In a recent review published in Patient Preference and Adherence written by Mwangi Murage, et al., researchers find low adherence and persistence rates for medication compliance in patients with rheumatoid arthritis, psoriasis and psoriatic arthritis.
Rheumatoid arthritis, psoriasis and psoriatic arthritis impact all aspects of the patients’ lives affecting hundreds of millions of adults combined worldwide. New advances in treatment have been developed over the last several decades, but outcomes are closely tied to adherence and persistence. While medications can be expensive, non-adherence and non-persistence exact a high cost in terms of treatment costs and patient outcomes.
The review is based on a collection of 43 studies that focused on clinical outcomes, rates of medication adherence and persistence. They also looked for reasons or factors related to non-adherence or non-persistence. Of the studies, 26 were in rheumatoid arthritis, 12 in psoriasis and five in psoriatic arthritis.
Adherence rates varied widely in rheumatoid arthritis. The median adherence rate for both etanercept and adalimumab was 63 percent. In studies where multiple medications were studied simultaneously, adherence rates were greater for infliximab than for adalimumab or etanercept. Methotrexate users were less likely to comply with their medications compared to infliximab users. Patients taking golimumab had a higher adherence rate (81 percent) than those taking adalimumab (70 percent) or etanercept (61 percent).
Being older being Caucasian, using a specicalty pharmacy and having used biologics in the past contributed to better adherence rates.
No biologic stood out as having higher persistence rates. Using the criteria of a gap of 45 days over one year, the median persistence rate was 61 percent for etanercept 57.5 percent for adalimumab, 63 percent for infliximab, 52 percent for Abatacept, 29. percent for golimumab, 40 percent for rituximab, and 33 percent for certolizumab.
Lower rates of persistence were reported in new biologic users and those switching for the first or second time. When looking at specific drugs the mean persistence rate in the overall population over one year was 74.6 percent, with higher rates for infliximab combination (78 percent) compared to etanercept (72.8 percent) and adalimumab (70.8 percent) combination.
High cost, younger age, race other than white, and high disease activity were linked to non-persistence.
Adherence was found to be the greatest with infliximab (49 percent) users, followed by ustekinumab (43 percent), adalimumab (41 percent), and etanercept (29 percent) users.
Experienced patients who had other prescriptions, were older, male and who had fewer comorbidities were associated with better adherence.
Needing to reschedule existing injection appointments the unaffordability of therapies, forgetfulness, and having other medical problems were linked to per adherence.
Median persistence rates for etanercept and adalimumab were 47 percent and 57 percent, respectively. Experienced users were more persistent and lack of efficacy was related to non-persistence.
Data were limited but in one retrospective study of 325 patients with psoriatic arthritis a 76 percent adherence rate was reported for golimumab users.
61 percent of patients took biologics for one year uninterrupted. Non-persistence was associated with a history of prior treatment with methotrexate, coronary artery disease, a higher body mass index, and patients with more disability and disease activity.
TAKE-HOME POINTS AND FINAL THOUGHTS
Factors leading to poor adherence and persistence were similar with high cost, high disease activity, and poor access to specialty pharmacies consistently leading to poor compliance.
The data point to clear opportunities for improvement. Clinicians can start by educating patients about how to use the prescribed biologics. This may improve outcomes such as disease activity and quality of life.
Management of comorbidities should be a part of every patient treatment plan regardless of primary diagnosis. Costs and access issues can be mitigated through education about assistance plans available to individual patients and referrals to specialty pharmacies.
Compliance begins with talking to our patients, providing information, and being there with encouragement to keep them on track to a better life.
Murage MJ, Tongbram V, Feldman SR, et al. Medication adherence and persistence in patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis: a systematic literature review. Patient Prefer Adherence. 2018;12:1483–1503. Published 2018 Aug 21. doi:10.2147/PPA.S167508