Lessons on Non-adherence Save

Dr. Nathalie Costedoat-Chalumeau gave an interesting lecture on non-adherence as part of the difficult to treat lupus sessions. She distinguished two patterns of nonadherence, most commonly of which is associated with frequently missed medications while severe nonadherence refers to the complete interruption or erratic intake of tablets. 

She emphasized that non-adherence can be diagnosed by asking a patient about their medication intake or measuring hydroxychloroquine levels. According to Dr. Costedoat-Chalumeau, clinicians should learn to listen and understand why a patient becomes non-adherent. This way, communication becomes more open and engaging and opportunities for more individualized management can be made. 

In relation to medication adherence, the group of Dr. Sun et al. from Duke University presented abstract POS0692 during one of the poster sessions entitled, “Lupus patients with concurrent inflammatory activity and symptom burdens have the lowest medication adherence and experience distinct adherence barriers.” They evaluated differences in self-reported medication adherence and reasons for nonadherence across Type 1 & 2 SLE classification groups, with a prespecified focus on comparing the Mixed Activity group to all other groups. 

Prior research from this group identified 2 SLE models (type 1 and 2) which classified patients into 4 phenotypes, namely: Minimal Activity (low Type 1 & Type 2), Type 1 Activity (high Type 1 & low Type 2), Type 2 Activity(low Type 1 & high Type 2), and Mixed Activity (high Type 1 & high Type 2). Based on their previous results, the mixed phenotype was associated most strongly with low hydroxychloroquine blood levels - a measure of non-adherence. 

This cross-sectional study used the Medication Adherence Self-Report Inventory (MASRI) to measure medication adherence. This tool, through a visual analog scale, estimates the proportion of medication taken in the past month. Meanwhile, adherence barriers were measured using the DOSE Nonadherence SLE questionnaire. Type 1 lupus activity was measured using the type 1 PGA and SLEDAI  while the Type 2 PGA and patient-reported Polysymptomatic Distress (PSD) scores measured Type 2 SLE  activity.

A total of 251 patients were included in the analysis. Twenty four percent (24%) of patients had Mixed Activity, defined as having concurrent high Type 1 (clinical SLEDAI ≥4, SLEDAI ≥6, active lupus nephritis, or Type 1 PGA ≥1) and high Type 2 activity (Type 2 PGA ≥1 or PSD ≥8). In addition, 28 (11%) had Type 1 Activity, and 67 (27%) with Type 2 Activity.

Nonadherence was reported in 30% particularly among those with mixed activity. After adjusting for age and race, results show that patients with the Mixed activity phenotype were significantly less likely to be adherent compared with Minimal activity (OR 0.44, p value 0.03). On the other hand, there was no significant difference noted between Type 1 and Type 2. In addition, compared with the other SLE phenotypes, patients with Mixed activity were more likely to report missing medication intake due to side effects (36% vs 7%, p=0.01), having a defeatist attitude (32% vs 9%, p=0.04), pill burden (32% vs 7%, p=0.03), concerns about possible side effects (27% vs 7%, p=0.04), have perceptions that medicines were ineffective (27% vs 2%, p=0.007), and depressive symptoms (23% vs. 0%, p=0.004).

What can we learn from Dr. Costedoat-Chalumeau and the above study? When patients come to the clinic, asking them about how they are doing isn’t enough. When symptoms persist despite appropriate treatment or patients not feeling good despite acceptable disease activity, always consider non-adherence as a potential reason.