How can patient compliance be improved?

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Rheumatoid arthritis, psoriasis and psoriatic arthritis patients have consistently low levels of biologic adherence and persistence. How can doctors improve patient compliance? Lower out-of-pocket costs, utilize specialty pharmacies and patient education can help, write researchers in the journal Patient Preference and Adherence.

The impact of rheumatoid arthritis (RA), psoriasis (PsO) and psoriatic arthritis (PsA) impact all aspects of patients’ lives affecting hundreds of millions of adults worldwide. Although, there have been many advancements in treatments for these conditions, outcomes are closely tied to adherence and persistence of use.

Adherence is defined as how compliant patients are with the prescribed dose and frequency of a particular medication while persistence descries how long from the initiation of treatment the patient continues to take it. Persistence also requires no prolonged gaps in therapy. While medications can be expensive, non-adherence and non-persistence exact a high cost in terms of treatment costs and patient outcomes.

The analysis, which was conducted by Eli Lilly, focused on the extent of adherence and persistence among patients with RA, PsO, and PsA who are treated with biologics.

THE STUDY

The authors conducted a systematic review of the literature looking for reported outcomes and rates of medication adherence and or persistence among patients in the U.S. They also looked for reasons or factors related to non-adherence or non-persistence. Three independent reviewers evaluated the studies and determined inclusion based on time, study design, location and age of patients.

Ultimately, 43 studies were included in the review with the majority being retrospective followed by cross-sectional and finally prospective in design. Adherence and or persistence in RA was examined in 26 studies, in Pso in 12 studies, and PsA in five studies.

RHEUMATOID ARTHRITIS

Adherence rates varied widely in rheumatoid arthritis. The median adherence rate for etanercept was 63 percent (range, 16–73 percent). The median adherence rate for adalimumab was also 63 percent (range, 21–70 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 ).

Using the criteria of at least a 45-day gap, the median persistence rate were 61 percent for etanercept; 57.5 percent for adalimumab;  63 percent for infliximab; 52 percent for abatacept; 29.5 percent for golimumab; 40 percent for rituximab; and, 33 percent for certolizumab.

“Experienced biologics users showed better adherence and persistence. Younger age, female gender, higher out-of-pocket costs, greater disease severity, and more comorbidities were associated with lower adherence and persistence rates,” wrote the authors who said patients who were not persistent were so because they felt the medications were ineffective, not safe or tolerable.

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.

For more than 80 days covered, “RA and PsO adherence rates for etanercept, adalimumab, and infliximab ranged from 16-73 percent, 21-70 percent, and 38-81 percent, respectively.”

PSORIASIS

“In PsO, persistence rates for etanercept and adalimumab ranged from 34-50 percent and 50-62 percent, respectively. Similar persistence rates were observed in PsA,” the authorts wrote.

Infliximab (49 percent) users were more adherent than other groups followed by those who were prescribed ustekinumab (43 percent), adalimumab (41 percent) and etanercept (29 percent).

Being adherent to other prescribed PsO medications was associated with better adherence to biologics. Older age, male gender, concomitant therapy, and low anxiety 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.

PSORIATIC ARTHRITIS

Data were limited but in one retrospective study of 325 patients with PsA a 76 percent  adherence rate was reported for golimumab users.

Overall, persistence for all biologics, described as no treatment gap or switching over one year of treatment, was 61 percent. Non-persistence was associated with a history of prior treatment with methotrexate, a history of coronary artery disease, a higher body mass index, and worse scores on most measures of baseline disability and disease activity.

TAKE-HOME POINTS AND FINAL THOUGHTS
 

Adherence and persistence rates with biologic medications in RA, PsO and PsA are low. 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.

While these data are troubling, they point out clear opportunities for improvement. Clinicians can start by educating patients with RA, PsO and PsA about how continuing to use the prescribed biologics will improve outcomes including 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.

REFERENCE

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

ABOUT THE AUTHOR

Gregory M. Weiss, M.D., is a cardiothoracic anesthesiologist practicing in Virginia. He is a frequent contributor to Rheumatology Network.