Only 1 in 5 patients with rheumatoid arthritis (RA) took at least 80% of prescribed oral doses, according to data from an electronic monitoring study published online May 31 and in the June issue of Arthritis & Rheumatism. Although biologicals get more attention, oral disease-modifying antirheumatic drugs (DMARDs) and steroids remain the keystone of early RA treatment, and the poor outcomes associated with poor adherence in this study might have major public health consequences.
Christian A. Waimann, MD, from the University of Texas M.D. Anderson Cancer Center in Houston, and colleagues enrolled 107 patients with RA in a 2-year study that electronically monitored their intake of oral RA medications, using medication containers with built-in monitoring each time the bottle was opened. Of those who participated, 87% were female with a mean disease activity of 8 years. The RA patient group was ethnically diverse, with 65% Hispanic, 19% black, and 16% white participants. Educational status was low, with 45% not completing high school, and 67% of the participants had incomes less than $20,000.
DMARD adherence was measured as doses taken as prescribed (percentage of days or weeks, for methotrexate and prednisone, respectively, in which the patient took the correct dose as prescribed).
"In summary, we found that adherence to oral DMARDs and steroid therapy in patients with RA was low, ranging from 58% to 71%, with only one-fifth of patients showing ≥80% adherence to DMARDs. Nonadherent patients had higher [Disease Activity Score in 28 joints (DAS28)] values across the 2 years of followup, with a trend toward lower function and increased radiographic damage as well. Our findings should alert physicians about the need to integrate adherence assessments into daily practice, to explore potential barriers to nonadherence, and to engage in discussions with patients to highlight the importance of taking medications as prescribed to reach therapeutic target goals," the authors note.
"We were not that surprised [by our findings], because there is extensive data for other chronic diseases showing that lack of adherence is a major issue in achieving therapeutic efficacy" senior author Maria E. Suarez-Almazor, MD, PhD, told Medscape Medical News. "Our results suggest that adherence is important and should be explored both at the individual patient level, when patients do not respond as well as we expect, and also in research studies, where it could partially account for the differences between the efficacy seen in clinical trials for a given agent and its effectiveness in real-world practice."
Dr. Suarez-Almazor is Barnts Family Distinguished Professor; deputy department chair (research); chief, Section of Rheumatology; and chief, Section of Clinical Research and Education, Department of General Internal Medicine, Division of Internal Medicine, the University of Texas M.D. Anderson Cancer Center.
She added, "Our participants were patients seen [in] a public clinic setting, and therefore encountered many financial and logistic barriers. In addition, many were not truly convinced about the potential benefits of therapy or were concerned about toxicity. Patient-centered communication is fundamental to appropriately discuss these issues in a constructive way."
Patients who took their medications as prescribed showed significantly lower disease activity scores (DAS28, 3.28) throughout the study period compared with those who were less adherent (DAS28, 4.09). Increases in radiological damage score were also higher in patients with RA who were nonadherent.
"In our view, it would be useful to ask patients routinely if they have any problems taking their medications as prescribed or if they have missed any doses. This should be framed as an open communication without making the patient feel guilty or threatened by the questioning. The purpose of this assessment is to explore and solve any potential barriers to full adherence," Dr. Suarez-Almazor said.
"Waimann et al's report is in line with what has been reported about adherence to RA treatment," Linda LI, PT, PhD, told Medscape Medical News. "A 2012 systematic review by van den Bernt found that adherence to RA medications was as low as 30% in some studies. In our own research, interviewing patients who were recently diagnosed with RA, they articulated a sense of 'ambivalence' toward medications. On the one hand, they understood that they needed the meds to prevent irreversible joint damage; on the other hand, they worried about the side effects. This might have contributed to the poor adherence to treatment." Dr. Li, who was not involved in the current study, is associate professor and Harold Robinson/Arthritis Society Chair in Arthritic Diseases at the Department of Physical Therapy, University of British Columbia, Vancouver, and senior scientist at the Arthritis Research Centre of Canada, Richmond, British Columbia.
Dr. Li's group has developed an online decision aid that is freely available to help patients decide whether they want to proceed with methotrexate treatment once their doctor has recommended it.
This study was supported by the National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Suarez-Almazor and Dr. Li have disclosed no relevant financial relationships.
Arthritis Rheum. 2013;65:1421-1429. Abstract
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Cite this: RA: Only 1 in 5 Patients Take Oral Meds as Prescribed - Medscape - Jun 05, 2013.