Factors associated with non-adherence to medications in systemic lupus erythematosus: Results from a Swedish survey

OBJECTIVE

To identify determinants of medication non-adherence in a Swedish population of systemic lupus erythematosus (SLE).

METHODS

Patients with SLE from Karolinska and Örebro University Hospitals participated in a survey-based cross-sectional study. Demographics, disease activity, organ damage, HRQoL (LupusQol, EQ-5D-5 L), medication non-adherence (<80% on CQR-19 or MASRI) and beliefs about medicines (BMQ) were registered. MASRI was used to report adherence to different drugs/drug classes, categorised into (i) antimalarial agents (AMA), (ii) glucocorticoids and (iii) other SLE medications. Multivariable logistic regression adjusted for age, sex, disease activity and organ damage.

RESULTS

Among 205 respondents, the median age was 52.0 years (IQR: 34.0-70.0), 86.3% were women, 66.8% were non-adherent to their medications according to CQR-19, and 6.6% and 6.3% were non-adherent to AMA and glucocorticoids, respectively, according to MASRI. Positive beliefs about glucocorticoids (OR; 95% CI: 0.77; 0.59-0.99; p = .039) and medications overall (0.71; 0.52-0.97; p = .029) were protective against non-adherence to glucocorticoids. Anxiety/depression (3.09; 1.12-8.54; p = .029), medication concerns (1.12; 1.05-1.20; p < .001) and belief that medications are overused (1.30; 1.15-1.46; p < .001) or harmful (1.36; 1.19-1.56; p < .001) were associated with medication non-adherence (CQR-19); beliefs in the necessity of medications (0.73; 0.65-0.82; p < .001) and positive beliefs in medications were protective (0.72; 0.60-0.86; p < .001). No associations were found between other investigated factors and medication non-adherence.

CONCLUSIONS

Beliefs about medications were a major determinant of medication non-adherence. Patient education may help alleviate the negative impact of misinformation/unawareness on adherence.

Polypharmacy prevalence and associated factors in patients with systemic lupus erythematosus: A single-centre, cross-sectional study

OBJECTIVES

This study aimed to clarify factors associated with polypharmacy among patients with systemic lupus erythematosus.

METHODS

This single-centre cross-sectional study was conducted by reviewing the medical records and questionnaire data of 261 systemic lupus erythematosus patients at a teaching hospital in Japan from 1 September to 30 November 2020. Polypharmacy was defined as the regular administration of five or more oral medications; excessive polypharmacy consisted of the regular use of 10 or more oral medications. This study investigated (1) the prevalence of polypharmacy and excessive polypharmacy, (2) the distribution of medication types, and (3) the factors associated with polypharmacy and excessive polypharmacy.

RESULTS

The proportions of patients who exhibited polypharmacy and excessive polypharmacy were 70% and 19%, respectively. Polypharmacy was associated with older age, long duration of systemic lupus erythematosus, high disease activity, and administration of glucocorticoids or immunosuppressive agents. Excessive polypharmacy was associated with a higher updated Charlson comorbidity index, history of visits to multiple internal medicine clinics, and presence of public assistance.

CONCLUSIONS

Polypharmacy and excessive polypharmacy in patients with systemic lupus erythematosus are related to medical aspects such as disease severity and comorbidities in addition to social aspects such as hospital visitation patterns and economic status.

Association Between Severe Nonadherence to Hydroxychloroquine and Systemic Lupus Erythematosus Flares, Damage, and Mortality in 660 Patients From the SLICC Inception Cohort

OBJECTIVE

The goals of this study were to assess the associations of severe nonadherence to hydroxychloroquine (HCQ), objectively assessed by HCQ serum levels, and risks of systemic lupus erythematosus (SLE) flares, damage, and mortality rates over five years of follow-up.

METHODS

The Systemic Lupus International Collaborating Clinics (SLICC) Inception Cohort is an international multicenter initiative (33 centers throughout 11 countries). The serum of patients prescribed HCQ for at least three months at enrollment were analyzed. Severe nonadherence was defined by a serum HCQ level <106 ng/mL or <53 ng/mL for HCQ doses of 400 or 200 mg/day, respectively. Associations with the risk of a flare (defined as a Systemic Lupus Erythematosus Disease Activity Index 2000 increase ≥4 points, initiation of prednisone or immunosuppressive drugs, or new renal involvement) were studied with logistic regression, and associations with damage (first SLICC/American College of Rheumatology Damage Index [SDI] increase ≥1 point) and mortality with separate Cox proportional hazard models.

RESULTS

Of the 1,849 cohort participants, 660 patients (88% women) were included. Median (interquartile range) serum HCQ was 388 ng/mL (244-566); 48 patients (7.3%) had severe HCQ nonadherence. No covariates were clearly associated with severe nonadherence, which was, however, independently associated with both flare (odds ratio 3.38; 95% confidence interval [CI] 1.80-6.42) and an increase in the SDI within each of the first three years (hazard ratio [HR] 1.92 at three years; 95% CI 1.05-3.50). Eleven patients died within five years, including 3 with severe nonadherence (crude HR 5.41; 95% CI 1.43-20.39).

CONCLUSION

Severe nonadherence was independently associated with the risks of an SLE flare in the following year, early damage, and five-year mortality.

A Flare Risk Index Informed by Select Immune Mediators in Systemic Lupus Erythematosus

OBJECTIVE

Systemic lupus erythematosus (SLE) is marked by immune dysregulation linked to varied clinical disease activity. Using a unique longitudinal cohort of SLE patients, this study sought to identify optimal immune mediators informing an empirically refined flare risk index (FRI) reflecting altered immunity prior to clinical disease flare.

METHODS

Thirty-seven SLE-associated plasma mediators were evaluated by microfluidic immunoassay in 46 samples obtained in SLE patients with an imminent clinical disease flare (preflare) and 53 samples obtained in SLE patients without a flare over a corresponding period (pre-nonflare). SLE patients were selected from a unique longitudinal cohort of 106 patients with classified SLE (meeting the American College of Rheumatology 1997 revised criteria for SLE or the Systemic Lupus International Collaborating Clinics 2012 revised criteria for SLE). Autoantibody specificities, hybrid SLE Disease Activity Index (hSLEDAI) scores, clinical features, and medication usage were also compared at preflare (mean ± SD 111 ± 47 days prior to flare) versus pre-nonflare (99 ± 21 days prior to nonflare) time points. Variable importance was determined by random forest analysis with logistic regression subsequently applied to determine the optimal number and type of analytes informing a refined FRI.

RESULTS

Preflare versus pre-nonflare differences were not associated with demographics, autoantibody specificities, hSLEDAI scores, clinical features, nor medication usage. Forward selection and backward elimination of mediators ranked by variable importance resulted in 17 plasma mediator candidates differentiating preflare from pre-nonflare visits. A final combination of 11 mediators best informed a newly refined FRI, which achieved a maximum sensitivity of 97% and maximum specificity of 98% after applying decision curve analysis to define low, medium, and high FRI scores.

CONCLUSION

We verified altered immune mediators associated with imminent disease flare, and a subset of these mediators improved the FRI to identify SLE patients at risk of imminent flare. This molecularly informed, proactive management approach could be critical in prospective clinical trials and the clinical management of lupus.

Association of Hurried Communication and Low Patient Self-Efficacy With Persistent Nonadherence to Lupus Medications

OBJECTIVE

Medication nonadherence is common among patients with systemic lupus erythematosus (SLE), and adherence often fluctuates with time. Underrepresented racial minorities have disproportionately lower rates of medication adherence and more severe SLE manifestations. We aimed to identify modifiable factors associated with persistent medication nonadherence.

METHODS

Patients taking ≥1 SLE medication were enrolled. Adherence data were obtained at baseline and at follow-up roughly 1 year later using both self-reported adherence and pharmacy refill data. Covariates included patient-provider interaction, patient self-efficacy, and clinical factors. We compared characteristics of patients in 3 groups using the Kruskal-Wallis H test: persistent nonadherence (low adherence by self-report and refill rates at both time points); persistent adherence (high adherence by self-report and refill rates at both time points); and inconsistent adherence (the remainder).

RESULTS

Among 77 patients (median age 44 years, 53% Black, 96% female), 48% had persistent nonadherence. Compared with other adherence groups, patients with persistent nonadherence were younger and more likely to be Black, have lower income, take ≥2 SLE medications, have higher SLE-related damage at baseline, and have higher physician global assessment of disease activity at follow-up. Persistently nonadherent patients also rated more hurried communication with providers (particularly fast speech and difficult word choice) and had lower self-efficacy in managing medications.

CONCLUSION

Potential avenues to improve medication adherence include optimizing patient-provider communication, specifically avoiding difficult vocabulary and fast speech, and enhancing patient self-efficacy, particularly among younger Black patients with lower income who are at higher risk for nonadherence.

Health care utilization and costs of systemic lupus erythematosus in the United States: A systematic review

OBJECTIVES

To evaluate health care utilization and costs for patients with systemic lupus erythematosus (SLE) by disease severity.

METHODS

We searched PubMed and Embase from January 2000 to June 2020 for observational studies examining health care utilization and costs associated with SLE among adults in the United States. Two independent reviewers reviewed the selected full-text articles to determine the final set of included studies. Costs were converted to 2020 US $.

RESULTS

We screened 9224 articles, of which 51 were included. Mean emergency department visits were 0.3-3.5 per year, and mean hospitalizations were 0.1-2.4 per year (mean length of stay 0.4-13.0 days). Patients averaged 10-26 physician visits/year. Mean annual direct total costs were $17,258-$63,022 per patient and were greater for patients with moderate or severe disease ($19,099-$82,391) compared with mild disease ($12,242-$29,233). Mean annual direct costs were larger from commercial claims ($24,585-$63,022) than public payers (Medicare and Medicaid: $18,302-$27,142).

CONCLUSIONS

SLE remains a significant driver of health care utilization and costs. Patients with moderate to severe SLE use more health care services and incur greater direct and indirect costs than those with mild disease.

Non-pharmacologic therapies in treatment of childhood-onset systemic lupus erythematosus: A systematic review

BACKGROUND

Childhood-onset systemic lupus erythematosus (cSLE) is a complex multisystem autoimmune disease often associated with pain, fatigue, and mood-related disturbances. cSLE is associated with increased disease severity and higher rates of mortality as compared to adult onset SLE. Therefore, a multi-faceted approach to care, including the use of non-pharmacologic therapies, is essential to ensure optimal patient outcomes. The use of non-pharmacologic therapies as adjunctive treatments has been shown to be beneficial in adults with SLE, yet, their use and effect is less well understood in cSLE. This is the first systematic review to explore the use and quality of evidence of non-pharmacologic approaches to treat cSLE.

METHODS

A literature review was performed using PRISMA guidelines. Studies until March 2021 with participants diagnosed with cSLE were included. The quality of the evidence was graded via OCEBM levels of evidence guidelines and bias assessed using Cochrane guidelines. Completed clinical trials (via clinicaltrials.gov) were also searched to identify unpublished results.

RESULTS

Eleven published studies consisting of 1152 patients met inclusion criteria for this review, as well as three additional studies with unpublished data on clinicaltrial.gov. Of the published trials, four studies used patient education/support, three studies used dietary supplementation, three used forms of psychotherapy (e.g., Cognitive behavioral therapy), and 1 used aerobic exercise to target the following issues: treatment adherence (n = 3), quality of life (n = 3), fatigue (n = 2), pain (n = 2), depressive symptoms (n = 1), anxiety (n = 1), and health-related outcomes including disease severity (n = 3), cardiovascular disease risk (Cardiovascular disease; n = 3), and muscle function (n = 1). Across investigations, the quality of the evidence based on study design was moderate/low. In terms of potential outcomes, dietary supplementation methods were successful in 2 of 3 studies and were associated with improvements in disease activity and fatigue. Aerobic exercise was effective in decreasing resting heart rate and increasing cardiorespiratory capacity. Patient education/support was related to significantly increased treatment adherence and decreased cardiovascular risk markers. Two of the three studies examining the impact of psychotherapy showed improvements (e.g., in treatment adherence, depression and fatigue).

CONCLUSION

This review identifies several promising non-pharmacologic therapies to use as adjunctive treatments to traditional pharmacologic regimens in health and mental health-related outcomes in patients with cSLE. Future well controlled clinical trials would be beneficial to more rigorously evaluate the effects of non-pharmacologic therapies in pediatric populations.

How Can We Enhance Adherence to Medications in Patients with Systemic Lupus Erythematosus? Results from a Qualitative Study

Medication non-adherence is common among patients with systemic lupus erythematosus (SLE) and may lead to poor clinical outcomes. Our aim was to identify influenceable contributors to medication non-adherence and suggest interventions that could increase adherence. Patients with SLE from two Swedish tertiary referral centres (n = 205) participated in a survey assessing self-reported adherence to medications. Responses were used to select patients for qualitative interviews (n = 15). Verbatim interview transcripts were analysed by two researchers using content analysis methodology. The median age of the interviewees was 32 years, 87% were women, and their median SLE duration was nine years. Reasons for non-adherence were complex and multifaceted; we categorised them thematically into (i) patient-related (e.g., unintentional non-adherence due to forgetfulness or intentional non-adherence due to disbelief in medications); (ii) healthcare-related (e.g., untrustworthy relationship with the treating physician, authority fear, and poor information about the prescribed medications or the disease); (iii) medication-related (e.g., fear of side-effects); and (iv) disease-related reasons (e.g., lacking acceptance of a chronic illness or perceived disease quiescence). Interventions identified that healthcare could implement to improve patient adherence to medications included (i) increased communication between healthcare professionals and patients; (ii) patient education; (iii) accessible healthcare, preferably with the same personnel; (iv) well-coordinated transition from paediatric to adult care; (v) regularity in addressing adherence to medications; (vi) psychological support; and (vii) involvement of family members or people who are close to the patient.

Controversies in Systemic Lupus Erythematosus: Are We Treating Our Patients Adequately?

ABSTRACT

Systemic lupus erythematosus (SLE) is characterized by great clinical heterogeneity. The objectives of its management are to make a timely diagnosis and to initiate treatment as promptly as possible so organ damage can be avoided while at the same time exposure to potentially toxic drugs is minimized so that its overall course and outcome improve. In reviewing the current literature, it became quite clear that there are specific topics in which controversies do exist. These include how to treat patients with incomplete lupus erythematosus, the real possibility of abandoning altogether the use of oral glucocorticoids, and the pros and cons of the use of cyclophosphamide and mycophenolate mofetil for the induction treatment of lupus nephritis. Herein we discuss different points of view regarding these still unresolved issues; these comments represent a debate that took place during the PANLAR Virtual Congress (Pan American League of Associations for Rheumatology) and that was organized by the PANLAR Lupus study group, GLADEL (Grupo Latino Americano De Estudio del Lupus) on September 19, 2020.

Medication adherence in systemic lupus erythematosus during Brazilian COVID-19 pandemic

BACKGROUND

Patients with chronic diseases are potential candidates for inadequate follow-up of drug therapy, tending to incur damage to the intended results. This deserves greater attention in the pandemic period, as they are in the considered risk group.

METHODS

We aim to assess Treatment Adherence Measure and analyze associations with characteristics related to the patient, treatment, disease, health professionals and service, and sociodemographic issues in patients with Systemic Lupus Erythematosus (SLE). W conducted a cross-sectional study with a sample of 116 participants, whose data were collected through individual interviews and review of medical records, during the first months of the COVID-19 pandemic in Brazil. Adherence was measured using the Treatment Adherence Measure, and associations were evidenced through described and inferential statistics.

RESULTS

The percentage of adherent patients was 55.2%. An association was found between MTA (Medication Treatment Adherence) and physical exercise practice (p = 0.032), and difficulties with treatment (p = 0.002). Conclusion: Participants who did not practice physical exercise were 3.71 times more likely to not adhere to the treatment. Individuals who identified difficulties in the treatment were 3.43 times more likely to not adhere to the treatment; we believe that the pandemic may have influenced this result. More targeted studies are needed to measure the impact on MTA in these patients.

Hydroxychloroquine PK and exposure-response in pregnancies with lupus: the importance of adherence for neonatal outcomes

OBJECTIVE

Evaluate the impact of pregnancy physiology and medication non-adherence on serum hydroxychloroquine (HCQ) pharmacokinetics (PK) and exposure-response in SLE.

METHODS

We conducted a PK analysis using data from two observational pregnancy registries. We enrolled pregnant women with SLE taking HCQ at least 3 months prior to, and throughout pregnancy, and excluded those with multiple gestations. Using the PK model, we conducted dosing simulations and imputed 0%/20%/40%/60% non-adherence to evaluate the impact of adherence versus physiological changes on HCQ concentrations. We compared the effect of pregnancy-average non-adherent concentrations (≤100 ng/mL vs >100 ng/mL) on preterm birth using adjusted logistic regression.

RESULTS

We enrolled 56 women who had 61 pregnancies. By the third trimester, mean apparent HCQ clearance increased by 59.6%. At a dosage of 400 mg/day, fully adherent patients are expected to have HCQ concentrations ≤100 ng/mL only 0.3% of the time, compared with 24.2% when 60% of doses are missed. Persistently low HCQ concentrations throughout pregnancy were associated with a significantly higher odds of preterm birth, controlling for lupus nephritis and race (OR 11.2; 95% CI 2.3 to 54.2; p=0.003).

CONCLUSIONS

We observed significant changes in HCQ PK during pregnancy, resulting in a shortening in the drug's half-life by 10 days; however, medication non-adherence had a more pronounced effect on HCQ exposure compared with physiological changes alone. Moreover, pregnant women with non-adherent HCQ concentrations had significantly higher rates of preterm birth. Accordingly, optimising adherence in pregnancy may be more clinically meaningful than adjusting HCQ dosage to account for physiological changes. PK modelling indicates that serum HCQ concentrations ≤100 ng/mL are suggestive of non-adherence regardless of trimester and may help identify pregnancies at risk for poor outcomes.

Transcriptomic analysis of immune cells in a multi-ethnic cohort of systemic lupus erythematosus patients identifies ethnicity- and disease-specific expression signatures

Systemic lupus erythematosus (SLE) is an autoimmune disease in which outcomes vary among different racial groups. We leverage cell-sorted RNA-seq data (CD14+ monocytes, B cells, CD4+ T cells, and NK cells) from 120 SLE patients (63 Asian and 57 White individuals) and apply a four-tier approach including unsupervised clustering, differential expression analyses, gene co-expression analyses, and machine learning to identify SLE subgroups within this multiethnic cohort. K-means clustering on each cell-type resulted in three clusters for CD4 and CD14, and two for B and NK cells. To understand the identified clusters, correlation analysis revealed significant positive associations between the clusters and clinical parameters including disease activity as well as ethnicity. We then explored differentially expressed genes between Asian and White groups for each cell-type. The shared differentially expressed genes across cells were involved in SLE or other autoimmune-related pathways. Co-expression analysis identified similarly regulated genes across samples and grouped these genes into modules. Finally, random forest classification of disease activity in the White and Asian cohorts showed the best classification in CD4+ T cells in White individuals. The results from these analyses will help stratify patients based on their gene expression signatures to enable SLE precision medicine.

Medication adherence is influenced by resilience in patients with systemic lupus erythematosus

OBJECTIVE

Evidence on the relationship between resilience and medication adherence in systemic lupus erythematosus (SLE) patients is lacking. We aimed to examine the impact of resilience on medication adherence in SLE patients.

METHOD

In a cross-sectional analysis SLE outpatients were assessed for resilience (Connor-Davison Resilience Scale, CD-RISC), depressive symptoms (CES-D) and medication adherence (Compliance Questionnaire for Rheumatology [CQR]). The disease activity index (mexSLEDAI) and damage (SLICC Damage Index) were administered. Factors independently associated with adherence were identified using multivariate logistic regression.

RESULTS

Of the 157 patients, 152 (96.8%) were female with a median age of 45.9 (IQR: 39.0-55.5) years and disease duration of 14 (IQR: 10.0-19.0) years. Medication adherence (CQR ≥80%) and depressive symptoms were found in 74.5% and 43.9% of patients, respectively. Adherent patients had a lower CES-D score and a higher CD-RISC score. In the multivariate analysis adjusting for demographic and clinical confounders, resilience and older age protected against non-adherence (OR 0.96, [95% CI 0.94-0.99] and OR 0.96 [95% CI 0.93-0.98], respectively).

CONCLUSION

In SLE patients, resilience and older age, which possibly associated with better medication adherence, may protect against non-adherence.

Exploring intentional medication non-adherence in patients with systemic lupus erythematosus: the role of physician-patient interactions

Objective

Medication non-adherence contributes to worse health outcomes among SLE patients. The underlying mechanisms that drive medication non-adherence are poorly understood. The purpose of this study was to explore possible mechanisms of medication non-adherence by eliciting patient experiences.

Methods

Consented adult patients with ACR- or SLICC-classified SLE were recruited. Ten semi-structured interviews were conducted across six participants. Interviews were audio recorded, transcribed, and analysed using an iterative process. The findings were presented to an interactive public forum with SLE patients, family members and friends of patients, and health-care professionals to assess validity and for elaboration of the concepts developed.

Results

The following three interrelated themes emerged from the interviews. First, why do rheumatologists not know more about lupus or share what they do know with their patients? Second, why do I have to take so many drugs and why do the drugs not work? Third, if my rheumatologist cannot communicate with me, why should I follow the prescribed medication regimen?

Conclusion

Our exploratory findings lay out a possible underlying logic by which patients might choose intentionally to engage with medication non-adherence behaviours. Patients suggested that poor communication with their rheumatologists along with a lack of validation of their symptoms contributed to them not valuing the recommendations of physicians. This also contributed to development of a cynical outlook and little belief that medication would improve their condition. Although further work is needed to validate these findings, our preliminary work suggests that interventions focusing on the development of communication skills among both patients and rheumatologists are necessary to reduce medication non-adherence.

Discovering prescription patterns in pediatric acute-onset neuropsychiatric syndrome patients

OBJECTIVE

Pediatric acute-onset neuropsychiatric syndrome (PANS) is a complex neuropsychiatric syndrome characterized by an abrupt onset of obsessive-compulsive symptoms and/or severe eating restrictions, along with at least two concomitant debilitating cognitive, behavioral, or neurological symptoms. A wide range of pharmacological interventions along with behavioral and environmental modifications, and psychotherapies have been adopted to treat symptoms and underlying etiologies. Our goal was to develop a data-driven approach to identify treatment patterns in this cohort.

MATERIALS AND METHODS

In this cohort study, we extracted medical prescription histories from electronic health records. We developed a modified dynamic programming approach to perform global alignment of those medication histories. Our approach is unique since it considers time gaps in prescription patterns as part of the similarity strategy.

RESULTS

This study included 43 consecutive new-onset pre-pubertal patients who had at least 3 clinic visits. Our algorithm identified six clusters with distinct medication usage history which may represent clinician's practice of treating PANS of different severities and etiologies i.e., two most severe groups requiring high dose intravenous steroids; two arthritic or inflammatory groups requiring prolonged nonsteroidal anti-inflammatory drug (NSAID); and two mild relapsing/remitting group treated with a short course of NSAID. The psychometric scores as outcomes in each cluster generally improved within the first two years.

DISCUSSION AND CONCLUSION

Our algorithm shows potential to improve our knowledge of treatment patterns in the PANS cohort, while helping clinicians understand how patients respond to a combination of drugs.

Impact of arthritis on the perceived need and use of mental healthcare among Canadians with mental disorders: nationally representative cross-sectional study

OBJECTIVE

To evaluate the association between having arthritis and the perceived need for mental healthcare and use of mental health support among individuals with mental disorders.

DESIGN

A cross-sectional analysis using data from Canadian Community Health Survey-Mental Health (2012).

SETTING

The survey was administered across Canada's 10 provinces using multistage cluster sampling.

PARTICIPANTS

The study sample consisted of individuals reporting depression, anxiety or bipolar disorder.

STUDY VARIABLES AND ANALYSIS

The explanatory variable was self-reported doctor-diagnosed arthritis, and outcomes were perceived need for mental healthcare and use of mental health support. We computed overall and gender-stratified multivariable binomial logistic regression models adjusted for age, gender, race/ethnicity, income and geographical region.

RESULTS

Among 1774 individuals with a mental disorder in the study sample, 436 (20.4%) reported having arthritis. Arthritis was associated with increased odds of having a perceived need for mental healthcare (adjusted OR (aOR) 1.71, 95% CI 1.06 to 2.77). In the gender-stratified models, this association was increased among men (aOR 2.69, 95% CI 1.32 to 5.49) but not women (aOR 1.48, 95% CI 0.78 to 2.82). Evaluation of the association between arthritis and use of mental health support resulted in an aOR of 1.50 (95% CI 0.89 to 2.51). Individuals with arthritis tended to use medications and professional services as opposed to non-professional support.

CONCLUSION

Comorbid arthritis among individuals with a mental disorder was associated with an increased perceived need for mental healthcare, especially in men, underscoring the importance of understanding the role of masculinity in health seeking. Assessing the mental health of patients with arthritis continues to be essential for clinical care.

Prevalence and associated factors of medication nonadherence among Thai patients with systemic lupus erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic disease requiring complex treatment strategies to prevent disease flare ups and to reduce hospitalizations. Medication adherence is the main concern for improving patient outcomes. Although various studies on medication nonadherence for SLE have been conducted, no definite conclusions have been reached.

OBJECTIVE

To quantify the prevalence of medication nonadherence among patients with SLE and to analyse the associated factors.

METHODS

A prospective, self-reported questionnaire study was conducted in Songklanagarind Hospital. Patient aged 18 years or older, who had an established diagnosis of SLE, and who had been receiving medications for at least 6 months, were included in the study. Medication adherence was assessed through a visual analogue scale (VAS) and through the medication-taking behaviour measure for Thai patients (MTB-Thai) scale.

RESULTS

One hundred and seventy-two SLE patients were enrolled in the study. Most SLE patients were young to middle aged (56.40%) and had no clinical disease activity (67.4%), as assessed by a clinical SLEDAI score. Nonadherence rates were 32% and 25.3% by VAS and the MTB-Thai scale, respectively. Patients aged 55 years or older, who used the universal coverage of health care system, who used multiple medications (>10 pills/day), and who had a good attitude towards the disease were associated with a low risk of nonadherence.

CONCLUSION

Up to 25% SLE patients poorly adhered to their prescriptions. Age, reimbursement scheme, pill number, and attitude towards SLE were associated with nonadherence in our patients with SLE.

Disparities in Lupus and Lupus Nephritis Care and Outcomes Among US Medicaid Beneficiaries

Systemic lupus erythematosus (SLE) is a serious chronic autoimmune disease with substantial morbidity and mortality. Although improved diagnostics and therapeutics have contributed to declining mortality rates, important disparities exist in SLE survival rates by race, ethnicity, gender, age, country, and social disadvantage. This review highlights the burden of SLE and lupus nephritis among Medicaid beneficiaries, outlines barriers in access to high-quality SLE care and medication adherence in the Medicaid SLE population, and summarizes disparities in adverse outcomes among SLE patients enrolled in Medicaid.

Adherence to hydroxychloroquine in patients with systemic lupus: Contrasting results and weak correlation between assessment tools

OBJECTIVES

Hydroxychloroquine (HCQ) is an anchor drug in the treatment of systemic lupus erythematosus (SLE). Adherence to HCQ is key for efficacy. Inaccurate evaluation of adherence could lead to non-justified switch to more expensive or less tolerated drugs.

METHODS

Severe non-adherence rate to HCQ was estimated in a sample of SLE patients during a routine visit using blood HCQ concentration<200μg/L. Adherence was assessesd by the Medication Adherence Self-Report Inventory (MASRI)<80/100, 8-item Morisky Medication Adherence Scale (MMAS-8) ≤6/8, Health Care Provider (HCP) visual analog scale (VAS)<80/100. Same procedures were to be repeated during a further routine visit 6 to 12 months later. We described agreement and correlations between tools and compared severely non-adherent patients and others on their characteristics.

RESULTS

The study involved 158 patients (86.1% females) aged 42.2±12.6 years treated with HCQ for 9.6±6.9 years. Blood HCQ concentration (mean±standard deviation) was 1046±662μg/L at visit 1 and 855±577μg/L at visit 2. At visit 1, the non-adherence rate varied from 3.2% (blood HCQ level<200μg/L) to 7.7% (MASRI), 12.4% (HCP-VAS) or 32.5% (MMAS-8). 37.8% of patients met at least one of the definitions of non-adherence. Patients' characteristics including SLE activity, damage and quality of life were similar between severely non-adherent patients and others. Correlations between blood HCQ-concentration and self-questionnaires were weak (r<0.25) and agreement between methods was poor.

CONCLUSION

Blood HCQ concentration<200μg/L reveals severe non-adherence. Combining blood HCQ concentration with MASRI and MMAS-8 may help to better identify non-adherence in SLE. Agreement between methods was poor and correlations with HCQ level and SLE activity were weak.

Epidemiology of Depression and Anxiety in Gout: A Systematic Review and Metaanalysis

OBJECTIVE

To conduct a systematic review of depression and anxiety among patients with gout that specifically evaluates the prevalence, incidence, determinants, and effects of these mental health comorbidities.

METHODS

We conducted a literature search in Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL, and PsycINFO using indexed terms and key words to identify studies reporting on depression/anxiety in patients with gout. This review included full-text articles published in English that reported on patients with gout, evaluated depression/anxiety using a routinely reported measure, and provided estimates or sufficient data on the prevalence, incidence, determinants, or effects of depression/anxiety. Metaanalyses were conducted using random effects models.

RESULTS

Twenty of 901 articles identified through the search strategy met our inclusion criteria. All 20 studies evaluated depression, while only 10 assessed anxiety (50%). Metaanalyses suggest a positive association between mental health disorders and gout, as resultant pooled OR were 1.29 (95% CI 1.07-1.56) for depression and 1.29 (95% CI 0.96-1.73) for anxiety. Findings from four studies reporting on the incidence of depression in patients with gout resulted in a pooled HR of 1.17 (95% CI 1.01-1.36). Significant determinants of depression included number of tophi, frequency of flares, and oligo/polyarticular gout.

CONCLUSION

Our systematic review suggests that depression and anxiety are significantly associated with gout, highlighting the need for future research to focus on the onset of mental disorders after gout diagnosis. We also identify potential targets for intervention.

Defining Depression and Anxiety in Individuals With Rheumatic Diseases Using Administrative Health Databases: A Systematic Review

OBJECTIVE

To conduct a systematic review to describe how administrative health databases have been used to study depression and anxiety in patients with rheumatic diseases and to synthesize the case definitions that have been applied.

METHODS

Search strategies to identify articles evaluating depression and anxiety among individuals with rheumatic diseases were employed in Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, and PsycINFO. Studies included were those using administrative health data and reporting case definitions for depression and anxiety using International Classification of Diseases (ICD) codes. We extracted information on study design and objectives, administrative health database, specific data sources (e.g., inpatient, pharmacy records), ICD codes, operational definitions, and validity of case definitions.

RESULTS

Of the 36 studies included in this review, all studies assessed depression, and 13 studies (36.1%) evaluated anxiety. A number of specific ICD-9/10 codes were consistently applied to identify depression and anxiety, but the overall combination of ICD codes and operational definitions varied across studies. Twenty-four studies reported operational definitions, and 19 of these studies (79.2%) combined claims from more than 1 type of administrative data source (e.g., inpatient, outpatient). Validated case definitions were used by 6 studies (16.7%), with sensitivity estimates for depression and anxiety case definitions ranging from 33% to 74% and 42% to 76%, respectively.

CONCLUSION

We identified numerous case definitions used to evaluate depression and anxiety among individuals with rheumatic diseases within administrative health databases. Recommendations include using case definitions with demonstrated validity as well as operationalizing case definitions within multiple data sources.

Depressive Symptoms Are Associated With Low Treatment Adherence in African American Individuals With Systemic Lupus Erythematosus

OBJECTIVE

African American (AA) people with systemic lupus erythematosus (SLE) are at high morbidity and mortality risk, and they often require multiple medications. Low medication adherence is a highly prevalent, multidimensional problem associated with poor outcomes in people with SLE. Depression, a predictor of low adherence in people with chronic conditions, has been described in over 35% of AAs with SLE. We hypothesized that depressive symptoms would be increasingly associated with low adherence in this population.

METHODS

Research subjects predominantly belong to the Georgians Organized Against Lupus cohort, a population-based cohort of predominantly AA individuals with SLE in the Atlanta metropolitan area. Medication adherence and severity of depressive symptoms were measured using validated self-reported tools: the 8-item Morisky Medication Adherence Scale and the 9-item Patient Health Questionnaire, respectively. We used univariate and multivariate logistic regression to examine the odds ratios of low medication adherence across individuals with increasing severity of depressive symptoms.

RESULTS

Among 632 AA SLE participants, 336 (54%) reported low medication adherence and 217 (34.6%) reported "moderate" or "severe" depressive symptoms. In univariate logistic regression, significant risk factors for low adherence were depressive symptoms, low self-efficacy, poor satisfaction with care, female sex, younger age, hurried patient-physician communication, poorer shared decision-making, less compassionate physician communication style, poor/fair health, and higher disease activity score. In multivariate regression, younger age, female sex, and more severe depressive symptoms were associated with low medication adherence.

CONCLUSIONS

This is the first study to examine factors associated with low medication adherence among a population-based cohort of AA individuals with SLE. Depression was a strong correlate of low medication adherence. Mental health interventions aiming to address and treat depression may increase medication adherence.

Real-world electronic health record identifies antimalarial underprescribing in patients with lupus nephritis

Antimalarials (AMs) reduce disease activity and improve survival in patients with systemic lupus erythematosus (SLE), but studies have reported low AM prescribing frequencies. Using a real-world electronic health record cohort, we examined if patient or provider characteristics impacted AM prescribing. We identified 977 SLE cases, 94% of whom were ever prescribed an AM. Older patients and patients with SLE nephritis were less likely to be on AMs. Current age (odds ratio = 0.97, p < 0.01) and nephritis (odds ratio = 0.16, p < 0.01) were both significantly associated with ever AM use after adjustment for sex and race. Of the 244 SLE nephritis cases, only 63% were currently on AMs. SLE nephritis subjects who were currently prescribed AMs were more likely to be followed by a rheumatologist than a nephrologist and less likely to have undergone dialysis or renal transplant (both p < 0.001). Non-current versus current SLE nephritis AM users had higher serum creatinine (p < 0.001), higher urine protein (p = 0.05), and lower hemoglobin levels (p < 0.01). As AMs reduce disease damage and improve survival in patients with SLE, our results demonstrate an opportunity to target future efforts to improve prescribing rates among multi-specialty providers.

Association between hydroxychloroquine levels and disease activity in a predominantly Hispanic systemic lupus erythematosus cohort

OBJECTIVES

Hydroxychloroquine (HCQ) is a key therapy in systemic lupus erythematosus (SLE). Medication non-adherence is reported in up to 80% of lupus patients and results in increased morbidity, mortality, and health care utilization. HCQ levels are a sensitive and reliable method to assess medication adherence. Our study evaluated the role of HCQ level measurement in routine clinical care and its association with disease activity in a predominantly Hispanic population.

METHODS

SLE patients from the Columbia University Lupus cohort treated with HCQ for ≥ 6 months and reporting medication adherence were included. HCQ levels were measured by whole blood high performance liquid chromatography. Non-adherence was defined as an HCQ level <500 ng/ml. The association between HCQ levels and disease activity measured by Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) was evaluated.

RESULTS

One hundred and eight patients were enrolled; the median age was 38 years, 91% were female, and 63% were Hispanic. The median SLEDAI-2K was 4.3 (0-20). Forty-one percent of patients had an HCQ level <500 ng/ml consistent with non-adherence, of which 19% had undetectable levels. A higher SLEDAI-2K score was associated with low HCQ levels (p = 0.003). This association remained significant after adjusting for depression (p = 0.0007).

CONCLUSION

HCQ levels < 500 ng/ml were associated with higher disease activity and accounted for 32% of the SLEDAI-2K variability. HCQ blood measurement is a simple and reliable method to evaluate medication adherence in SLE. Reasons for non-adherence (levels < 500 ng/ml) should be further explored and addressed.

Effectiveness of renoprotective approaches for persistent proteinuria in lupus nephritis: more than just immunosuppression

OBJECTIVE

The objective of this study is to evaluate the efficacy of a tightly controlled renoprotective protocol in systemic lupus erythematosus (SLE) patients with persistent proteinuria.

METHODS

Thirteen SLE patients with nephritis and persistent proteinuria (>1 g/24 hours) were included. The protocol consisted of regular clinical evaluations every two weeks to assess blood pressure (BP, target <130/80 mmHg), adherence to therapy, diet and smoking. No change in immunosuppressive drugs was allowed but reduction of glucocorticoid dose was permitted if indicated. Clinical, laboratory and treatment evaluations were performed at baseline and at the end of the study (after three months).

RESULTS

SLE patients had a mean age of 37.85 ± 7.68 years and disease duration of 9.85 ± 7.29 years. At baseline, patients had a mean duration of maintenance therapy of 10.38 ± 7.56 months, 12 with mycophenolate mofetil (92.3%) and one with azathioprine (7.7%). At least one dose optimization of antihypertensive regimen was required in all patients during the study. Seven patients (53.8%) had BP>130/80mmHg at baseline. At the end, 11 patients (84.6%) achieved stable BP target; 92.3% were using an angiotensin-converting enzyme inhibitor, 53.9% an angiotensin receptor blocker, and 46.2% were using combined therapy. All patients had a significant reduction in proteinuria levels (2.26 ± 1.09 vs 0.88 ± 0.54 g/24 hours, p < 0.001) and 61.5% achieved proteinuria <1 g/24 hours. A significant decrease in mean prednisone dose was observed (10.96 ± 6.73 vs 5.38 ± 3.36 mg/day, p = 0.013) as well as mean Systemic Lupus Erythematosus Disease Activity Index score (4.38 ± 0.72 vs 3.08 ± 1.86, p = 0.043). No significant changes were identified in serum creatinine, albumin, potassium, complement 3 and complement 4 levels ( p > 0.05).

CONCLUSION

This study provides evidence that a tightly controlled renoprotective protocol is effective in reducing persistent proteinuria in lupus nephritis. The concomitant reduction of prednisone without any change in immunosuppression reinforces the importance of strategies beyond the treatment of nephritis activity.

Dynamic patterns and predictors of hydroxychloroquine nonadherence among Medicaid beneficiaries with systemic lupus erythematosus

BACKGROUND

Hydroxychloroquine (HCQ) is the standard of care medication for most SLE patients, however nonadherence is common. We investigated longitudinal patterns and predictors of nonadherence to HCQ in a U.S. SLE cohort of HCQ initiators.

METHODS

We used Medicaid data from 28 states to identify adults 18-65 years with prevalent SLE. We included HCQ initiators following ≥6 months without use, and required ≥1 year of follow-up after first dispensing (index date). We used the proportion of days covered (PDC) to describe overall HCQ adherence (<80% = nonadherent) and novel group-based trajectory models (GBTM) to examine monthly patterns (<80% of days/month covered = nonadherent), during the first year of use. Multivariable multinomial logistic regression models were used to examine predictors of nonadherence.

RESULTS

We identified 10,406 HCQ initiators with SLE. Mean age was 38 (±12) years, 94% were female, 42% black, 31% white; 85% had a mean PDC < 80%. In our 4-group GBTM, 17% were persistent adherers, 36% persistent nonadherers, and 47% formed two dynamic patterns of partial adherence. Adherence declined for most patients over the first year. Compared to persistent adherers, the odds of nonadherence were increased for blacks and Hispanics vs. whites and for younger ages vs. older; increased SLE-related comorbidities were associated with reduced odds of nonadherence for persistent nonadherers (0.95, 95% CI: 0.91-0.99).

CONCLUSIONS

Among HCQ initiators with SLE, we observed poor adherence which declined for most over the first year of use. HCQ adherence is a dynamic behavior and further studies of associated predictors, outcomes, and interventions should reflect this.

Medical adherence in patients with systemic lupus erythematosus in Germany: predictors and reasons for non-adherence – a cross-sectional analysis of the LuLa-cohort

Objective

Adherence to medication has a major impact on treatment control and success especially in chronic diseases but often remains unrecognized. Besides clinical, socioeconomic, disease-related and treatment-related parameters, general and personal health beliefs, as well as perception of health, can affect adherence. Our aim was to investigate the adherence to lupus-specific medications in German lupus patients and to assess influencing factors including detrimental or beneficial effects of health perceptions and beliefs.

Methods

The Lupus Erythematosus (LE) Long-Term Study (LuLa-study) is a nationwide longitudinal study among German Caucasian patients with systemic lupus erythematosus who have been assessed annually using a self-reported questionnaire since 2001. In 2013, we included questions concerning medical adherence (Morisky Medication Adherence Scale; MMAS-4), beliefs about medication prescribed (BMQ), illness perception and about the patients’ health locus of control (HLC). We present a cross-sectional analysis to assess predictors of adherence using a multivariable stepwise logistic regression.

Results

Five hundred and seventy-nine patients participated, 81 of whom did not take any lupus-specific medication and 40 of whom did not complete the MMAS-4 and were therefore omitted. Only 62.7% reported high adherence. Unintentional behaviour for low medical adherence exceeded the intentional behaviour by far. The use of azathioprine (OR: 1.85; 95% CI: 1.02–3.34), prednisone <7.5 mg (OR: 1.56; 95% CI: 0.97–2.49), a higher age (OR: 1.06; 95% CI: 1.03–1.08) and higher external HLC (OR: 1.15; 95% CI: 1.01–1.30) proved conducive for high adherence in our multivariable model. On the contrary, the general perception of medication being harmful or addictive (OR: 0.89; 95% CI: 0.82–0.97) was detrimental.

Conclusion

A low belief that one's own health is determined by healthcare providers (external HLC) and the belief of the harmfulness of medication were independent predictors of low adherence besides age and the choice of the medical agent. The recognition of these potential obstacles in physician–patient relationships is essential to ameliorate adherence. Provision of sufficient information and education might help to reach the best possible outcome.

Depression and medication nonadherence in childhood-onset systemic lupus erythematosus

Objectives Depression and medication nonadherence are important in managing chronic diseases, but little is known about these factors in childhood-onset systemic lupus erythematosus (cSLE). The objectives of this cross-sectional study were to estimate prevalence of depression and medication nonadherence, describe demographic and disease characteristics associated with depression and medication nonadherence, and evaluate the association between depression and medication nonadherence in cSLE patients. Methods Patients with cSLE ( n = 51) completed validated screening questionnaires to identify depression and medication nonadherence, Patient Health Questionnaire-9 and Medication Adherence Self-Report Inventory, respectively. Demographic and disease characteristics were obtained via chart abstraction, and compared between groups of depression or medication nonadherence status. A multivariable linear regression model adjusting for propensity scores was conducted to evaluate the association between depression and medication nonadherence. Results The prevalence of a positive depression screen was 58.8%, and seven patients reported suicidal ideation (13.7%). The prevalence of self-reported medication nonadherence was 19.7%. No statistically significant differences for demographic and disease characteristics were found between patients with a positive vs. negative depression screen. Patients reporting medication nonadherence were more likely to have longer disease duration (4.8 vs. 2.6 years, p = 0.035). As the severity of depression symptoms increased, the degree of medication nonadherence also increased (beta = -1.89; p = 0.011). Conclusions The prevalence of depression and medication nonadherence is high in cSLE, and these factors have a direct relationship. Interventions that better recognize and treat depression and increase rates of medication adherence are needed to improve outcomes in cSLE.

Quality of life of patients with osteonecrosis of the femoral head: a multicentre study

PURPOSE

Quality-of-life (QOL) assessments in patients with osteonecrosis of the femoral head (ONFH) have rarely been reported. This multicentre study aimed to elucidate the relationship between disease severity, including necrotic lesion type and radiological staging, and QOL, as well as between patients' characteristics and QOL.

METHODS

Two hundred seventy-four patients with ONFH (108 females, 166 males; median age, 46 years) were asked to complete self-assessment QOL questionnaires including the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, Oxford Hip Score, and SF-12v2.

RESULTS

Patients with large necrotic lesion type or collapsed ONFH had low QOL scores. Among patients with non-collapsed lesions, patients with alcohol-associated ONFH had lower QOL scores than those with steroid-associated ONFH, those with bilateral ONFH had lower mental scores, and male patients had worse social condition scores. Among patients with collapsed lesions, middle-aged patients exhibited lower mental QOL, and a strong correlation was observed between social activity and mental health.

CONCLUSION

Collapsed ONFH was associated with low QOL scores. Among patients with non-collapsed lesions, alcohol-associated ONFH, bilateral disease, and male sex were linked to low QOL scores.

Predictors of medication nonadherence in patients with systemic lupus erythematosus in Sichuan: a cross-sectional study

PURPOSE

The aim of this study was to determine the prevalence and predictors of medication nonadherence among patients with systemic lupus erythematosus (SLE) in Sichuan.

PATIENTS AND METHODS

A cross-sectional investigation was performed. Participants were recruited by consecutive sampling from the Rheumatic Clinic of a university hospital between June and September 2016. Patients' self-reported medication adherence was assessed by the eight-item Morisky Medication Adherence Scale. Additional surveys included patients' demographics, and clinical and treatment characteristics. Logistic regression analysis was used to identify the predictors of medication nonadherence.

RESULTS

A total of 140 patients were included in analysis. The percentage of patients classified as nonadherent to medication was 75%. Low education, rural residency, childlessness, limited comprehension of medication instructions, side effects experienced, dissatisfaction with treatment and better physical health were associated with an increased risk of nonadherence.

CONCLUSION

This study demonstrated a high prevalence of medication nonadherence among SLE patients in Sichuan, and factors associated with the nonadherence are multifaceted. Interventions for these factors, such as appropriate adjustment of the service resources for patients with rheumatic disease in rural communities and improved communication between the health care providers and the patients, may contribute to improve the medication adherence of this cohort.

A Prospective International Study on Adherence to Treatment in 305 Patients With Flaring SLE: Assessment by Drug Levels and Self-Administered Questionnaires

Nonadherence to treatment is a major cause of lupus flares. Hydroxychloroquine (HCQ), a major medication in systemic lupus erythematosus, has a long half-life and can be quantified by high-performance liquid chromatography. This international study evaluated nonadherence in 305 lupus patients with flares using drug levels (HCQ <200 ng/ml or undetectable desethylchloroquine), and self-administered questionnaires (MASRI <80% or MMAS-8 <6). Drug levels defined 18.4% of the patients as severely nonadherent. In multivariate analyses, younger age, nonuse of steroids, higher body mass index, and unemployment were associated with nonadherence by drug level. Questionnaires classified 39.9% of patients as nonadherent. Correlations between adherence measured by questionnaires, drug level, and physician assessment were moderate. Both methods probably measured two different patterns of nonadherence: self-administered questionnaires mostly captured relatively infrequently missed tablets, while drug levels identified severe nonadherence (i.e., interruption or erratic tablet intake). The frequency with which physicians miss nonadherence, together with underreporting by patients, suggests that therapeutic drug monitoring is useful in this setting. (Trial registration: ClinicalTrials.gov: NCT01509989.).

Treatment Satisfaction in Systemic Lupus Erythematosus: Development of a Patient-Reported Outcome Measure

Objective

The aim of this study was to develop a patient-reported outcome measure specific for systemic lupus erythematosus (SLE) to assess patient satisfaction with treatment, treatment options, and medical care.

Methods

Patients with SLE were recruited from four US rheumatology practices. Concept elicitation interviews identified aspects that patients considered important and relevant regarding satisfaction with treatment and medical care. Concept elicitation interviews and clinical input were used to draft the Lupus Satisfaction Questionnaire (LSQ). A second cohort of patients with SLE participated in combined concept elicitation/cognitive debriefing interviews, after which the LSQ was revised.

Results

Fourteen patients completed concept elicitation interviews: 93% were female, 57% were white, and 85% had moderate/severe SLE. Current treatments included hydroxychloroquine (93%), steroids (79%), and belimumab (57%), and 43% were biologic naive. Patients were generally satisfied with their treatment and medical care; however, they were dissatisfied with treatment adverse effects and the number of available treatment options. Cognitive debriefing interviews (n = 8) demonstrated that the LSQ was comprehensive, clear, and relevant; therefore, only minor revisions were made to the questionnaire. The LSQ assesses satisfaction with current SLE treatments (25 items), medical care (11 items), and insurance coverage (3 items). The draft LSQ was evaluated in 195 adults with SLE. Fifty-eight percent of patients reported that they were “somewhat satisfied” with their SLE treatment.

Conclusions

The LSQ has been developed to assess treatment satisfaction among patients with SLE. Following further testing to support its validity and reliability, it will provide a useful tool to facilitate assessment of satisfaction with treatments for SLE and help inform treatment decisions.

Patient- and Physician-reported Satisfaction With Systemic Lupus Erythematosus Treatment in US Clinical Practice

PURPOSE

This two-part study comprised two descriptive, cross-sectional surveys to evaluate treatment satisfaction among patients with systemic lupus erythematosus (SLE) and their physicians from US clinical practices. The Lupus Plus Project (LPP; part one) involved belimumab-containing regimens; the Disease Specific Program (DSP; part two) included all treatments and was designed to build on the body of evidence from part one.

METHODS

The LPP recruited patients receiving belimumab, and comprised 2 paper questionnaires: a patient self-completion questionnaire (PSC) and a patient record form (PRF) completed by the physician. The DSP enrolled patients with SLE receiving any treatment and comprised four parts: a PSC, a PRF completed by the physician after patient consultation, face-to-face physician interviews, and a workload form completed by the physicians to indicate their total SLE patient workload. The key objective of this study was to assess physician and patient satisfaction with current treatment.

FINDINGS

From the PSCs, data regarding patient-reported satisfaction with current treatment were available for 263 patients who were receiving belimumab combination therapy (LPP) and 250 patients who were receiving non-belimumab treatment (DSP). The majority of patients (belimumab, 86.3% [227/263]; non-belimumab, 78.4% [196/250]) responded positively (at least "somewhat satisfied") when asked about current treatment satisfaction, as did physicians (belimumab, 82.9% [311/375]; non-belimumab, 74.3% [326/439]). In multivariate analysis, factors most strongly associated with patient-reported satisfaction for patients receiving belimumab were patient-reported improvements in leisure activities since taking belimumab (odds ratio [OR] = 4.66), physician-reported improvements in fatigue (OR = 3.72), patient-reported improvements in general symptoms (OR = 3.02), and pain/achiness (OR = 2.71). Physician satisfaction was associated with clinical outcome such as improvements in pain/achiness (OR = 6.16), fatigue (OR = 3.76), and patient-reported satisfaction with treatment frequency (OR = 3.91). In patients receiving other SLE treatments, dosing frequency of current treatment (OR = 3.64) and a reduction in fatigue severity (OR = 3.61) were most strongly associated with patient-reported satisfaction; physician satisfaction was most strongly associated with a reduction in fatigue (OR = 6.22) and current remission status (OR = 6.05).

IMPLICATIONS

When considering SLE treatment satisfaction patients tend to consider impact on daily functioning, whereas physicians take into account a wider range of clinical outcomes; however, both strongly consider improvements in fatigue. These surveys provide insights into treatment satisfaction among prescribers and patients with SLE. GSK-ClinicalStudyRegister.com identifiers: GSK study 202146 [HO 15-15509] and 205086 [HO 15-16709].

Mapping Perceptions of Lupus Medication Decision-Making Facilitators: The Importance of Patient Context

OBJECTIVE

Numerous factors can impede or facilitate patients' medication decision-making and adherence to physicians' recommendations. Little is known about how patients and physicians jointly view issues that affect the decision-making process. Our objective was to derive an empirical framework of patient-identified facilitators to lupus medication decision-making from key stakeholders (including 15 physicians, 5 patients/patient advocates, and 8 medical professionals) using a patient-centered cognitive mapping approach.

METHODS

We used nominal group patient panels to identify facilitators to lupus treatment decision-making. Stakeholders independently sorted the identified facilitators (n = 98) based on their similarities and rated the importance of each facilitator in patient decision-making. Data were analyzed using multidimensional scaling and hierarchical cluster analysis.

RESULTS

A cognitive map was derived that represents an empirical framework of facilitators for lupus treatment decisions from multiple stakeholders' perspectives. The facilitator clusters were 1) hope for a normal/healthy life, 2) understand benefits and effectiveness of taking medications, 3) desire to minimize side effects, 4) medication-related data, 5) medication effectiveness for "me," 6) family focus, 7) confidence in physician, 8) medication research, 9) reassurance about medication, and 10) medication economics.

CONCLUSION

Consideration of how different stakeholders perceive the relative importance of lupus medication decision-making clusters is an important step toward improving patient-physician communication and effective shared decision-making. The empirically derived framework of medication decision-making facilitators can be used as a guide to develop a lupus decision aid that focuses on improving physician-patient communication.

Flares in systemic lupus erythematosus: diagnosis, risk factors and preventive strategies

Despite advances in the treatment, patients with systemic lupus erythematosus (SLE) often experience disease exacerbations (flares) of varying severity. Their diagnosis is primarily made on clinical grounds after exclusion of other diseases or disturbances, primarily infections, and can be assisted by the use of validated clinical indices. Serological tests such as serum complement fractions and anti-dsDNA autoantibodies, are helpful in monitoring SLE activity, but they lack high diagnostic accuracy. Flares are more frequent in patients with persistent immunological and clinical activity, and have been described as significant risk factor for development of irreversible end-organ damage. Accordingly, prevention of flares has been recognized as a distinct therapeutic target in SLE and involves adequate control of disease activity, use of hydroxychloroquine, maintaining immunosuppressive or biologic therapy for several years, and avoiding non-compliance issues. The future holds promise for the discovery of biomarkers that will accurately predict or diagnose SLE flares, thus allowing for the implementation of patient-tailored preventive strategies.

Use of medication reminders in patients with rheumatoid arthritis

Patients with rheumatoid arthritis (RA) often have difficulties adhering to their medical treatment plans. We determined the characteristics of patients with RA who used reminders and the association between reminders and adherence. A total of 201 patients with RA were asked the frequency of reminders use such as pill containers, calendars, or diaries. Patients completed self-reported adherence questionnaires, and their disease activity and functional ability were measured. Sixty-eight patients (34 %) reported using a reminder. Factors associated with reminder use were older age (yes-mean age 54 vs no-mean age 49, p = 0.004), race (Whites-54 % vs Blacks-30 % vs Hispanics-26 %, p = 0.003), and sex (males-50 % vs females 28 %, p = 0.005). Working patients were less likely to use reminders (employed-21 % vs unemployed-43 %, p = 0.006). Use of calendars was associated with adherence while away from home (ρ = 0.16, p = 0.03), when busy (ρ = 0.16, p = 0.03), and use of any reminder was associated with adherence when running out of pills (ρ = 0.15, p = 0.04). The use of calendar reminders was associated with fewer tender joints (ρ = -0.17, p = 0.02). Few patients with RA used reminders, and whites, males and patients of increasing age were most likely to use reminders. Our findings show that reminders can assist patients with RA in taking medications, particularly when they are most prone to forgetting, such as when they are away from home or busy. Providers should encourage using reminders as a low-cost aid to enhance adherence.

Insights into the epidemiology and management of lupus nephritis from the US rheumatologist's perspective

Lupus nephritis is a common and severe manifestation of systemic lupus erythematosus that disproportionately affects nonwhites and those in lower socioeconomic groups. This review discusses recent data on the incidence, prevalence, and outcomes of patients with lupus nephritis with a focus on low-income US Medicaid patients. We also review recent guidelines on diagnosis, treatment, and screening for new onset and relapses of lupus nephritis. Finally, we discuss the management of lupus nephritis from a rheumatologist's perspective, including vigilance for the common adverse events related to disease and treatment, and we review prevention and new treatment strategies.

Medication Nonadherence Is Associated With Increased Subsequent Acute Care Utilization Among Medicaid Beneficiaries With Systemic Lupus Erythematosus

OBJECTIVE

We examined whether nonadherence to hydroxychloroquine (HCQ) or immunosuppressive medications (ISMs) was associated with higher subsequent acute care utilization among Medicaid beneficiaries with systemic lupus erythematosus (SLE).

METHODS

We utilized US Medicaid data from 2000-2006 to identify adults ages 18-64 years with SLE who were new users of HCQ or ISMs. We defined the index date as receipt of HCQ or ISMs without use in the prior 6 months. We measured adherence using the medication possession ratio (MPR), the proportion of days covered by total days' supply dispensed, for the 1-year post-index date. Our outcomes were all-cause and SLE-related emergency department (ED) visits and hospitalizations in the subsequent year. We used multivariable Poisson regression models to examine the association between nonadherence (MPR <80%) and acute care utilization, adjusting for sociodemographics and comorbidities.

RESULTS

We identified 9,600 HCQ new users and 3,829 ISM new users with SLE. The mean ± SD MPR for HCQ was 47.8% ± 30.3% and for ISMs was 42.7% ± 30.7%. Seventy-nine percent of HCQ users and 83% of ISM users were nonadherent (MPR <80%). In multivariable models, among HCQ users, the incidence rate ratio (IRR) of ED visits was 1.55 (95% confidence interval [95% CI] 1.43-1.69) and the IRR of hospitalizations was 1.37 (95% CI 1.25-1.50), comparing nonadherers to adherers. For ISM users, the IRR of ED visits was 1.64 (95% CI 1.42-1.89) and of hospitalizations was 1.67 (95% CI 1.41-1.96) for nonadherers versus adherers.

CONCLUSION

In this cohort, nonadherence to HCQ and ISMs was common and was associated with significantly higher subsequent acute care utilization.

Efficacy of plasma exchange and immunoadsorption in systemic lupus erythematosus and antiphospholipid syndrome: A systematic review

Extracorporeal treatments have been used since the 1970s in the management of systemic lupus erythematosus (SLE). A randomised controlled trial comparing the efficacy of standard of care (SOC) combined with plasma exchange against SOC alone in patients with lupus nephritis revealed no difference in terms of renal outcome. Subsequently, initial expectations have been dampened and further experience with plasma exchange is mainly limited to observational studies and single case reports. Beneficial effects have been reported in patients with refractory disease course or in pregnancy with prior complications due to SLE and antiphospholipid syndrome. A more specific form of extracorporeal treatment, immunoadsorption (IAS), has emerged as a valuable option in the treatment of SLE. In line with the plasma exchange experience, IAS seems to have beneficial effects in patients with refractory disease, contraindications to standard immunosuppression or during pregnancy. The mechanism IAS relates to autoantibody removal but for plasma exchange removal of activated complement components, coagulation factors, cytokines and microparticles may also be relevant. Both treatment forms have good safety profiles although reactions to blood product replacement in plasma exchange and procedure related complications such as bleeding or catheter-related infections have occurred. There is a need to more clearly define the clinical utility of plasma exchange and IAS in refractory lupus and APS subgroups.

Targeting Medication Non-Adherence Behavior in Selected Autoimmune Diseases: A Systematic Approach to Digital Health Program Development

BACKGROUND

29 autoimmune diseases, including Rheumatoid Arthritis, gout, Crohn's Disease, and Systematic Lupus Erythematosus affect 7.6-9.4% of the population. While effective therapy is available, many patients do not follow treatment or use medications as directed. Digital health and Web 2.0 interventions have demonstrated much promise in increasing medication and treatment adherence, but to date many Internet tools have proven disappointing. In fact, most digital interventions continue to suffer from high attrition in patient populations, are burdensome for healthcare professionals, and have relatively short life spans.

OBJECTIVE

Digital health tools have traditionally centered on the transformation of existing interventions (such as diaries, trackers, stage-based or cognitive behavioral therapy programs, coupons, or symptom checklists) to electronic format. Advanced digital interventions have also incorporated attributes of Web 2.0 such as social networking, text messaging, and the use of video. Despite these efforts, there has not been little measurable impact in non-adherence for illnesses that require medical interventions, and research must look to other strategies or development methodologies. As a first step in investigating the feasibility of developing such a tool, the objective of the current study is to systematically rate factors of non-adherence that have been reported in past research studies.

METHODS

Grounded Theory, recognized as a rigorous method that facilitates the emergence of new themes through systematic analysis, data collection and coding, was used to analyze quantitative, qualitative and mixed method studies addressing the following autoimmune diseases: Rheumatoid Arthritis, gout, Crohn's Disease, Systematic Lupus Erythematosus, and inflammatory bowel disease. Studies were only included if they contained primary data addressing the relationship with non-adherence.

RESULTS

Out of the 27 studies, four non-modifiable and 11 modifiable risk factors were discovered. Over one third of articles identified the following risk factors as common contributors to medication non-adherence (percent of studies reporting): patients not understanding treatment (44%), side effects (41%), age (37%), dose regimen (33%), and perceived medication ineffectiveness (33%). An unanticipated finding that emerged was the need for risk stratification tools (81%) with patient-centric approaches (67%).

CONCLUSIONS

This study systematically identifies and categorizes medication non-adherence risk factors in select autoimmune diseases. Findings indicate that patients understanding of their disease and the role of medication are paramount. An unexpected finding was that the majority of research articles called for the creation of tailored, patient-centric interventions that dispel personal misconceptions about disease, pharmacotherapy, and how the body responds to treatment. To our knowledge, these interventions do not yet exist in digital format. Rather than adopting a systems level approach, digital health programs should focus on cohorts with heterogeneous needs, and develop tailored interventions based on individual non-adherence patterns.

Adherence to Oral and Topical Medications in Cutaneous Lupus Erythematosus is not Well Characterized

INTRODUCTION

Treatment adherence plays a large role in chronic dermatologic diseases and may play an important role in the outcomes of patients with cutaneous lupus erythematosus (CLE). We sought to gauge what is currently known about adherence to topical and oral medications in patients with CLE.

METHODS

A review of MEDLINE was performed using a combination of the phrases "adherence", "compliance", "lupus", and "cutaneous". Studies were hand searched and prospective and cross-sectional studies evaluating medication adherence in patients with CLE and systemic lupus erythematosus (SLE) were included.

RESULTS

Only two articles explored adherence in patients with CLE, while 17 articles discussed treatment adherence in patients with SLE. Depression was consistently cited as detrimental to adherence. The impact that race, ethnicity, and education has on adherence is unclear. Three studies noted a clear connection between adherence and disease activity, while two others did not. Few studies investigated methods that have improved adherence to treatment which have showed promise.

CONCLUSION

Much of what we know about adherence to medication in patients with lupus is limited to SLE. Although cutaneous symptoms are among the most common manifestations of SLE, cutaneous disease is often managed at least in part with topical agents, and adherence to topical treatment was not assessed in any of the articles, though one study investigated sunscreen usage in patients with CLE. Understanding adherence in patients with CLE may help contribute to better CLE treatment outcomes.

Rituximab and lupus--a promising pair?

Systemic lupus erythematosus (SLE) is a clinically diverse and potentially life-threatening auto-immune disease that can affect almost any organ system. Although much is still unknown regarding its pathogenesis, B cell abnormalities are thought to be central. A high relapse rate along with the toxicity associated with conventional treatments signify the need for more tailored approaches in this very heterogeneous disease. Both its mechanism targeting B cells and a relatively large number of case series and observational studies have suggested that the B cell-depleting agent rituximab could be a potent SLE drug. However, two randomized controlled trials failed to meet efficacy endpoints. Nevertheless, rituximab has continued to be used as an off-label alternative mainly in patients refractory to conventional immunosuppressive treatment. This article will review the current role of rituximab in SLE.

Lupus (SLE): Existence and Impact of Depressive Symptomatology

The purpose of this cross-sectional study (N = 84) is to: (1) further identify the unique psychosocial challenges facing those living with Systemic Lupus Erythematosus (SLE) and (2) discern the validity of the depression dimension of the System Lupus Erythematosus Needs Questionnaire (SLENQ) (by including the Beck Depression Inventory [BDI-II]). Utilizing the BDI-II, this study replicates and confirms the validity of studies that employed the SLENQ, establishing that those who have manifested signs of depression in the SLENQ, are equally likely to show signs of depression in the BDI-II. Authors identify and confirm that patients who experience SLE-related depression are significantly more likely to forget taking or stop taking their SLE medications. The authors review relevant research, discuss findings, and provide evidence-based recommendations for social workers providing mental health care to patients living with Lupus.