Treatment adherence behaviours in rheumatic diseases during COVID-19 pandemic: a Latin American experience

Learning from the COVID-19 pandemic: health care disturbances and telemedicine as an alternative rheumatology practice in Indonesia

BACKGROUND

Coronavirus disease 2019 (COVID-19) affects health care services. Our aim was to assess health care disruptions, treatment interruptions, and telemedicine reception regarding autoimmune rheumatic diseases (ARDs) in Indonesia.

METHOD

A cross-sectional population online-based questionnaire was conducted in Indonesia from September to December 2021.

RESULTS

A total of 311 ARD patients were included, of whom 81 (26.0%) underwent consultations via telemedicine during the COVID-19 pandemic. The respondents showed increased concern about their susceptibility to COVID-19 (score of 3.9/5). Approximately 81 (26.0%) avoided hospital visits, and 76 (24.4%) stopped taking the medication without medical advice. Respondents' concerns correlated with their social distancing behaviors (p value 0.000, r 0.458). Respondent concerns, behaviors, and blocked access to the hospital during the pandemic were associated with avoiding hospital visits (p value 0.014; 0.001; 0.045; 0.008). Sex was associated with stopping medication (p value 0.005). In multivariate analysis, blocked access and sex remained significant. Approximately 81 (26%) respondents who used telemedicine services during the COVID-19 pandemic as an alternative medical consultation method showed high satisfaction (3.8/5).

CONCLUSION

Health care disruptions and treatment interruptions were affected by patients' internal and external factors during the COVID-19 pandemic. Telemedicine may be the best option to address barriers to health care access in Indonesia's rheumatology practice during and after the pandemic situation.

Unauthorized change of immunosuppressants by patients with rheumatic diseases in the COVID-19 pandemic: a cross-sectional analysis of a patient survey

This study provides insight in behavior and perspective of rheumatic patients during the first COVID-19 wave. Especially, we analyzed the patients' fear of COVID-19 and unauthorized change of immunosuppressive medication in consequence of their fear. We hereby provide data from 877 patients with valuable insights into the patients' point of view. We retrospectively interviewed patients of our rheumatic university outpatient clinic. This way, we collected information about the patients' personal point of view. Data like the rheumatic diagnosis and immunosuppressive medication was extracted from the health records. Statistical analysis was conducted using IBM® SPSS® Statistics (version 26). A total of 877 patients were included into our study. We could show that fear of COVID-19 was clearly present in rheumatic patients. Higher fear levels seem to be associated with comorbidity burden. Unauthorized change of immunosuppressive medication was rare in our study (5%). In our study we provide novel insight into patients' point of view and behavior of rheumatic patients. Unauthorized change of immunosuppressive medication was rare (5%) as seen in other studies. The low rate of unauthorized change and high rate of compliance is reassuring since good disease control appears to be prognostically important in the progression of COVID-19 disease. Therefore, as the pandemic continues, treatment decisions should be made in close consultation between patient and practitioner to improve adherence and reduce morbidity and mortality.

Impact of COVID-19 Pandemic on Adherence to Chronic Therapies: A Systematic Review

The spread of the coronavirus disease 2019 (COVID-19) pandemic caused a sudden and significant disruption in healthcare services, especially for patients suffering from chronic diseases. We aimed at evaluating the impact of the pandemic on adherence to chronic therapies through a systematic review of available studies. PubMed, EMBASE, and Web of Science were searched since inception to June 2022. Inclusion criteria were: (1) observational studies or surveys; (2) studies on patients with chronic diseases; (3) reporting the effects of COVID-19 pandemic on adherence to chronic pharmacological treatment, as a comparison of adherence during the pandemic period vs. pre-pandemic period (primary outcome) or as rate of treatment discontinuation/delay specifically due to factors linked to COVID-19 (secondary outcome). Findings from 12 (primary outcome) and 24 (secondary outcome) studies showed that many chronic treatments were interrupted or affected by a reduced adherence in the pandemic period, and that fear of infection, difficulty in reaching physicians or healthcare facilities, and unavailability of medication were often reported as reasons for discontinuation or modification of chronic therapies. For other therapies where the patient was not required to attend the clinic, continuity of treatment was sometimes ensured through the use of telemedicine, and the adherence was guaranteed with drug stockpiling. While the effects of the possible worsening of chronic disease management need to be monitored over time, positive strategies should be acknowledged, such as the implementation of e-health tools and the expanded role of community pharmacists, and may play an important role in preserving continuity of care for people with chronic diseases.

Rapid Review of Medication Taking (Adherence) Among Patients With Rheumatic Diseases During the COVID-19 Pandemic

OBJECTIVE

We aimed to identify, appraise, synthesize, and contextualize rapidly emerging reports on medication taking (adherence) among patients with rheumatic diseases during the COVID-19 pandemic.

METHODS

We searched MEDLINE, EMBASE, and CINAHL for peer-reviewed communications, letters, and articles published during the COVID-19 pandemic evaluating medication taking among individuals with rheumatic diseases. We appraised assessment and reporting of medication adherence according to established definitions of 3 distinct problems of medication taking (i.e., noninitiation, poor implementation, and discontinuation) and pooled findings using random-effects models.

RESULTS

We included 31 peer-reviewed studies in our synthesis from various jurisdictions, of which 25 described medication taking among rheumatology patients and 6 described medication prescribing among rheumatology providers. The pooled prevalence of overall medication nonadherence was 14.8% (95% confidence interval [95% CI] 12.3-17.2) and that of medication discontinuation (i.e., stopping of prescriptions) and poor implementation (i.e., not taking medication at the dose/frequency prescribed) as 9.5% (95% CI 5.1-14.0) and 9.6% (95% CI 6.2-13.0), respectively. Noninitiation (i.e., not starting/not filling new prescriptions) was not addressed.

CONCLUSION

Medication taking among individuals with rheumatic diseases during the COVID-19 pandemic varies globally. Unclear reporting and extensive variation in research methods between studies create barriers to research replication, comparison, and generalization to specific patient populations. Future research in this area should use consistent and transparent approaches to defining and measuring medication taking problems to ensure that findings appropriately describe the epidemiology of medication adherence and have the potential to identify modifiable targets for improving patient care.

Impact of COVID-19 Pandemic on Patients with Rheumatic and Musculoskeletal Diseases: Disruptions in Care and Self-Reported Outcomes

The COVID-19 pandemic presented a challenge to the care of patients with rheumatic and musculoskeletal diseases (RMDs). The objective of this study was to evaluate the impact of the pandemic on the care of RMDs patients and their health and well-being. This cross-sectional study involved 120 RMDs patients at the rheumatology department at Suez Canal University Hospital in Ismailia, Egypt, in July 2020. Patients were interviewed for sociodemographic and disease-related history. Further assessments were performed using Kessler 6-items, fears of COVID-19, and COV19–impact on quality of life scales. Rheumatoid arthritis and systemic lupus erythematosus represented the majority of our sample of RMDs patients (72.5% and 19.2%, respectively). About 50% of patients reported experiencing limitations in the access to rheumatologic care, and a similar percentage had changed or discontinued their medications. Disease-modifying antirheumatic drugs shortage and concerns about the increased risk of COVID-19 infection due to immunosuppressive drugs were the most frequently reported reasons for nonadherence. The percentage of patients with uncontrolled disease had significantly increased from 8.3% prior to the COVID-19 pandemic to 20% during the pandemic. About 60% of patients reported a high level of psychological distress. In conclusion, the pandemic negatively influenced mental health, quality of life, adherence to medications, access to rheumatology care, and the degree of disease control of RMDs patients.

Medication Adherence Evaluated Through Electronic Monitors During the 2020 COVID-19 Pandemic Lockdown in Switzerland: A Longitudinal Analysis

BACKGROUND

During the 2020 COVID-19 lockdown, patients included in the Interprofessional Medication Adherence Program (IMAP) in Switzerland continued to use electronic monitors (EMs) that registered daily drug-dose intake. We aimed to understand to what extent patients' medication implementation (ie, the extent to which the patient took the prescribed medicine), measured with EMs, was impacted by the lockdown.

METHODS

Patients participating in the IMAP were diagnosed with diabetic kidney disease (DKD), solid cancer, human immunodeficiency virus (HIV) and miscellaneous long-term diseases (MLTD). Patient implementation was defined through a proxy: if all patient EMs were opened at least once daily, implementation was considered active (=1), and no implementation was considered (=0) otherwise. Implementation before (from December 2019 to March 2020), during (March to June 2020) and after (June to September 2020) the lockdown was compared. Subanalyses were performed according to the patients' diseases. Subanalyses were performed in patients who used at least one EM in 2018-2019 during the same periods (defined as winter, spring and summer). The logistic regression models used to estimate medication implementation according to the period were fitted using generalized estimating equations.

RESULTS

In 2020, patient implementation (n = 118) did not differ significantly before versus during (OR = 0.98, 95% CI: 0.84-1.15, p = 0.789) and before versus after (OR = 0.91, 95% CI: 0.79-1.06, p = 0.217) the lockdown. These findings remained stable when separately analyzing the implementation of patients with HIV (n = 61), DKD (n = 25) or MLTD (n = 22). Too few patients with cancer were included (n = 10) to interpret the results. In 2019, the implementation of 61/118 (51.7%) patients was significantly lower during summertime versus wintertime (OR = 0.73, 95% CI: 0.60-0.89, p = 0.002).

CONCLUSION

Medication implementation remained steady before, during and after the lockdown in 2020. The IMAP before, during and after the lockdown may have supported the adherence of most patients, by ensuring continuity of care during periods of routine disturbances.

COVID-19 from a rheumatology perspective: bibliometric and altmetric analysis

The Coronavirus disease 2019 (COVID-19) outbreak turned out the greatest pandemic for decades. It challenged enormously the global health system, forcing it to adjust to the new realities. We aimed to analyze articles covering COVID-19 papers in the rheumatological field and outline emerging topics raising within this frame. We applied the bibliometric database Scopus for our literature search and conducted it on the 5th of June using the following keywords: "rheumatic" OR "rheumatology" OR "rheumatoid arthritis" OR "systemic lupus erythematosus" OR "myositis" OR "systemic sclerosis" OR "vasculitis" OR "arthritis" OR "ankylosing spondylitis" AND "COVID-19". We analyzed all selected articles according to various aspects: type of document, authorship, journal, citations score, rheumatology field, country of origin, language, and keywords. With the help of the software tool VOSviewer version 1.6.15, we have built the visualizing network of authors and keywords co-occurrence. The measurement of the social impact of articles was made using Altmetric data. This study included 1430 retrieved articles with open access mostly. The top five journals in this field were Annals of the Rheumatic Diseases (n = 65), Rheumatology International (n = 51), Clinical Rheumatology (n = 50), Lancet Rheumatology (n = 50), and Frontiers In Immunology (n = 33). Most studies originate from countries with a high incidence of COVID-19 among the general population (the USA-387; Italy-268; UK-184; France-114; Germany-110; India-98 and Spain-96, China-94, Canada-73 Turkey-66). Original Articles (42.1%) were the most common articles' type, following by Letters (24.4%), Reviews (21.7%), Notes (6%), Editorials (4.8%), Erratum (1%). According to the citations scores, articles dedicated to the clinical course of COVID-19 in patients with rheumatic diseases were of the highest importance for the scientific rheumatologic community. Rheumatoid arthritis (n = 527), systemic lupus erythematosus (n = 393), vasculitis (n = 267), myositis (n = 71), systemic sclerosis (n = 68), and psoriatic arthritis (n = 68) were the most widely discussed rheumatic diseases in the view of COVID-19. The analysis of Altmetric and citations scores revealed a moderate correlation between them. This article provides a comprehensive bibliometric and altmetric analysis of COVID-19 related articles in the rheumatology field and summarizes data about features of rheumatology service in the time of the pandemic.

Attitudes of patients with a rheumatic disease on drug use in the COVID-19 pandemic

Background

Anti-rheumatic drugs can increase the predisposition to infection, and patients may be unaware of continuing their treatment during the COVID-19 pandemic.

Objective

This study aimed to assess whether patients maintain their treatment for rheumatic conditions during the pandemic period and determine the factors responsible for discontinuation.

Methods

Patients were randomly selected from the prospectively collected database of our tertiary referral center. The patients were interviewed by telephone through a standardized closed-ended questionnaire, which is targeting the continuity of the treatment plan and the considerations related to the individual choice. The patients were asked whether they hesitated to visit the hospital for follow-up or intravenous drug administration.

Results

A total of 278 patients completed the questionnaire. While 62 of the patients (22.3%) had reduced or interrupted the treatment, only 11 patients (3.9%) stopped the treatment completely. A significant difference was observed between the duration of illness and the discontinuation of treatment. (p = 0.023) There was a significant difference in disease activity between the group that stopped treatment and continued treatment. (p = 0.001) There was no statistically significant difference in other demographic characteristics. One hundred thirty-five patients (48.6%) made the treatment decision by themselves, and 80% continued the treatment. Reasons for stopping the treatment were anxiety (48.4%), not being able to go to the hospital for intravenous treatment (45.1%), and not being able to find the drug (6.5%).

Conclusion

Since patients with long-term illnesses were found to be significantly more likely to stop their treatment, this group of patients should be monitored.

Assessing forgetfulness and polypharmacy and their impact on health-related quality of life among patients with hypertension and dyslipidemia in Greece during the COVID-19 pandemic

Purpose

We estimate the association between forgetfulness to take medications as prescribed and polypharmacy and health-related quality of life (HRQoL) among a cohort of patients with hypertension, dyslipidemia or both in Greece during the COVID-19 pandemic.

Methods

A telephone survey of 1018 randomly selected adults was conducted in Greece in June 2020. Participants were included in the survey, if they (a) had a diagnosis of hypertension, dyslipidemia or both and (b) were on prescription treatment for these conditions. HRQoL was calculated using the short form (SF) -12 Patient Questionnaire. A multivariable generalized linear regression model (GLM) was used to estimate the association between forgetfulness and polypharmacy and HRQoL, controlling for sociodemographic and health-related covariates.

Results

Overall, 351 respondents met the inclusion criteria, of whom 28 did not fully complete the questionnaire (response rate: 92%, n = 323). Of those, 37% were diagnosed with hypertension only, 28% with dyslipidemia only, and 35% with both. Most reported good to average physical (64.1%) and mental health (48.6%). Overall, 25% indicated that they sometimes forget to take their prescribed medications, and 12% took two or more pills multiple times daily. Total HRQoL score was 68.9% (s.d. = 18.0%). About 10% of participants reported paying less attention to their healthcare condition during the pandemic. Estimates of multivariable analyses indicated a negative association between forgetfulness (− 9%, adjusted β: − 0.047, 95% confidence interval − 0.089 to − 0.005, p = 0.029), taking two or more pills multiple times daily compared to one pill once a day (− 16%, adjusted β: − 0.068, 95% confidence interval − 0.129 to − 0.008, p = 0.028) and total HRQoL.

Conclusion

Our results suggest that among adult patients with hypertension, dyslipidemia or both in Greece, those who forget to take their medications and those with more complex treatment regimens had lower HRQoL. Such patients merit special attention and require targeted approaches by healthcare providers to improve treatment compliance and health outcomes.

Updated APLAR consensus statements on care for patients with rheumatic diseases during the COVID-19 pandemic

AIM

To update previous guidance of the Asia Pacific League of Associations for Rheumatology (APLAR) on the management of patients with rheumatic and musculoskeletal diseases (RMD) during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Research questions were formulated focusing on diagnosis and treatment of adult patients with RMD within the context of the pandemic, including the management of RMD in patients who developed COVID-19. MEDLINE was searched for eligible studies to address the questions, and the APLAR COVID-19 task force convened 2 meetings through video conferencing to discuss its findings and integrate best available evidence with expert opinion. Consensus statements were finalized using the modified Delphi process.

RESULTS

Agreement was obtained around key aspects of screening for or diagnosis of COVID-19; management of patients with RMD without confirmed COVID-19; and management of patients with RMD with confirmed COVID-19. The task force achieved consensus on 25 statements covering the potential risk of acquiring COVID-19 in RMD patients, advice on RMD medication adjustment and continuation, the roles of telemedicine and vaccination, and the impact of the pandemic on quality of life and on treatment adherence.

CONCLUSIONS

Available evidence primarily from descriptive research supported new recommendations for aspects of RMD care not covered in the previous document, particularly with regard to risk factors for complicated COVID-19 in RMD patients, modifications to RMD treatment regimens in the context of the pandemic, and COVID-19 vaccination in patients with RMD.

Impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection and disease-2019 (COVID-19) on the quality of life of rheumatoid arthritis patients in Benin

Aim of the work

To study the impact on the quality of life (QoL) of rheumatoid arthritis (RA) patients following up in a university hospital in Benin during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) disease 2019 (COVID-19) pandemic.

Patients and methods

The QoL of 68 RA patients was assessed using Medical Outcome Study Short Form 36 (MOS-SF36) scale across the physical (PCS) and mental (MCS) components scores. The disease activity score (DAS28) was considered. Patients accepting to participate and having a mean of communication via social network, in particular WhatsApp were included.

Results

The mean age of the patients was 49.9 ± 12.1 years (11-83 years) and were 65 females and 3 males. The mean DAS-28 at the start of the restriction measures was 3.4 ± 1.5, the mean PCS and MCS were 71.1 ± 20.3 and 67.1 ± 16.02 respectively and became 4.7 ± 2.04, 38.1 ± 4.96 and 36.8 ± 3.8 respectively. After 2 months, none of the RA patients presented with classic symptoms of COVID-19 infection. 8 patients were screened by Rapid Diagnostic Test and Reverse Transcription-Polymerase Chain Reaction. Only 1 case was positive but asymptomatic. All patients had altered QoL according to MOS-SF36. Factors associated with this deterioration were stress related to SARS-CoV2 isolation (p = 0.001), stress of having an activity flare-up (p = 0.001), fear of being stigmatized (p = 0.009). The economic factors were significantly associated with temporary unemployment, decrease in monthly income, and drug discontinuation (p = 0.001, p = 0.002 and p = 0.046 respectively).

Conclusion

The impact of the SARS-CoV2 pandemic is negative on the QoL of RA patients and many factors were contributing.

Self-protection strategies and health behaviour in patients with inflammatory rheumatic diseases during the COVID-19 pandemic: results and predictors in more than 12 000 patients with inflammatory rheumatic diseases followed in the Danish DANBIO registry

AIMS

In Danish patients with inflammatory rheumatic diseases to explore self-protection strategies and health behaviour including adherence to disease-modifying antirheumatic treatment (DMARD) during the initial phase of the COVID-19 pandemic and again after the reopening of the society started. Furthermore, to identify characteristics of patients with high levels of anxiety and self-isolation.

METHODS

Patients in routine care followed prospectively in the nationwide DANBIO registry were invited to answer an online questionnaire regarding disease activity and COVID-19 infection, behaviour in March and June 2020. Responses were linked to patient data in DANBIO. Characteristics potentially associated with anxiety, self-isolation and medication adherence (gender/age/diagnosis/education/work status/comorbidity/DMARD/smoking/EQ-5D/disease activity) were explored with multivariable logistic regression analyses.

RESULTS

We included 12 789 patients (8168 rheumatoid arthritis/2068 psoriatic arthritis/1758 axial spondyloarthritis/795 other) of whom 65% were women and 36% treated with biological DMARD. Self-reported COVID-19 prevalence was 0.3%. Patients reported that they were worried to get COVID-19 infection (March/June: 70%/45%) and self-isolated more than others of the same age (48%/38%). The fraction of patients who changed medication due to fear of COVID-19 were 4.1%/0.6%. Female gender, comorbidities, not working, lower education, biological treatment and poor European Quality of life, 5 dimensions were associated with both anxiety and self-isolation.

CONCLUSION

In >12 000 patients with inflammatory arthritis, we found widespread anxiety and self-isolation, but high medication adherence, in the initial phase of the COVID-19 pandemic. This persisted during the gradual opening of society during the following months. Attention to patients' anxiety and self-isolation is important during this and potential future epidemics.