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High mortality risk with medication nonadherence among teenage heart transplant recipients
Nine percent of pediatric and adolescent heart transplant recipients studied in a national review may have experienced compromised health due to medication nonadherence within 2 years after transplant.
“It is widely known that nonadherence is a particularly difficult problem among adolescent patients,” Christopher S. Almond, MD, MPH, a cardiologist in the Heart Transplant Program at Boston Children’s Hospital, said in a press release. “But, prior to this study, the scope and gravity of the problem wasn’t well understood.”
Christopher S. Almond
The researchers conducted a national review of 2,070 pediatric heart transplants in 2,030 US patients using 1999 to 2007 data from the Organ Procurement Transplant Network. Median age at transplant was 6 years. Forty percent of patients had congenital heart disease and 7% were re-transplants.
Overall, 186 children had a report of medication nonadherence at a median age of 15 years. More than two-thirds of nonadherence reports occurred after age 12 years. The risk for mortality among children who did not adhere to prescribed post-transplant medications was 26% within 1 year and 33% within 2 years after transplant.
The researchers identified several key risk factors associated with increased risk for nonadherence in pediatric heart transplant recipients, including age (12 to 17 years), Medicaid insurance, black race and invasive hemodynamic support at transplant. Time on transplant wait list and sex were not associated with nonadherence in this study.
Melisa Oliva
“With all the advances that have been made in transplant medicine, nonadherence has become the leading cause of fatal graft rejection in adolescent patients, and it’s completely avoidable,” Melisa Oliva, PsyD, formerly a staff psychologist at Boston Children’s Pediatric Transplant Center, said in the press release. “We hope these data can help raise awareness of the seriousness of the problem and guide clinicians in identifying those most at risk, so interventions can be put into place early, before adherence issues develop.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to TopThis study reflects what we see in our practice, especially with congenital vs. noncongenital causes for heart transplant. Children who have grown up with heart disease as part of their life since birth tend to do better in the adherence area because they are sort of used to that life of medical visits and taking medicines, compared with the teenager who suddenly develops an acute heart infection or for some reason finds they need a transplant and have never had that type of experience in the past. It hits them at a time in their life when they are the most vulnerable to nonadherence. At our center, we see the same things as in the study — that the congenital patients tend to do much better with adherence than the noncongenital patient.
Another thing with teenagers is that they don’t want to be different. No one wants to stand out. I have heard many patients say that they don’t want to take their medication because they don’t want to be different than their peers. In our practice, I also believe teenage girls tend to have more problems with nonadherence than teenage boys. That, again, may go back to the issues with self image. They are much more aware of how they look to others, and if they have to stop what they are doing to take medicine they feel that singles them out.
There really is no great way to monitor adherence in teenagers after heart transplantation. Many suggestions have been discussed, such as pill bottles with monitoring caps. In the future, we hope to see once-daily medication regimens rather than twice-daily regimens. Simplified medication regimens may help decrease the amount of nonadherence. However, it seems teenagers always find a way to get around things. If we can adapt our medical practice to make it easier for them to be adherent, that’s where we need to focus our energy.
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Oliva M. J Heart Lung Transplant. 2013;doi:10.1016/j.healun.2013.03.008.