Medication adherence and persistence in patients with autoimmune rheumatic diseases: a narrative review

Psychometric evaluation of the Adherence to Refills and Medications Scale (ARMS) in Australians living with gout

This study aimed to examine psychometric properties of the Adherence to Refills and Medications Scale (ARMS) in people with gout. We conducted exploratory factor analysis (EFA) and tested internal consistency (ordinal and Cronbach's alpha coefficients) and agreement (intraclass correlation coefficient (2,1)) in ARMS scores across three timepoints (baseline, 6, and 12 months) in 487 people with gout. The Kruskal-Wallis test, Spearman's rank, Kendall's tau-b correlations, and logistic regression were used to examine the criterion-related validity of the ARMS and factors associated with the ARMS. EFA suggested a one-factor structure, explaining 43.2% of total variance. High internal consistency (ordinal alpha = 0.902 at baseline) and moderate agreement in ARMS scores over time (ICCs > 0.5; p < 0.001) were observed. Lower ARMS scores (indicating better adherence) predicted achieving target serum urate (OR, 0.89; 95% CI, 0.83-0.95; p < 0.001), but not urate-lowering therapy (ULT) adherence (Proportion of Days Covered (PDC) ≥ 80%) (OR, 0.93; 95% CI, 0.81-1.05; p = 0.261). Negative correlations between ARMS and PDC were not statistically significant (Kendall's tau-b, r =  - 0.126, p = 0.078; Spearman's rho =  - 0.173, p < 0.073). Differences in median ARMS scores (IQR) of 16 (14-20), 13 (12-15), and 17.5 (15-21) in three groups of participants who reported (1) not taking ULT, (2) taking ULT and adherent, and (3) taking ULT but not adherent, respectively, were statistically significant (p < 0.001). Age was the only patient factor independently associated with optimal adherence (ARMS score = 12) (OR, 1.91; 95% CI, 1.50-2.43; p < 0.001). The ARMS is a reliable and valid measure of medication adherence behaviours in people with gout, justifying its use in gout medication adherence research.

Serial mediation of illness perception and beliefs about medicines in the relationship between patient satisfaction and medication adherence: An evaluation of self-regulatory model in rheumatoid arthritis and ankylosing spondylitis patients

This study examined the effect of patient satisfaction on medication adherence through serial mediation of Self Regulatory Model (SRM) components which are illness perception and beliefs about medicines in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). The 222 outpatients (nRA = 112; nAS = 110) were administered a sociodemographic form, the Medication Adherence Report Scale, the Brief Illness Perception Questionnaire, the Short Assessment of Patient Satisfaction, and the Beliefs about Medicines Questionnaire. The results showed that SRM components fully mediated the relationship between patient satisfaction and medication adherence. This proposed model had acceptable and better fit indices than the alternative model where patient satisfaction was introduced as a direct predictor. Furthermore, patient satisfaction, illness perception, and beliefs about medicines had an extremely good relationship, so these may be interpreted as variables of a latent construct of the illness experience which deserves further research in these group of patients.

Perceived quality of life by patients with immune-mediated inflammatory diseases treated with biological therapies. SACVINFA study

OBJECTIVES

To evaluate health-related quality of life perceived by patients with the most prevalent immune-mediated inflammatory diseases in Spain: inflammatory bowel disease (IBD), psoriasis (Ps), psoriatic arthritis (AP), rheumatoid arthritis (RA), and spondyloarthropathies (SpAs), and to determine the factors that influence patient quality of life.

METHODS

The SACVINFA study (SA=satisfaction, CV=quality of life, IN=immune-mediated, FA=pharmacy) consisted of an observational study conducted in 4 hospitals in the Community of Madrid. A cross-sectional analysis was made for adult patients diagnosed with an immune-mediated inflammatory disease who attended the Pharmacy Service. Quality of life was assessed using the EQ-5D-5L questionnaire (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and specific questionnaires: SIBDQ-9, DLQI, PsAQoL, QoL-RA, and ASQoL.

RESULTS

A total of 578 patients were analysed (inflammatory bowel disease=25.3%; psoriasis=19.7%; spondyloarthropathies=18.7%; rheumatoid arthritis=18.5%; psoriatic arthritis=17.8%). The mean age (standard deviation) was 49.8 (12.3) years and 50.7% were male. The average score (standard deviation) for the global EQ-5D-5L was 0.771 (0.2) and the mean (standard deviation) visual analogue scale score was 71.5 (20.0). Type of immune-mediated inflammatory diseases was associated with differences in quality of life showing psoriasis and inflammatory bowel disease higher values of EQ5D-5L than psoriatic arthritis, rheumatoid arthritis, and spondyloarthropathies, p<.05 in all comparisons. Patients with RA, IBD, and Ps achieved 70% of the maximum score, while patients with PsA and SpAs did not reach 50% of the maximum possible score. Female gender, a state of moderate/severe disease severity, an older age, and a higher number of previous treatments were correlated with worse quality of life. Conversely, persistence to current treatment correlated with better quality of life.

CONCLUSIONS

Patients with immune-mediated inflammatory diseases have markedly affected quality of life, mainly in the pain/discomfort dimension, especially in those immune-mediated inflammatory diseases with a rheumatological component.

Treating rheumatoid arthritis

ABSTRACT

Rheumatoid arthritis (RA) affects about 1% of the world's population and can lead to loss of joint function, reduced mobility, and permanent damage to cartilage and bone. Treatment options for RA primarily include disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, but the development of new drugs has complicated treatment decisions. Weighing treatment options for patients with RA largely depends on three major factors: efficacy, adverse reaction profile, and cost. A review of the literature supports methotrexate monotherapy as the current best-practice model for treating RA, compared with combination therapy of methotrexate and/or other DMARDs.

Using an Intervention Mapping Approach to Improve Adherence to Disease-Modifying Treatment in Multiple Sclerosis

BACKGROUND

Up to 50% of individuals with multiple sclerosis (MS) who are prescribed disease-modifying treatments (DMTs) do not take them as advised. Although many studies report on DMT adherence rate, few studies report on interventions involving individuals with MS. The current paper describes the development of an intervention aimed at improving adherence to DMTs among identified nonadherent individuals with MS.

METHODS

An intervention was developed using an Intervention Mapping approach, recommendations from reviews on medication adherence, and input from individuals with MS. Its content was determined by theories of health behavior (specifically, a perceptions and practicalities approach), empirical evidence collected among the specific target population (an observational "needs assessment" stage [n = 186]), and other studies.

RESULTS

A personalized intervention was tailored to the reasons for nonadherence, uncovered during the observational needs assessment stage, to be delivered sequentially by a neurologist and a psychologist. After the intervention objectives were identified, components of the intervention were set: psychoeducation and ways of coping with adverse effects; modification of unhelpful treatment beliefs (such modifications were found predictive of adherence in the observational phase of the study); improving confidence and self-efficacy; and developing strategies for remembering to take DMTs. These components were embedded within motivational interviewing.

CONCLUSIONS

Intervention Mapping was useful in developing an intervention grounded both in the theoretical approach of perceptions and practicalities and in empirical evidence from the literature and the target sample; concurrently, identifying determinants that the intervention did not address. The effectiveness of the intervention-which could potentially improve adherence among individuals with MS-needs to be examined.

Annual Direct Cost and Cost-Drivers of Systemic Lupus Erythematosus: A Multi-Center Cross-Sectional Study from CSTAR Registry

BACKGROUND

To estimate the annual direct costs and cost-drivers associated with systemic lupus erythematosus (SLE) patients in China.

METHODS

A multi-center, cross-sectional study was conducted based on the CSTAR registry. The information on demography and expenditures for outpatient and inpatient visits due to SLE were collected using online questionnaires. These patients' medical records were from the database of the Chinese Rheumatology Information System (CRIS). The average direct costs and 95% confidence interval were estimated using the bootstrap method with 1000 bootstrap samples by resampling with replacement. The cost-drivers were identified using multivariate regression models.

RESULTS

A total of 1778 SLE patients from 101 hospitals participated in our study, with 92.58% as females, a mean age of 33.8 years old, a median duration of SLE of 4.9 years, 63.8% in an active disease state, 77.3% with two organs or more damaged, and 8.3% using biologics as treatment. The average annual direct cost per patient was estimated at CNY 29,727, which approximates to 86% for direct medical costs. For moderate to severe disease activities, the use of biologics, hospitalization, treatment of moderate or high dose glucocorticoids, and peripheral vascular, cardiovascular, and/or renal system involvements were found to substantially increase the direct costs, while health insurance slightly decreased the direct costs of SLE.

CONCLUSIONS

This study provided reliable insight into financial pressures on individual SLE patients in China. The efforts focusing on preventing flare occurrences and limiting disease progression were recommended to further reduce the direct cost of SLE.

Clinical and psychological characteristics associated with negative beliefs and concerns about treatment necessity in rheumatic diseases

Identifying factors that influence problematic beliefs and behaviors related to pharmacotherapy may be useful for clinicians to improve the patients' adherence. The study aims to assess patients' beliefs about the necessity and concerns regarding pharmacotherapy in rheumatic diseases and attitude styles, and to investigate the association between clinical factors and negative beliefs about medication. A sample of 712 patients affected by Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis was enrolled. They were assessed using the Beliefs about Medicines Questionnaires-Specific (BMQ), the Simplified Disease Activity Index (SDAI), the Visual Analogue Scale for pain (VAS), the Chalder Fatigue Scale (CFQ) and the Health Assessment Questionnaire-Disability Index (HAQ-DI). The balance between benefits and costs in the BMQ-Specific was positive in the 79.4% of patients, negative in the 12.1% and equal in the 8.6%. SDAI, taking more than 5 medications, taking anti interleukin 6 (Anti-IL6) or biological disease-modifying antirheumatic drugs (bDMARDs), or targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs), pain, and fatigue were significantly associated to higher Concerns. Having a longer disease duration was significantly associated with a higher Necessity, together with the current pharmacological treatments and the disability. The multivariate regression models estimated that higher pain and fatigue were associated to higher Concerns (p < 0.001), while a longer disease duration (p < 0.001) and all pharmacological treatments for a rheumatologic disease (p = 0.001) were associated to higher Necessity levels. A high length of disease, a low level of remission, a high number of total medications, the prescription of an Anti-IL6/bDMARDs/tsDMARDs drug, a high level of pain, fatigue and disability identified patients potentially less adherent to pharmacotherapy to be carefully looked after by clinicians.

Attitudes of Australians with inflammatory arthritis to biologic therapy and biosimilars

OBJECTIVES

To investigate the knowledge and beliefs of Australian patients with inflammatory arthritis regarding biologic/targeted synthetic DMARDs (b/tsDMARDs) and biosimilars and their sources of information.

METHODS

Participants enrolled in the Australian Rheumatology Association Database (ARAD) with RA, PsA and axial SpA were sent an online survey. They were asked about information sources for b/tsDMARDs and how positive or negative this information was. The Beliefs about Medicine Questionnaire (BMQ) was used to measure beliefs about b/tsDMARDs with scores ranging from 1 (strongly disagree) to 5 (strongly agree). Participants were asked about their knowledge of biosimilars and willingness to switch to biosimilar.

RESULTS

There was a response rate of 66% (994/1498; 67% female, median age 62 years). Participants currently taking b/tsDMARDs (n = 794) had a high b/tsDMARD-specific BMQ 'necessity' score {median 4.2 [interquartile range (IQR) 3.6-4.8]}, with a lower specific 'concerns' score [median 2.4 (IQR 2.0- 3.0)]. Participants consulted multiple information sources [median 3 (IQR 2-5)]. Positive sources were rheumatologists and educational websites and negative were chat rooms and social media. Only 18% were familiar with biosimilars, with half knowing of availability in Australia. Following a short paragraph describing biosimilars, 75% (744) of participants indicated they would consider switching if recommended by their rheumatologist, with nearly half identifying safety and efficacy of biosimilars as an important concern.

CONCLUSION

Australian patients have positive attitudes towards b/tsDMARDs overall, although little knowledge of biosimilars specifically. They have a high degree of trust in their rheumatologist regarding treatment decisions, even if they are unfamiliar with the medication recommended.

Medication Non-Adherence in Rheumatology, Oncology and Cardiology: A Review of the Literature of Risk Factors and Potential Interventions

Medication adherence is directly associated with health outcomes. Adherence has been reviewed extensively; however, most studies provide a narrow scope of the problem, covering a specific disease or treatment. This project's objective was to identify risk factors for non-adherence in the fields of rheumatology, oncology, and cardiology as well as potential interventions to improve adherence and their association with the risk factors. The project was developed in three phases and carried out by a Steering Committee made up of experts from the fields of rheumatology, oncology, cardiology, general medicine, and hospital and community pharmacy. In phase 1, a bibliographic review was performed, and the articles/reviews were classified according to the authors' level of confidence in the results and their clinical relevance. In phase 2, 20 risk factors for non-adherence were identified from these articles/reviews and agreed upon in Steering Committee meetings. In phase 3, potential interventions for improving adherence were also identified and agreed upon. The results obtained show that adherence is a dynamic concept that can change throughout the course of the disease, the treatments, and other factors. Educational interventions are the most studied ones and have the highest level of confidence in the authors' opinion. Information and education are essential to improve adherence in all patients.

Satisfaction and Adherence to Biological Treatment in Patients with Rheumatic Diseases

BACKGROUND

Autoimmune inflammatory rheumatic diseases have long been treated by conventional disease-modifying anti-rheumatic drugs. Biological therapy is a new era in the treatment of rheumatic diseases, but satisfaction and adherence to it is still not well tested.

AIM

To assess the satisfaction and adherence to biological treatment among patients with autoimmune inflammatory rheumatic diseases.

METHODS

A cross sectional study was conducted among 56 patients suffering from inflammatory rheumatic diseases using Morisky 8 questionnaire and Treatment Satisfaction Questionnaire for Medication (TSQM) over a period of one month.

RESULTS

About 76.8% of the patients had medium adherence and the underlying cause of missing doses was the unavailability of the drugs. The mean satisfaction with biological treatment was 62.7±6.9. Patients who did not receive formal education had significantly higher satisfaction with the biological treatment than others 64.94±5.01 at a P value 0.04 (<0.05).

CONCLUSION

Patients with inflammatory rheumatic diseases in our study showed medium adherence and satisfaction. Authorities in the medical field are providing great help to these patients in need of biological therapy, but ensuring the availability of all doses of the biological treatment regimen is still necessary. Patient, family and nurse education programs are also necessary to maximize adherence and satisfaction.

Assessment of physical function, quality of life, and medication adherence in elderly patients with rheumatic diseases

Background

The proportion of older people in the total population has increased in Turkey as well as worldwide. As life expectancy rises, the increasing prevalence of rheumatic diseases poses major problems in the elderly. Comorbid diseases and the aging-induced changes in the endogenous immune response and the pharmacokinetic properties of therapeutic agents may complicate the decision to use a particular drug and result in a different clinical picture and treatment response. We, therefore, aimed to investigate the characteristics of chronic inflammatory diseases, their impact on physical function and quality of life, the prevalence of comorbid diseases that may complicate treatment planning, and treatment adherence in patients aged 65 years or older.

Results

One hundred seventy-four patients were included and divided into two age groups: 18–64 years (group 1, n = 85) and 65 years or older (group 2, n = 89). The mean age of all recruited patients was 57.55 ± 16.98 years. Of 174, 99 (56.9%) were female and 75 (43.1%) were male. The mean duration of rheumatic disease was 7 ± 4.8 years and age at onset was 51.46 ± 14.78 years. Gender distribution differed significantly by age group (P = 0.024). The percentage of females in group 1 was 48.2% and 65.2% in group 2. The occupational status also differed significantly by age group (P < 0.001). 48.2% of group 1 were employed and 57.3% of group 2 were housewives. Marital status varied significantly by age (P < 0.001). The percentage of married was 74.1% in group 1 and the percentage of separated/divorced/widowed in group 2 was 28.1%. There was no difference between groups 1 and 2 in terms of place of residence (P = 0.459). The prevalence of comorbid diseases and the rate of use of medications for comorbid diseases (non-rheumatic treatments) were higher in elderly patients. The rate of use of disease-modifying anti-rheumatic drugs (DMARDs) was 30.3% and biological agents 61.8% in the elderly group (≥ 65 years) (group 2) (P < 0.001). There were positive correlations between, Health Assessment Questionnaire (HAQ), Bath Ankylosing Spondylitis Functional Index (BASFI) and Nottingham Health Profile (NHP) domains in both groups. There was also a significant negative correlation between Medication Adherence Rating Scale (MARS) and all dimensions.

Conclusions

Elderly and younger patients with rheumatic diseases have different demographic and clinical characteristics. Physical function and quality of life are more affected by rheumatic diseases and treatment adherence is poorer in the elderly. Our study found a positive correlation between physical function and quality of life in both age groups. The treatment adherence rating scale showed a negative correlation with physical function and quality of life scores, with individuals with poor treatment adherence having worse physical function and quality of life.

Juvenile Idiopathic Arthritis and COVID-19 Pandemic: Good Compliance With Treatment, Reluctance to Return to School

Objective: The SARS-CoV-2 pandemic has induced an exceptional sanitary crisis, potentially having an impact on treatment continuation, for juvenile idiopathic arthritis (JIA) patients receiving immunosuppressive therapies. After national lockdowns, many patients were also concerned about their safety at school. We evaluated the impact of the pandemic on the optimal continuation of treatment and on the return to school in JIA patients.

Methods: JIA patients under 18 years of age, usually treated with disease-modifying anti-rheumatic drugs (DMARDs) were prospectively included during their outpatient visit and completed a standardized questionnaire. The primary outcome was DMARD treatment modification in relation to the context of the pandemic but we also evaluated the pandemic's impact on the schooling.

Results: One hundred and seventy three patients from 8 different expert centers were included between May and August 2020. Their mean age was 11.6 years (± 4.1 years), and most of them 31.2% (54/173) had a rheumatoid factor-negative polyarticular JIA. Fifty percent (86/172) were treated with methotrexate, and 72.5% (124/171) were treated with bDMARDs. DMARD treatment modification in relation to the pandemic was observed in 4.0% (7/173) of participants. 49.1% (81/165) of the patients did not return to school due to a personal/parental decision in 69.9% (55/81) of cases. Two patients were diagnosed positive for SARS-CoV-2 infection.

Conclusion: This study suggests that JIA patients treated with DMARDs continued their treatment during the pandemic and were rarely affected by symptomatic COVID-19. In contrast, parents' reluctance was a major obstacle for returning to school. Therefore, more solidified school reopening strategies should be developed.

Multilevel factors predict medication adherence in rheumatoid arthritis: a 6-month cohort study

Non-adherence challenges efficacy and costs of healthcare. Knowledge of the underlying factors is essential to design effective intervention strategies.

OBJECTIVES

To estimate the prevalence of treatment adherence in rheumatoid arthritis (RA) and to evaluate its predictors.

METHODS

A 6-month prospective cohort study of patients with RA selected by systematic stratified sampling (33% on first disease-modifying rheumatic drug (DMARD), 33% on second-line DMARD and 33% on biologics). The outcome measure was treatment adherence, defined by a score greater than 80% both in the Compliance Questionnaire in Rheumatology and the Reported Adherence to Medication scale, and was estimated with 95% CIs. Predictive factors included sociodemographic, psychological, clinical, drug-related, patient-doctor relationship related and logistic. Their effect on 6-month adherence was examined by multilevel logistic models adjusted for baseline covariates.

RESULTS

180 patients were recruited (77% women, mean age 60.8). The prevalence of adherence was 59.1% (95% CI 48.1% to 71.8%). Patients on biologics showed higher adherence and perceived a higher medication need than the others; patients on second-line DMARDs had experienced more adverse events than the others. The variables explaining adherence in the final multivariate model were the type of treatment prescribed (second-line DMARDs OR=5.22, and biologics OR=3.76), agreement on treatment (OR=4.57), having received information on treatment adaptation (OR=1.42) and the physician perception of patient trust (OR=1.58). These effects were independent of disease activity.

CONCLUSION

Treatment adherence in RA is far from complete. Psychological, communicational and logistic factors influence treatment adherence in RA to a greater extent than sociodemographic or clinical factors.

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

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

Real-world Evidence for Adherence and Persistence with Atorvastatin Therapy

Atorvastatin, which has been approved by regulatory agencies for primary- and secondary-prevention patients with dyslipidemia, has historically been the most commonly prescribed statin and is now widely available in generic formulations. Despite widespread statin usage, many patients fail to attain recommended (LDL-C) targets. While several factors impact the successful treatment of dyslipidemia, suboptimal patient adherence is a major limiting factor to medication effectiveness. In this narrative review we sought to investigate patient adherence and persistence with atorvastatin in a real-world setting and to identify barriers to LDL-C goal attainment and therapy outcomes beyond the realm of clinical trials. Moreover, in light of growing generic usage, we carried out targeted literature searches to investigate the impact of generic atorvastatin availability on patient adherence/persistence, and on lipid and efficacy outcomes, compared with branded formulations. Unsurprisingly, real-world data suggest that patient adherence/persistence to atorvastatin is suboptimal, but few studies have attempted to address factors impacting adherence. Data from studies comparing adherence/persistence in patients prescribed branded or generic atorvastatin are limited and show no clear evidence that initiation of a specific preparation of atorvastatin impacts adherence/persistence. Furthermore, results from studies comparing adherence/persistence of patients who switched from the branded to the generic drug are conflicting, although they do suggest that switching may negatively impact adherence over the long term. Additional real-world studies are clearly required to understand potential differences in adherence and persistence between patients initiating treatment with branded versus generic atorvastatin and, moreover, the factors that influence adherence. Targeted education initiatives and additional research are needed to understand and improve patient adherence in a real-world setting.

Medication Adherence and Patients' Characteristics in Chronic Diseases: A National Multi-Center Study

Chronic diseases constitute a significant threat to health. Worldwide, medication adherence in chronic diseases remains unsatisfactory. Understanding factors affecting adherence is essential. This study examined medication adherence by characteristics of patients with chronic diseases. This cross-sectional study included 800 patients. The Adherence to Chronic Diseases Scale was used to measure adherence. Descriptive statistics and logistic regression was used to examine factors influencing medication adherence. Low adherence was found in 19.5% of the patients, 45% had medium adherence, and 35.5% had high adherence. Logistic regression showed that retired (OR 0.496, 95% CI [0.33-0.75]), having COPD (OR 0.460, 95% CI [0.32-0.67]) and duration of disease ≤5 years (OR 1.554, 95% CI [1.11-2.17]) remain independent predictors for high adherence. Mixed findings regarding the relationship between medication adherence and patients' characteristics were noticed. Patients' characteristics should be examined with the individual population when examining and attempting to improve medication adherence in clinical practice.

Tele-rheumatology for overcoming socioeconomic barriers to healthcare in resource constrained settings: lessons from COVID-19 pandemic

OBJECTIVES

To assess acceptability of teleconsultation among the socioeconomically marginalized sections of patients with rheumatic and musculoskeletal diseases (RMDs), to identify the socioeconomic barriers in continuing rheumatology care during the COVID-19 crisis and to identify patients who could benefit by shifting to tele-rheumatology consultations.

METHODS

This was a cross sectional analytical study done at a tertiary care teaching hospital in India including patients with RMDs who were not on biological diseases modifying agents. Assessment of disease status, socioeconomic status and economic impact of COVID-19 was done via tele-consultation.

RESULTS

Out of the 680 patients satisfying inclusion criteria, 373 completed the study. The format was found easy by 334 (89.6%) of them and 284 (76.1%) considered tele-rheumatology better than in-person consultation. During the pre-COVID months, the median monthly per capita income of the families of our patients and cost of illness was Indian rupees (INR) 2000 (US$ 26) and INR 1685 (US$ 21.91), respectively. Families whose financial needs were met (OR = 0.38, 95% CI: 0.239, 0.598) or those with schooling upto at least secondary school (OR = 0.442, 95% CI: 0.260, 0.752) (P =0.002) were less likely to stop prescription drugs. In a hypothetical model, 289 (77.4%) could be successfully switched to tele-rheumatology follow-up.

CONCLUSION

The acceptability of tele-rheumatology among socioeconomically marginalized patients with RMDs is good. During times of crisis, patients from poorer strata of society and lower educational background are likely to abruptly stop medications. Switching to a telemedicine-based hybrid model is likely to improve drug adherence with substantial savings on loss of pay and out of pocket expenditure.

GO-BEYOND: a real-world study of persistence of golimumab in patients with axial spondyloarthritis and rheumatoid arthritis in Turkey

Aim: To evaluate the retention rate of golimumab (GLM) in patients with rheumatoid arthritis (RA) and axial spondyloarthritis (ax-SpA). Materials & methods: Patients had received/were receiving GLM as their first or second biological drug for at least 3 months. We recorded demographic and clinical data, data on drug continuation and disease activity. Patients were classified as biologic-naive and biologic-experienced. Results: The study included 60 RA and 269 ax-SpA patients. At month 24, the retention rates were 67.2 and 57.1% (biologic-naive and biologic-experienced RA) and 74.8 and 80.4% (anti-TNF-naive and -experienced ax-SpA). No significant differences in retention were observed between the biologic-naive and -experienced groups for either disease. Conclusion: The results of this study confirm the effectiveness of GLM in the treatment of RA and axSpA with good retention rates at 2 years in a real-world setting in Turkey.

Assessment of the effects of loneliness, perceived social support, and depression on medication adherence in patients with ankylosing spondylitis

PURPOSE

This study aims to investigate the effects of loneliness, perceived social support, and depression on medication adherence of patients with ankylosing spondylitis (AS).

DESIGN AND METHODS

This cross-sectional study was conducted with 119 AS patients. Data were collected using the Morisky-Green-Levine Medication Adherence Scale, the UCLA Loneliness Scale (ULS), the Multidimensional Scale of Perceived Social Support (MSPSS), and the Beck Depression Inventory (BDI).

FINDINGS

Nonadherent patients were younger (P = .033), scored higher on the ULS (P = .015), and BDI (P = .024) scales, and lower on the MSPSS scale (P = .039) and on family support (P = .002).

PRACTICAL IMPLICATIONS

The biopsychosocial aspects of patients with AS should be managed holistically to improve their medication adherence.

Beliefs about medication as predictors of medication adherence in a prospective cohort study among persons with multiple sclerosis

BACKGROUND

Though adherence to disease-modifying therapies (DMTs) among persons with multiple sclerosis (PwMS) varies and is often below 80%, only few prospective studies on adherence examined predictors beyond demographic and clinical characteristics.

OBJECTIVES

Identify antecedents to adherence and persistence to DMT in a prospective design among PwMS.

METHODS

PwMS (n = 186) were prospectively assessed at three time points: baseline, 6 (Time 1) and 12 months later (Time 2). Clinical, demographic information and patient-reported medication beliefs, illness perceptions, medication habits, perceived health and affect were surveyed in-person. Adherence and persistence were assessed by a combination of self-reports and retrospective review of medication claims.

FINDINGS

PwMS were 69.9% (Time 1) and 71% (Time 2) adherent to their DMTs and 64.5.9% were persistent. Beliefs about Medications were consistently predictive at both time points (baseline to Time 1 and Time 1 to Time 2) of medication adherence and persistence whereas other perceptions were predictive in some analyses; clinical and demographic characteristics were mostly not predictive of adherence nor persistence. The prospective association of beliefs about medication with adherence held also in multivariate analyses (OR = 0.88, 95% CI 0.78-0.99, p = 0.029).

CONCLUSIONS

Adherence and persistence are predicted by medication beliefs of PwMS. As medication beliefs are modifiable, they should be assessed periodically and targeted as a focus of tailored interventions aimed to improve adherence and consequently health outcomes in PwMS.

REGISTRATION

Clinical trials registry # NCT02488343 , date: 06/08/2015.

Therapeutic alliance is associated to treatment adherence in children with juvenile idiopathic arthritis

OBJECTIVES

Therapeutic alliance (TA) is the agreement between caregiver and patient during the care process. Therapeutic adherence is a major issue for the management of Juvenile Idiopathic Arthritis (JIA) requiring child's strong ability to follow treatments. The aim of this study was to evaluate the relationship between TA and adherence in patients with JIA.

METHODS

Observational, cross-sectional, multicenter study. Children, with JIA, aged 8-16, were included. Children, parents and physicians completed the Helping Alliance Questionnaire (HAQ-CP) for assessing TA. Adherence was measured using the Child/Parent Adherence Report Questionnaire (CARQ & PARQ). Demographic data, disease characteristics, current treatments and social environment were collected. The univariate relationship between TA and adherence, was studied by Pearson correlation coefficient. The multivariate analysis used a multiple linear regression model.

RESULTS

A total of 119 patients were included: 68.9% girls, mean age (SD) 12.4 (2.9) years, disease duration 73.1 (48.2) months. JIA was in remission (52%), in low activity (32%) and active (16%). TA scores were high (≥80/100) for children, parents and physicians. HAQCP was highly correlated with CARQ (r=0.31; P<0.001) PARQ (r=0.37; P<0.001). In univariate analysis, disease activity (P<0.05), place of residence (P<0.01) and family status (P<0.01) were associated with child's TA. In multivariate analysis, only the place of residence (P<0.001) and the family status (P<0.05) remained associated with TA.

CONCLUSION

TA strongly influences therapeutic adherence and therefore may be important for treatment effectiveness.

Impact of pharmacist care in the management of autoimmune disorders: A systematic review of randomized control trials and non-randomized studies

INTRODUCTION

Autoimmune disorders are chronic, self-mediated, misdirected immune responses against their own immune system. It required intensive, complex and costly drug treatment regimen increased the risk of pharmacotherapy error and adversely affects patients. Hence, pharmacist care will have vital roles in autoimmune disorders to achieve health related outcomes.

OBJECTIVES

This review aimed to gather evidence on the impact of pharmacist care on clinical, humanistic and economic outcomes, adherence to medications, and drug related problems in the management of autoimmune disorders among the usual care group.

METHODOLOGY

A comprehensive review conducted in compliance with the PRISMA statement and systematic search was performed across five databases included PubMed Central, Web of Sciences, Scopus, Cochrane Library andgoogle scholar from inception until August 2020. This research included full-text articles of randomized and non-randomized studies that evaluated impact of pharmacist care in autoimmune disorders.

RESULTS

A total of nine studies were included (seven RCTs and two non-RCTs), including 829 patients with autoimmune disorders. A total of four studies (80%) show an enhancement in at least one clinical parameter due to pharmacist care. A substantial improvement in at least one humanistic parameter observed in all five studies (100%). While four out of five studies (80%) clearly displayed a remarkable improvement in medication adherence in the pharmacist care group from baseline to the completion of follow-ups. One study quantified a 99.08% resolution of DRPs in the pharmacist care group. Another study estimated the cost of medical resources uses per patient and found no difference in cost-effectiveness over six months between groups.

CONCLUSION

This review reinforces the vital contribution of pharmacists to achieve clinical outcomes, humanistic outcomes, adherence to medications and DRPs in the efficient management of autoimmune disorders. However, no notable changes in economic outcomes were observed in this review.

Predictors of Health-Related Quality of Life in Patients with Ankylosing Spondylitis in Southwest China

PURPOSE

The purpose of this study was to evaluate health-related quality of life (QoL) and explore its predictors in patients with ankylosing spondylitis (AS) in Southwest China.

PATIENTS AND METHODS

We recruited AS patients from a tertiary hospital in Chengdu, China. Data were collected by self-reported questionnaires, including sociodemographic and disease-related variables, the Medical Outcomes Study 36-Item Short Form (SF-36), Beck Depression Inventory-Second Edition (BDI-II), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), and Bath Ankylosing Spondylitis Global score (BAS-G). Stepwise multiple linear regression analysis was used to determine the factors affecting physical component summary (PCS) and mental component summary (MCS) of SF-36.

RESULTS

A total of 125 patients with AS were included in the current study. The PCS, MCS scores of SF-36 were 41.06±9.12, 47.82±9.84, respectively. Stepwise multiple linear regression analysis showed that higher educational level (β=0.237, P<0.001) and income (β=0.141, P=0.017), lower BASDAI (β=-0.195, P=0.006), BASFI (β=-0.317, P<0.001) and BAS-G (β=-0.288, P<0.001) scores were associated with higher PCS scores of SF-36. Higher BDI-II (β=-0.444, P<0.001) and fatigue (β=-0.293, P<0.001) scores were associated with worse MCS scores of SF-36.

CONCLUSION

AS patients in Southwest China had impaired health-related QoL. Healthcare providers should take effective strategies to modify the factors affecting health-related QoL, which may prompt disease management and increase QoL.

Association of Self-Reported Medication Adherence with Potentially Inappropriate Medications in Elderly Patients: A Cross-Sectional Pilot Study

BACKGROUND

Polypharmacy (PP) and potentially inappropriate medications (PIMs) cause problematic drug-related issues in elderly patients; however, little is known about the association between medication adherence and PP and PIMs. This study evaluated the association of self-reported medication adherence with PP and PIMs in elderly patients.

METHODS

A cross-sectional pilot study was conducted using data collected from electronic medical records of 142 self-administering patients aged ≥65 years, excluding emergency hospitalization cases. Self-reported medication adherence was assessed using the visual analogue scale (VAS).

RESULTS

Of the 142 patients, 91 (64.1%) had PP and 80 (56.3%) used at least one PIM. In univariate analysis, patients with a VAS score of 100% had a significantly higher number of female patients and ≥1 PIM use compared to other patients. We found no association between the VAS score and PP. In multivariable analysis, the use of PIMs was significantly associated with a VAS score of 100% (odds ratio = 2.32; 95% confidence interval = 1.16-4.72; p = 0.017).

CONCLUSIONS

Use of PIMs by elderly patients is significantly associated with self-reported medication adherence. Pharmacists should pay more attention to prescribed medications of self-administering elderly patients in order to improve their prescribing quality.

Treatment Pattern Analysis and Health-care Resource Consumption on Patients with Psoriatic Arthritis or Ankylosing Spondylitis Treated with Biological Drugs in a Northern Italian Region

Purpose

To analyze the treatment patterns of psoriatic arthritis (PSA) or ankylosing spondylitis (AS) patients under biological therapies and to evaluate in this population the health-care resource consumption and related costs.

Patients and Methods

A retrospective analysis was performed on administrative databases of the Veneto region. Patients ≥18 years with at least one prescription of biological drugs and a diagnosis at any level for PSA or AS from January 1, 2011 to December 31, 2016 (inclusion period) were included. Index date (ID) was defined as date of first biological drug prescription during inclusion period. Patients were characterized the year before ID and followed-up for one year after ID. The drug utilization profile in terms of adherence, persistence and therapeutic regimen changes, and the health-care resource consumption was analyzed during follow-up.

Results

A total of 2602 patients were included: 1857 with PSA and 745 with AS. In the PSA cohort, 40.3% of patients were prescribed adalimumab, 35.6% etanercept, 8.0% golimumab, 7.5% infliximab, 5.6% ustekinumab and 3.0% certolizumab. Percentage of PSA patients adherent to treatment was higher among ustekinumab patients (91.3%) and lower among etanercept users (54.3%). Persistence ranged from 53.2% (infliximab) to 70.3% (etanercept). Regarding AS cohort, 45.5% of patients were prescribed adalimumab, 26% etanercept, 17.3% infliximab, 9.7% golimumab and 1.5% certolizumab. Adherence ranged from 46.9% (etanercept) to 90.9% (certolizumab) and persistence from 62.8% (adalimumab) to 81.8% (certolizumab). Mean annual health-care costs (including costs for drug treatment, diagnostic services, specialist visits and hospital admissions) ranged from €9727 (certolizumab) to €14,994 (ustekinumab) among PSA patients and from €9875 (infliximab) to €12,991 (golimumab) among AS patients.

Conclusion

This study in Veneto region gave a picture of biological treatment patterns among PSA and AS patients in a real-world setting. Our findings showed the high degree of variability concerning utilization of each biological drug and provided insight on the economic burden of both diseases.

Mycophenolate mofetil, azathioprine and tacrolimus: mechanisms in rheumatology

The introduction of biologic DMARDs into rheumatology has resulted in a substantial reduction of the burden of many rheumatic diseases. In the slipstream of the success achieved with these biologic DMARDs, some conventional immunosuppressive drugs have also found use in new indications. Notably, mycophenolate mofetil, azathioprine and tacrolimus have made their way from solid organ transplantation drugs to become useful assets in rheumatology practice. Mycophenolate mofetil and azathioprine inhibit the purine pathway and subsequently diminish cell proliferation. Both drugs have a pivotal role in the treatment of various rheumatic diseases, including lupus nephritis. Tacrolimus inhibits lymphocyte activation by inhibiting the calcineurin pathway. Mycophenolate mofetil and tacrolimus are, among other indications, increasingly being recognized as useful drugs in the treatment of interstitial lung disease in systemic rheumatic diseases and skin fibrosis in systemic sclerosis. A broad array of trials with mycophenolate mofetil, azathioprine and/or tacrolimus are ongoing within the field of rheumatology that might provide further novel avenues for the use of these drugs. In this Review, we discuss the historical perspective, pharmacodynamics, clinical indications and novel avenues for mycophenolate mofetil, azathioprine and tacrolimus in rheumatology.

Self-Reported Medication Adherence in Patients With Ankylosing Spondylitis: The Role of Illness Perception and Medication Beliefs

Objectives

This study aims to investigate medication adherence in Turkish patients with ankylosing spondylitis (AS) and analyze the related factors for non-adherence.

Patients and methods

Ninety-nine patients with AS (60 males, 39 females; mean age 41.3±8.4 years; range, 18 to 66 years) were included in the study. Sociodemographic and clinical data were collected. Disease activity (Bath Ankylosing Spondylitis Disease Activity Index, C-reactive protein, and erythrocyte sedimentation rate), functional status (Bath Ankylosing Spondylitis Functional Index), spinal pain and fatigue (visual analog scale), quality of life (Ankylosing Spondylitis Quality of Life), and depression and anxiety (Hospital Anxiety and Depression Scale) were evaluated. Adherence to anti-rheumatic drugs was elicited using the Compliance Questionnaire on Rheumatology (CQR). Medication beliefs were assessed using the Beliefs about Medicines Questionnaire (BMQ), and illness perception using the Brief Illness Perception Questionnaire (B-IPQ).

Results

Non-adherence was reported in 64 patients (64.6%). No significant relationship between demographic, clinical, or psychological factors and adherence was found, except for disease duration (p=0.031). High B-IPQ treatment follow-up, illness coherence, and BMQ-Specific necessity scores were associated with good adherence (p=0.007, p=0.039, and p=0.002, respectively). BMQ-General overuse and harm scores showed an inverse correlation with the CQR score (p=0.005 r=-0.278; p=0.029 r=-0.219, respectively). Longer disease duration [odds ratio (OR): 0.98, 95% confidence interval (CI): 0.97-0.99] and higher B-IPQ item-1 score regarding the effect of the illness on the individual's life (OR: 0.58, 95% CI: 0.42- 0.81) were important predictors of low adherence.

Conclusion

Nearly three out of five AS patients were identified as at risk for non-adherence with the CQR. Medication adherence is influenced by the patient’s beliefs about medicines and illness perceptions, and these may be key targets for future interventions to improve medication adherence.

Effects of a Trans-Theoretical Model-Based Health Education Program on the Management of Cognitive Dysfunction in Older Adults With Mild Cognitive Impairment: Study Rationale and Protocol Design for a Randomized Controlled Trial

Introduction: Recent studies have confirmed that the management of cognitive dysfunction produces considerable positive effects in individuals with mild cognitive impairment (MCI), however, compliance with participation in various cognitive dysfunction management strategies remains scant in older adults with MCI. Health education programs can improve the level of knowledge of the disease effectively, though it remains unclear as to whether health education programs are sufficient to promote behavior changes of older adults with MCI in the community. Objective: The study aims to provide insight into the effect of a trans-theoretical Model (TTM)-based health education program on increasing knowledge about mild cognitive impairment (MCI), compliance in cognitive dysfunction management, and other cognition-related health outcomes (general cognitive function, sleep quality, depression symptoms, apathy symptoms) for older adults with MCI. Methods: This study is a single-blinded, randomized, prospective clinical trial. We will recruit 132 participants with MCI who will be randomly assigned to a TTM-based health education group and a standard health education group in a ratio of 1:1. The intervention group will receive a TTM-based health education program (1 session/week, 4-560 min/session for 8 weeks), while the control group will receive standard health education. Assessors blinded to participant allocation will conduct baseline, post-intervention, and 3-month follow-up assessments. Statistical analyses will consist of the Wilcoxon test, the Chi-square test, the T-test, and 2 (group) × 3 (time) ANOVA with a 5% cut-off for significance. Discussion: Supposing the TTM-based health education program will provide validated community-based cognitive dysfunction management strategies for older adults with MCI, this would be a feasible approach to improve the compliance of participation in cognitive dysfunction management and the cognition-related health outcomes. Clinical Trial Registration: ChiCTR1900028351. Registered on December 19, 2019. http://www.chictr.org.cn/edit.aspx?pid=47223&htm=4.

Biological therapy in the treatment of psoriatic arthritis: economic and epidemiological considerations

Background: Biological therapies have a significant economic and clinical burden but, in general, lose their effectiveness over time. This study evaluated the medication persistence and costs associated to use of anti-TNF agents for psoriatic arthritis (PsA) treatment. Methods: A historical cohort composed of individuals in Brazil with PsA diagnosis was developed during the period between 2010 and 2015. The difference among the anti-TNF agents was verified by the log-rank test. The predictors of medication non-persistence were identified by Cox regression. The costs were compared by variance analysis with Bonferroni correction. Results: 11,008 patients were analyzed. Adalimumab (51%) was the most used anti-TNF agent. Individuals using adalimumab presented higher medication persistence as compared to etanercept and infliximab. The costs with anti-TNF agents corresponded to 90% of the total costs and were similar among anti-TNF agents. The non-persistence predictors were female sex, younger patients, to live in the Northeastern and Northern regions of Brazil, to use infliximab and etanercept, and have more comorbidities. Conclusion: The direct costs with anti-TNF agents were the main component of total costs. Outpatient and inpatient costs increase when medication persistence decreases. A considerable price reduction of anti-TNF agents has been observed over the years.

Factors Associated with Adherence to Allergen Specific Subcutaneous Immunotherapy

PURPOSE

Allergen-specific immunotherapy (AIT) is known to be the only therapeutic modality to alter the natural course of allergic diseases. However, at least 3 years of treatment is recommended for achieving long-term disease modifying effect. This study aimed to investigate factors associated with immunotherapy non-adherence in real practice.

MATERIALS AND METHODS

We retrospectively reviewed medical records of patients who were diagnosed with allergic rhinitis, asthma, or atopic dermatitis, and received AIT to common allergens such as house dust mite and/or pollens from January 2007 to August 2014. In this study, non-adherence was defined as not completing 3 years of AIT.

RESULTS

Among 1162 patients enrolled, 228 (19.6%) failed to complete 3 years of AIT. In multivariate analysis, age less than 20 years [odds ratio (OR) 3.11, 95% confidence interval (CI) 1.70-5.69] and 20 to 40 years (OR 2.01, 95% CI 1.17-3.43), cluster build-up (OR 1.78, 95% CI 1.05-3.02) and ultra-rush build-up schedules (OR 5.46, 95% CI 2.40-12.43), and absence of visit to other departments in the same hospital (OR 1.87, 95% CI 1.05-3.32) were independently associated with immunotherapy non-adherence. Disease duration of 5-10 years was negatively associated with non-adherence compared to shorter disease duration of less than 5 years (OR 0.61, 95% CI 0.40-0.94). Although male sex and commercial product of AIT, Tyrosine S®, compared to Novo-Helisen® were non-adherent factors in univariate analysis, no statistical significances were identified in multivariate analysis.

CONCLUSION

Various factors are associated with immunotherapy adherence affecting the utility of immunotherapy. Clinicians should be aware of factors associated with adherence to maximize the utility of allergen-specific subcutaneous immunotherapy.

An overview of the common methods used to measure treatment adherence

Background and aims

The success of a treatment depends on the effectiveness of the medication regimen, provided that patients take the medicines as prescribed. A low rate of adherence in chronic conditions is associated with poor outcome and decreased quality of life, which constitutes an additional burden for the healthcare systems. To correctly identify the dimension of this problem may be a challenge, as there are numerous methods, definitions, patient settings and factors, each with their specific roles. Our aim was to give an appropriate overview of the most common validated methods that can be used to identify non-adherent patients.

Methods

This overview is based on an online search of PubMed database and includes the relevant articles in this field.

Results

We included both direct and indirect methods for measuring treatment adherence and presented concise information that can help researchers and clinicians when choosing an appropriate method. Both subjective and objective methods have advantages and disadvantages that should be fully understood and taken into consideration.

Conclusions

Choosing a simple, accurate and inexpensive method that can give supplementary information about the patterns, beliefs and barriers of adherence would be desirable. But because this perfect method to measure treatment adherence does not exist, the best solution seems to be the combined use of at least two methods.

Medication persistence for psoriatic arthritis in a Brazilian real-world setting

Aim:

To evaluate the persistence of biological (TNF inhibitor [anti-TNF]) and synthetic (conventional synthetic disease-modifying antirheumatic drugs [csDMARDs]) antirheumatic agents for psoriatic arthritis and their associated factors.

Methods:

A historical cohort was developed. Persistence and associated factors were evaluated at 6 and 12 months.

Results:

A total of 161 patients were included. The anti-TNF treatment presented higher persistence as compared with csDMARDs at 6 (83.4 vs 50.8%; p < 0.05) and 12 months (66.4 vs 35.6%; p < 0.05). From anti-TNFs, adalimumab and etanercept presented similar persistence, along with leflunomide and methotrexate among the csDMARDs. The factors associated with non-persistence with regard to anti-TNF agents were female sex and use of infliximab.

Conclusion:

Anti-TNF agents are important therapeutic alternatives and present lower rates of discontinuation as compared with csDMARDs.

Conventional synthetic disease-modifying antirheumatic drugs (csDMARD) and anti-TNF agents were included in the Brazilian National Health System in 2009, yet were not previously the target of evaluations in a Brazilian context. Persistence, that is the time between starting and discontinuing the drug, is a proxy of effectiveness and safety for antirheumatic agents. This study evaluated medication persistence and relevant factors associated with it. Patients using infliximab showed a lower medication persistence when compared with adalimumab and etanercept. The medication persistence with anti-TNF agents was higher when compared with csDMARDs. Female sex and infliximab were predictors of medication non-persistence.