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Medication adherence in children post liver transplant varies with time

New data suggests that initial immunosuppressant adherence among pediatric liver transplantation patients does not guarantee continued adherence, and nonadherence is likely to persist without intervention.

“Nonadherence to prescribed immunosuppressive medications is associated with most cases of late acute rejection (LAR) in pediatric liver transplant recipients,” Eyal Shemesh, MD, from the Icahn School of Medicine at Mount Sinai, New York, and colleagues wrote. “As the field still struggles to develop effective strategies to assess and mitigate nonadherence, it is important to understand how variation in adherence behaviors might inform intervention and monitoring strategies.”

Shemesh and colleagues recruited 400 patients from five pediatric liver transplant centers in the U.S. to participate in the prospective Medication Adherence in Children Who Had a Liver Transplant (MALT) cohort.

Investigators measured adherence with the Medication Level Variability Index (MLVI), which measures the degree of fluctuation of tacrolimus blood levels over time.

The researchers followed patient medical variables and outcomes for 2 years until June 2015 and analyzed patient and family socioeconomic variables including whether the child lived in a single-parent household and the patients’ type of medical insurance.

Overall, 59.7% of the patients were nonadherent in both year 1 and year 2, 18.5% were adherent in year 1 and became nonadherent in year 2, and 4.4% were adherent during both years. Researchers observed a significant correlation between MLVI during year 1 and year 2 (r = 50.45; P < .001).

The rate of rejection was significantly higher among patients with nonadherence during one of the two years (22.9%) and those who were nonadherent both years (34.9%) compared with those who were adherent both years (4.4%; P < .001). Overall, the frequency of LAR was higher among patients with a greater MLVI variance (mean, 0.8% vs. 0.4%; P < .001).

Among patients who were adherent in year 1, those with government-issued insurance or no insurance compared with private insurance (73.2% vs. 26.8%; P = .01), and those whose parents did not have a college degree (70.7% vs. 26.8%; P = .02) were more likely to become nonadherent in year 2.

“Previously good adherence is not always an indication of good adherence later on. This finding suggests that regular monitoring of adherence should be considered for all patients, including those who appear to be managing their medications well at baseline,” the researchers concluded. “In clinical use, we suggest that the MLVI be computed anew every time a blood level is obtained, from blood levels recorded in the 12-month period leading to the time in which this new level was recorded.” – by Talitha Bennett

Disclosure: Shemesh reports no relevant financial disclosures.