Nonadherence to DMARD Therapy: An Attitude Problem?

Aug 27, 2018

Here: 6 key beliefs patients hold about DMARDs that drive their reluctance to continue therapy.

References1. Nam JL, Ramiro S, Gaujoux-Viala C, et al. Efficacy of biological disease-modifying antirheumatic drugs: a systematic literature review informing the 2013 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis. 2014;73:516-528.2. Nam JL, Takase-Minegishi K, Ramiro S, et al. Efficacy of biological disease-modifying antirheumatic drugs: a systematic literature review informing the 2016 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis. 2017;76:1113-1136.3. Smolen JS, LandewÃ© R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis. 2014;73:492-509.4. ScheimanâElazary A, Duan L, Shourt C, Agrawal H, Ellashof D, CameronâHay M, et al. The rate of adherence to antiarthritis medications and associated factors among patients with rheumatoid arthritis: a systematic literature review and metaanalysis. J Rheumatol. 2016;43:512â523.5. Kelly A, Tymms K, Tunnicliffe DJ, et al. Patients’ attitudes and experiences of disease-modifying antirheumatic drugs in rheumatoid arthritis and spondyloarthritis: a qualitative synthesis. Arthritis Care Res. 2018;70:525-532.6. Ruderman EM. Overview of safety of non-biologic and biologic DMARDs. Rheumatology. 2012;51(suppl 6):vi37-43.

Patient adherence to disease-modifying antirheumatic drug (DMARD) therapy remains a major clinical challenge in the management of rheumatoid arthritis (RA). Nonadherence can result in increased disease activity and greater disability as RA progresses.

A recent study identified 6 key beliefs patients hold about DMARDs that drive their reluctance to continue therapy. Scroll through the slides for the details-and for steps to alleviate their concerns.

(Image credit: ©AlexanderRaths/Shutterstock.com)

Disease-modifying antirheumatic drugs (DMARDs) are often prescribed with a goal of remission. The efficacy of DMARD therapies for rheumatoid arthritis (RA) has been well established in European League Against Rheumatism (EULAR) guidelines.^1,2 Both synthetic and biologic DMARDs are recognized as first-line therapies to reduce disease activity from RA and to prevent the onset of future disability.^1,2 Therapy is recommended to be initiated as soon as possible after RA diagnosis to have the greatest impact.³

Despite evidence-based recommendations for DMARD therapy, patient adherence remains a major clinical challenge. Only about 66% of patients for whom DMARD therapies are prescribed adhere to them, leading to increases in disease activity and greater disability as RA continues to progress.⁴ While patients have many individual reasons for nonadherence or discontinuation of therapy, the main drivers are negative beliefs about the chronicity of therapy and the safety of the drugs.

Much research has been done into patient attitudes toward DMARD therapy. A recent review by Kelly and colleagues⁵ identified 6 distinct “themes” across patient rationales for nonadherence:

1) Intensifying disease identity refers to patient perceptions that long-term therapy with frequent changes and escalations is a constant reminder of the seriousness of their disease. They often report feeling more unwell as a result of this heightened awareness and the adverse effects of the therapy.

2) Fear of uncertainties and consequences. Necessary counseling about DMARD therapies contributes to patient fears about the safety of these drugs. Patients often develop perceptions that the drug is “poisoning the body” and may see treatment as a second illness. They also express uncertainty related to frequent changes in drug regimens and doubt the efficacy of each new therapy.

3) Power of social influences. Because of uncertainty, patients are easily swayed by the opinions of others, including family and friends and their clinicians. Those who trust their physicians are most likely to adhere to even multiple changes to therapy.

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Continuing the 6 distinct “themes” identified by Kelly and colleagues5 across patient rationales for nonadherence, rationales 4 to 6 refer to beliefs that influence patient attitudes while on therapy:

4) Privilege and right of access to biologic DMARDs. Patients frequently perceived more expensive medications to be superior to less expensive drugs. They often argued to receive a more expensive biologic, even if it was not the best therapeutic choice, and failed to report adverse effects for fear of losing access to the drug.

5) Maintaining control. Some patients wanted to take ownership of the decision to use DMARD therapy. They did not want to hand over control of their disease to someone else, including a healthcare provider.

6) Negotiating treatment expectations. Patient responses to therapy were overwhelmingly based on other perceptions of safety and efficacy before initiating treatment.