Improving Medication Adherence in Rheumatoid Arthritis

Slideshow

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  How Can Nonadherence Be Identified in Clinical Practice?

  Currently, there is no gold-standard for evaluating nonadherence in RA patients, but numerous assessment methods are available. These include subjective, direct, and indirect measures, each with benefits and limitations.[1] Subjective methods include self-report and physician estimation, but these measures provide no direct evidence that the medication is being taken. In contrast, biomarker testing (drug concentration/metabolites) can show whether a medication is being ingested, but it is invasive, expensive, and subject to patients’ metabolism. Indirect methods, such as counting tablets and administering questionnaires (eg, 8-item Morisky's scale), are commonly used in clinical practice, but they provide no objective evidence that a drug is being ingested and rely on patient reporting.[1] Until more definitive assessment methods are available, a combination of the aforementioned measures may be needed to more accurately identify nonadherence.

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  Which Factors Place Patients at Higher Risk of Nonadherence?

  Numerous factors have been shown to contribute to nonadherence. In a study assessing adherence to methotrexate (MTX), one of the most commonly used frontline therapies for RA, patients of low socioeconomic status (P <.0001) and on MTX for longer duration (P <.001) had a higher risk of nonadherence.[7] Lack of affordability, lack of medication availability locally, lack of family support, and lack of understanding of the need and importance of MTX were found to be other significant contributors to nonadherence (P <.001 for all).[7] Systematic literature reviews that examined adherence across disease-modifying antirheumatic drugs (DMARDs) showed patients were significantly more likely to be adherent if they believed their treatment was necessary. [5,8] However, the quality of studies and findings on adherence vary considerably, indicating a need for better research in this area.

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  What Should Be Done Once Nonadherence Is Identified?

  Once nonadherence is identified, it is essential for clinicians to determine exactly which factors are preventing the patient from adhering to his or her regimen, taking into consideration that not all cases are intentional. [2] Many patients might simply forget to take their medication, not understand how to take their medication, or not understand the consequences of altering their regimen. Determining the cause(s) of nonadherence requires good communication with patients, a factor that has consistently been shown to be crucial in improving adherence. [2,6,] Ethnic minorities and those with lower education have been reported to be at particularly high risk of having interaction difficulties with their providers, indicating a need to tailor communication to every patient. [2] Additionally, communication between all healthcare providers should be strengthened so that the importance of adherence is emphasized across all points of care.[3]

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  How Can Communication With Patients With RA Be Improved?

  When communicating with patients, it is essential to provide them with key information about their drug regimen, including what the drug is, why they need it, when and how to take it, and for how long they need to take it. [6] They should also be educated about the fluctuating nature of RA, the consequences of nonadherence, and the potential adverse effects associated with their treatment so that they know what to expect and when to call for instruction, reducing the risk of them altering their regimen. [6,10] Because patients of lower socioeconomic status and ethnic minorities are at especially high risk of nonadherence, the RESPECT model of communicating, which has received recognition for improving cultural competence and overall rapport, might be especially beneficial in the RA setting. RESPECT comprises seven core elements: Respect (show), Explain (provide), Support (provide), Power (share), Empathy (show), Concerns (address), and Trust (build). [11]

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  Should Visual Aids Be Used to Aid Medication Adherence?

  A recently published study suggests that showing, rather than just telling, can improve adherence. [10] Of the 20 RA patients in the study, 8 (40%) stated that seeing an ultrasound scan of their inflamed joints made them better understand the seriousness of their condition and the importance of treatment adherence. Similar findings were previously reported in a larger study (n=111) that evaluated the impact of visual feedback on adherence over a 1-year period. [12] In the study, patients provided with visualization charts that tracked their disease activity (n=55) demonstrated significant improvement in adherence to DMARD therapy vs those who did not (n=56), and they also had significant improvement in their disease activity parameters. Although both studies are small, they suggest visuals can be an important tool in improving adherence.

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  How Can I Address Intentional Nonadherence?

  When considering intentional nonadherence, it is important to determine whether it stems from patient beliefs or from other barriers, such as financial difficulties. Patients who do not adhere because of negative beliefs might benefit from educational interventions, including cognitive behavioral approaches that are reinforced and supported with visual evidence. [2,10] Those who do not adhere because of other barriers might benefit from consultation with a medical social worker. Social workers can provide RA patients with many psychosocial services, including emotional support and access to resources that can help overcome adherence barriers, such as difficulty affording medications. [15] Because psychosocial problems have been shown to increase the burden of RA and affect adherence, it has been suggested that medical social workers should be members of every RA team and be involved early in the course of the disease to optimize outcomes. [16]

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  Which Interventions Have Shown the Greatest Efficacy in RA?

  Generally, multicomponent interventions have been shown to be most beneficial because of the complex nature of RA nonadherence. [3] Multicomponent interventions use multiple strategies to improve adherence, such as individual or group counseling, distribution of educational booklets or multimedia resources (eg, videos or audio), enrollment into programs that facilitate medication management or provide social support, and/or use of mobile technology programs. [16] Thus far, no multicomponent regimens have been compared head-to-head; thus, it is unclear which combinations might be most beneficial, including in certain patient subsets. Until research yields more definitive answers, the components are best tailored to each patient’s unique circumstances.

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  How Can I Address Intentional Nonadherence?

  When considering intentional nonadherence, it is important to determine whether it stems from patient beliefs or from other barriers, such as financial difficulties. Patients who do not adhere because of negative beliefs might benefit from educational interventions, including cognitive behavioral approaches that are reinforced and supported with visual evidence. [2,10] Those who do not adhere because of other barriers might benefit from consultation with a medical social worker. Social workers can provide RA patients with many psychosocial services, including emotional support and access to resources that can help overcome adherence barriers, such as difficulty affording medications. [15] Because psychosocial problems have been shown to increase the burden of RA and affect adherence, it has been suggested that medical social workers should be members of every RA team and be involved early in the course of the disease to optimize outcomes. [16]

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  What Constitutes Nonadherence?

  The World Health Organization defines adherence to long-term therapy as “the extent to which a person’s behavior—taking medication, following a diet, and/or executing lifestyle changes—corresponds with agreed recommendations from a healthcare provider.” [4] In studies and clinical practice, patients are generally considered to be adherent to their regimen if they follow their treatment recommendations ≥80% of the time; however, the impact of this cutoff on RA disease outcomes has yet to be researched.[5] When determining medication nonadherence, 3 key components need to be considered: primary or initiation nonadherence, where a prescription is given but never filled or taken; persistence nonadherence, where the medication is prematurely discontinued; and execution nonadherence, where the patient modifies the regimen, such as by skipping or altering doses and/or taking the medication at incorrect times. [1,6] Photo credit: CNRI / Science Source