicated that INA was associated with monthly income<3000 Chinese Yuan (CNY) (OR, 3.11; 95% CI, 1.58-6.12; p=0.001), number of prescribed concomitant drugs (OR, 1.23; 95% CI, 1.12-1.50; p=0.003) and concerns about immunosuppressants (OR, 1.09; 95% CI, 1.01-1.18; p=0.031).

CONCLUSIONS

Heart recipients had a high prevalence of INA. Lower income, greater number of prescribed concomitant drugs, and more concerns about immunosuppressants correlated most with timing nonadherence and taking nonadherence among heart recipients. These findings will be helpful to intervene on and prevent future INA of heart recipients.