Study: Nonadherence to SLE, RA treatments is a persistent and common issue

In the treatment of systemic lupus erythematosus and rheumatoid arthritis, treatment nonadherence is an ongoing and common problem with potential implications for successful management of these chronic conditions, according to an editorial published in Rheumatology.
In the editorial, Nathalie Costadoat-Chalumeau and colleagues cited a Canadian study that reported high rates of medication nonadherence data across various conditions. The authors noted these figures are possibly higher in areas where there is a shortage of specialists or barriers to care. While this type of nonadherence is classified as unintentional and is strongly linked to social factors, the editorial primarily focused on intentional nonadherence in patients with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA). Forgetful nonadherence was included in the “intentional” category.
For this report, the authors defined adherence as the percentage of prescribed medication doses the patient took. Poor adherence was classified as rates of less than 80%. They noted that self-administered questionnaires may involve patient under-reporting of non-adherence. In addition, clinician evaluations may not accurately characterize a patient’s adherence behaviors outside the context of scheduled visits.
The use of pill counts, refilling data and electronic monitoring devices may be effective in measuring adherence by comparing the number of tablets brought back by patients, collected in the pharmacy, or taken from the device against the total number prescribed. However, while these approaches consistently identify higher nonadherence rates than subjective methods, the authors noted these are not routinely used. Direct objective measurements, like unscheduled blood and urine screenings for drug concentrations, may have some utility but are costly and limited in availability. These approaches also may fail to overcome “white coat compliance” in detecting longer-term nonadherence habits. As hydroxychloroquine (HCQ) has a half-life of a minimum of 7 days, these restrictions do not apply in blood screenings for HCQ. If a patient has undetectable HCQ levels, this means they have not taken HCQ for a significant amount of time, the authors noted. For this reason, some centers have begun using this test to routinely evaluate nonadherence to SLE and RA.
The authors cited nonadherence rates ranging from 3% to 76% in SLE patients and from 14 to 80% in RA patients, depending on the evaluation approach and the drug. Two, 2-year prospective cohort studies reported 74% of 78 patients with SLE and 79% of 107 patients with RA had average rates of adherence of less than 80%. The authors noted a recent study using U.S. pharmacy refill information reported 79% of 9,600 patients with SLE newly initiating HCQ treatment and 83% of 3819 patients with SLE newly initiating oral immunosuppressant drugs had adherence rates of less than 80%.
Once nonadherence has been identified, the next major hurdle is to try to improve or reverse this nonadherence in a long-term way. As there is no single cause for nonadherence, the authors noted interventions should utilize a combination of strategies. In cases of unintentional nonadherence related to access issues, providers can assist patients with finding patience assistance programs, making social work referrals and using interpreters. In cases of intentional nonadherence, studies have indicated mere exposure to additional education and guidance, or the use of persuasive or authoritative communication, does not suffice to yield permanent adherence. Patients may be helped to understand the need for medication by viewing the inflamed joint on musculoskeletal ultrasound, but this does not necessarily translate to long-term change. Self-management and cognitive behavioral programs have likewise not provided good long-term improvements, they noted. Newer approaches using smart e-technologies and social support have shown more promise, particularly among younger patients, but need to be further studied. The authors emphasized the importance of simple changes, such as reducing dosing or choosing IV infusions, to improve adherence. Positive patient interactions and communication without judgment are also valuable in encouraging adherence.
“Nonadherence is, unfortunately, a regular occurrence and has important clinical implications,” the researchers wrote. “Adherence behavior should therefore be systematically and routinely considered within our clinical practice. This assessment should be repeated from visit to visit, because patient attitudes toward treatment and behavior may vary over time.” -by Jennifer Byrne

Disclosures: The researchers report no relevant disclosures.