Tuesday, March 8, 2016

Lessons from rheumatology

Betegnie AL, Gauchet A, Lehmann A, Grange L, Roustit M, Baudrant M, Bedouch P, Allenet B. Why Do Patients with Chronic Inflammatory Rheumatic Diseases Discontinue Their Biologics? An Assessment of Patients' Adherence Using a Self-report Questionnaire. J Rheumatol. 2016 Feb 15.
Concerns have been raised about nonadherence behavior among patients with chronic inflammatory rheumatic diseases (CIRD) receiving biologics. This nonadherence may be caused by various factors. The main objective was to explain why patients discontinue their biologics of their own accord.
A quantitative and descriptive study was performed using a self-report questionnaire that was sent through the Internet to members of different patient associations. Sociodemographic data, medical and therapeutic history, management of biologic administration, previous experiences, and patients' beliefs and perceptions about treatment efficacy and side effects were studied to explain self-discontinuation (SD). 


A total of 581 patients answered the questionnaire between June 16, 2012, and July 4, 2012, including patients with ankylosing spondylitis (351/581, 60.4%), rheumatoid arthritis (196/581, 33.7%), psoriatic arthritis (30/581, 5.2%), and other CIRD (4/581, 0.7%). More than 1000 different biologics were described by the 581 patients, with a median of 2 lines per patient. Eighty-six patients discontinued their biologics of their own accord (14.8%). In a multivariate analysis, factors that were significantly related to SD were low level of pain, more than 1 line of biologics tried, self-administration of biologics, negative beliefs about the treatment, and a lack of medical and social support. 


Five predictive factors of this SD were identified, which should be assessed in routine with patients with CIRD receiving biologic treatment: pain, treatment history, self-administration of injections, negative beliefs about treatment, and a lack of perceived medical and social support.


From the paper:

The first factor related to SD in our study was pain. The more pain the patient experienced, the better their adherence to their biologic. This correlation was independent of the type of disease. Similar results have been reported in fibromyalgia. However, pain was measured over the last 8 days, while participants may have discontinued their biologics far longer ago. Further investigation should analyze the evolution of pain during time and its link to adherence. Relief from pain could be interpreted by the patient as a remission, which may lead to discontinuation. In contrast, pain leading up to the next injection may be perceived as a treatment efficacy, which is the most influential factor for longterm persistence according to Brod, et al. 

The duration of therapy seems to be a major component of adherence. Our results show that the number of different lines of therapy tried by the patient is an independent factor for discontinuation. Persistence to biologic treatments decreases with time, as Koncz, et al reported in a review of the literature.

According to the literature, the previous experience of side effects is also a major driver of discontinuation. In our study, more than 70% of patients declared having already felt  side effects. However, no significant correlation with SD  was found.

There is little evidence of the link between CAM and adherence. Our univariate analysis suggests that patients who self-discontinued were more likely to use CAM than others. Westhoff and Zink showed that a preference for CAM was the strongest risk predictor of lack of adherence to DMARD (conventional disease-modifying antirheumatic drugs) therapy among patients with RA. In our multivariate model, this relationship does not remain significant.

In our study, patients who self-administered their biologics  were also more predisposed to discontinue their biologics compared with patients whose injection was given by someone else. A qualitative study has suggested that the most critical period concerning adherence to self-injectable treatment is the first month of therapy. During this period, patients need encouragement and support to continue selfadministered treatment. 

The relationship between drug adherence and beliefs about medication among patients with RA was described by Neame, et al using the Belief about Medicines Questionnaire. In line with this, we concluded a significant correlation between negative beliefs and SD (impression that treatment hurts more than does good, and that it is like a poison).

Further, we found that medical and social support were significantly related to SD, which suggests that a supportive environment may improve adherence to a biologic. Regarding internal resources, we found no significant correlation between self-efficacy and SD in our study, although the literature reports this factor as an important determinant of adherence. However, de Klerk, et al and Brus, et al assessed self-efficacy among patients with conventional DMARD drugs only and did not use the same questionnaire.
Courtesy of :  http://www.hcplive.com/medical-news/5-factors-that-predict-medication-nonadherence-in-patients-taking-biologics-for-rheumatic-disease/P-1

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