The use of traditional and biologic disease-modifying antirheumatic drugs (DMARDs) has led to significant improvements over the past 2 decades.in morbidity and mortality associated with rheumatoid arthritis (RA). Using an appropriate treat-to-target paradigm of these agents, improved clinical outcomes, delayed radiographic progression, and remission have become realistic goals.1 However, these benefits can only be realized if patients closely follow treatment regimens as prescribed.
Suboptimal adherence is common in patients with RA and a variety of other inflammatory arthritides, with rates of 10.5% to 98.5% for RA,2 10% to 46% for gout,3 49% to 61% for systemic lupus erythematosus,4 and 75% for ankylosing spondylitis (AS).5
The vexing problem of adherence has drawn considerable interest from researchers. Recently published systematic literature reviews have attempted to critically analyze studies on adherence from several different angles.
Among them is a meta-analysis by Anat Scheiman-Elazary, MD, of the David Geffen School of Medicine at the University of California, Los Angeles and colleagues that examined medical literature published between 1970 and 2014 that described medication adherence data for patients with RA.2
The researchers found an overall medication adherence rate of 66%. They hypothesized that the wide range of adherence reported across studies may be related to the variety of methods used to measure it, such as drug levels, pill count, insurance claims, questionnaires and electronic medication event monitors.
However, no association between measurement methods and adherence rates was found. The team also analyzed the papers for reports of positive and negative factors associated with adherence.
Positive factors found in at least 2 studies were the use of infliximab compared with etanercept or methotrexate (MTX); use of MTX compared with sulfasalazine or etanercept; belief in the efficacy of treatment; white race; and older age.2
In another literature review, Eleni Vangeli, DPsych, of London South Bank University and colleagues analyzed the medical literature from 1980 to 2014 to identify factors associated with treatment nonadherence in RA, AS, psoriatic arthritis, inflammatory bowel disease, and psoriasis.6
To be eligible for inclusion, articles had to include statistics that examined associations of factors with nonadherence. An analysis of the identified 73 studies found that factors with the greatest impact on adherence were psychosocial in nature, such as healthcare professional–patient relationships, treatment concerns, depression, decrements in self-efficacy and beliefs in the necessity of treatment, and practical barriers.
Interventions to promote adherence
Although the problem of nonadherence has been amply recognized, evidence-based solutions remain elusive. Jessica Galo, BSc of the University of British Columbia and colleagues undertook a systematic review of medical literature published from 1946 to 2014 to identify and classify adherence interventions and assess evidence of effects on outcomes of patients with rheumatic diseases.7 Inclusion criteria were met by 23 of 2726 studies examined.
The interventions with positive effects on adherence outcomes were those that directly focussed on medication adherence , incorporated an educational component, were tailored to individual patients, and were delivered by a healthcare professional.
The current research on adherence to interventions for arthritis has shown inconsistent impacts on disease outcomes.
1. Nam JL. RA management of early disease. Curr Opin Rheumatol. 2016;28(3):267-274.
2. Scheiman-Elazary A, Duan L, Shourt C, 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(3):512-523.
3. De Vera MA, Marcotte G, Rai S, Galo JS, Bhole V. Medication adherence in gout: a systematic review. Arthritis Care Res (Hoboken). 2014;66(10):1551-1559.
4. de Achaval S, Suarez-Almazor ME. Treatment adherence to disease-modifying antirheumatic drugs in patients with rheumatoid arthritis and systemic lupus erythematosus. Int J Clin Rheumatol. 2010;5(3):313-326.
5. Arturi P, Schneeberger EE, Sommerfleck F, et al. Adherence to treatment in patients with ankylosing spondylitis. Clin Rheumatol. 2013;32(7):1007-1015.
6. Vangeli E, Bakhshi S, Baker A, et al. A systematic review of factors associated with non-adherence to treatment for immune-mediated inflammatory diseases. Adv Ther. 2015;32(11):983-1028.
7. Galo JS, Mehat P, Rai SK, Avina-Zubieta A, De Vera MA. What are the effects of medication adherence interventions in rheumatic diseases: a systematic review. Ann Rheum Dis. 2016;75(4):667-673.