Long-term Adherence to Topical Psoriasis Treatment Can Be Abysmal

A 1-year Randomized Intervention Study Using Objective Electronic Adherence Monitoring

H. Alinia; S. Moradi Tuchayi; J.A. Smith; I.M. Richardson; N. Bahrami; S.C. Jaros; L.F. Sandoval; M.E. Farhangian; K.L. Anderson; K.E. Huang; S.R. Feldman

Disclosures

The British Journal of Dermatology. 2017;176(3):759-764. 

In This Article

Discussion

Psoriasis is a chronic immune-mediated skin disease that severely affects patients' quality of life and poses a considerable socioeconomic challenge. The majority of people with psoriasis suffer from mild disease that potentially could be treated with topical agents.[10] However, nearly 50% of patients with chronic diseases do not take their medications regularly[11] and adherence rates are lower for topical treatment than for systemic treatment.[10] Poor adherence leads to poor treatment outcomes, inefficient use of health resources, and higher rates of morbidity and mortality.[10,12] Adherence to treatment is crucial for the successful management of psoriasis but there are relatively few studies, if any, assessing long-term adherence to topical medication with a reliable measure.

Studying adherence has many hurdles. Electronic monitors can provide reliable information but do not totally solve the problems of adherence measurement. Some of the most effective treatments, such as clobetasol, are used only intermittently. For treatments used on an as-needed basis, it would be difficult to distinguish poor use from appropriate lack of use due to disease clearing, even with electronic adherence monitoring. For this study, we used topical fluocinonide, a potent (not ultra-potent) topical corticosteroid widely prescribed for psoriasis, in order to be able to instruct patients to use the medication twice daily on a regular basis. Despite having continued psoriasis (as evidenced by the lack of change in IGA score), adherence to the topical treatment was low and decreased over time.

Richards et al.[4] reported that 40% of survey respondents with psoriasis reported not taking their medication as recommended by their physician; we found that 100% of subjects did not take the medication as directed, with the recommended dose being taken on only 15% of the observed study days. On most days, most patients in the standard-of-care group did not apply treatment at all.

The abysmal level of adherence to topical fluocinonide observed in this study still likely overestimates real-life patient use. Subjects in clinical trials use their medications better than do patients in clinical practice. Factors that may improve adherence in the trial include signing a consent to participate, the high frequency of follow-up visits, and being told that medication use would be monitored (in this study, subjects were told medication containers would be weighed, but use of the electronic monitors was not disclosed until the end of the study). Moreover, in our study, subjects were given the medication; in real-life practice, patients have to fill their prescriptions, and as many as 50% of those psoriasis prescriptions go unfilled.[13] The high frequency of noncompletion of the 12-month study – due to worsening psoriasis, requiring an additional medication, not liking the medication, side-effects of treatment and loss to follow-up – is further indication of the need to address adherence issues and to do so by providing patients with treatments that are rapidly effective, very safe and easy to use.

The finding of low adherence in the standard-of-care group and the decrease in adherence over time has critical implications for the management of patients with chronic skin diseases. We can anticipate that much better disease control could be obtained if we could help patients use their treatments better. The findings highlight the need for physicians to go beyond making the correct diagnosis and prescribing the correct treatment; interventions that improve use of the recommended treatment are critically important, too. Many approaches have been proposed to improve patients' adherence to treatment. These include strengthening the physician–patient relationship, choosing treatments patients are willing to use, giving written instructions, providing detailed education and scheduling follow-up, among a host of others.[14] These interventions need to be tested for both their immediate effect and for their effects on long-term adherence.

While major efforts continue to be made to create marginally better psoriasis treatments, the development of tools to improve adherence to the treatments we already have may be a more effective and lower-cost way to improve the disease. The long-term adherence findings in this study also support the notion that long-term treatment failure – the phenomenon termed 'tachyphylaxis' – is likely a manifestation of adherence behaviours.

One of the ways to address the challenge of adherence is to create accountability to the treatment regimen. Scheduling a follow-up visit just a few days after a medication is prescribed improves adherence but may not be practical in clinical practice.[15,16] Using web- or other electronic-based reporting instead of an office visit may be a more convenient, time-saving and less costly way of encouraging patients to fill their medication promptly and to use it well, at least in the short term.[17,18] Our intervention had a large effect on adherence over the first month, but this effect attenuated over time; the effects of electronic interventions often attenuate over time.[19]

Interventions may be effective in the short run, but psoriasis is a long-term disease. Improving adherence in the short run could have long-term benefits by getting patients into the habit of using the medication and by improved early outcomes, which would make clear to the patient the treatment is effective, encouraging long-term use as needed. Patients in the intervention group had better adherence in the first month of study, experienced greater improvement in their PASI score compared with the control group, and had numerically better adherence until month 10 of the study. Our power to assess changes through the last 2 months of the study was severely limited by the small size of our study and study dropouts. Moreover, a hurdle in adherence research is that good adherence that improves disease initially can be associated with lower adherence at later times (because with improvement in the skin condition, there is less perceived need to continue treatment). A limitation of this study is that we did not have a continuous measure of disease severity and cannot fully assess how much any changes in disease severity affected subjects' use of the medication.

While we did observe greater improvements in PASI scores with the intervention, there was no statistically significant difference between the control and intervention groups for the less-sensitive IGA score, and almost no one in either group achieved 'success' as measured by clear or almost clear disease. Fluocinonide alone is not the most effective topical psoriasis treatment, although, despite still having psoriasis, almost no one used the medication well enough to find out how effective it could be, particularly not in the standard-of-care group. Getting patients to use topical treatment for long-term management of a chronic illness is a very difficult proposition. In addition to new drugs with mechanisms of action or delivery approaches that make it easier to treat the disease, new interventions to promote adherence are needed. In addition to being skilled in making the right diagnosis and prescribing the right treatments, dermatologists need to be expert in using the available approaches that facilitate patients' use of their treatment.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....