Jaume Sastre-Garriga Unitat de Neuroimmunologia Clínica Centre d’ Esclerosi Múltiple de Catalunya – CEMCat Hospital Universitari Vall d’ Hebron, Barcelona Adherence in multiple sclerosis: Neurologist ’ s view
Jaume Sastre-Garriga
Unitat de Neuroimmunologia Clínica
Centre d’Esclerosi Múltiple de Catalunya – CEMCat
Hospital Universitari Vall d’Hebron, Barcelona
Adherence in multiple sclerosis: Neurologist’s view
Adherence
http://www.instablogsimages.com/images/2008/02/26/global-warming-myth_65.jpg
The definition
“...the extent to which a person’s behaviour –
taking medication, following a diet, and/or
executing lifestyle changes – corresponds with
agreed recommendations from a healthcare
provider.” (OMS –WHO)
http://www.who.int/chp/knowledge/publications/adherence_report/en/print.html
The definition
“... Strong emphasis was placed on the need to
differentiate adherence from compliance.
The main difference is that adherence requires
the patient’s agreement to the
recommendations..”
(OMS –WHO)
http://www.who.int/chp/knowledge/publications/adherence_report/en/print.html
The definition
Downloaded from: http://alignmap.com/2008/10/01/you-say-compliance-i-say-adherence-who-cares/
The definition
Outline
Non-adherence to treatment in Multiple Sclerosis
1. The magnitude
2. Factors related with non-adherence
3. The consequences
4. Key points
The magnitude
The magnitude
The magnitude
14% Relapsing Remitting MS
23% Secondary Progressive MS
The magnitude
The magnitude
Yeaw et al., J Manag Care Pharm 2009
The magnitude
The magnitude
Authors n* Follow-up Stopping**
Portaccio et al. 225 / -- 50mo (5%) / 45%
Río et al. 488 / 134 47mo 17% / (22%)
O’Rourke et al. 246 / 148 49mo 28% / --
Mohr et al. -- / 939 8.3mo 7.35% / --
Clerico et al. 162 / 31 -- 19%
Tremlett et al. 844 23mo (13%) / 33%
* Relapsing-Remitting / Secondary Progressive
** Stoppers / Stoppers plus switchers
The magnitude
From: http://www.acpm.org/?MedAdherTT_ClinRef
The magnitude
Blaschke, Osterberg, Vrijens, Urquhart, Ann Rev Pharmacol Toxicol 2012
Devonshire et al., Eur J Neurol 2011
Devonshire et al., Eur J Neurol 2011
The magnitude
Adherence defined as
MPR≥80%
Fernandez et al., PLOS ONE 2012
The magnitude
Adherence: 79.2%
(never forgot to take an injection in the last four weeks)
The magnitude
The magnitude
CONCLUSIONS
Up to 30% of patients discontinue Disease Modifying Drugs
This figure is lower in clinical trials and in patients with Relapsing Remitting Multiple Sclerosis compared to routine clinical practice and patients with Secondary Progressive Multiple Sclerosis
Discontinuation mostly occurs in the first two years, but lingers for at least to 8 years
In a further percentage of patients a switch to a different Disease Modifying Drug is needed
Factors related with non-adherence
Treatment discontinuation due to lack of efficacy may be prompted by the physician
This may actually not be considered as real lack of adherence
Physician-rated
lack of efficacy
Patient-perceived
lack of efficacy
Factors related with non-adherence
Factors related with non-adherence
Authors n* Follow-up Stopping** Reasons for stopping (% of n)
Lack of Efficacy Side effects Other
Portaccio et al. 225 / -- 50mo (5%) / 45% 28.9% 14.7% 2.2%
Río et al. 488 / 134 47mo 17% / (22%) 9% 2.7% 5.3%
O’Rourke et al. 246 / 148 49mo 28% / -- 13.8% 14.2% 0%
Mohr et al. -- / 939 8.3mo 7.35% / -- -- -- --
Clerico et al. 162 / 31 -- 19% 12% 3% 4%
Tremlett et al. 844 23mo (13%) / 33% 10% 17% 6%
* Relapsing-Remitting / Secondary Progressive
** Stoppers / Stoppers plus switchers
BETTER ADHERENCE WAS ACHIEVED
If sites were…
• …more empathetic
• …instilling a sense of purpose in the patient
• …promoting less formal relationships
If sites paid attention to…
• …patients’ emotional status
• …patients’ expectations of trial participation
Factors related with non-adherence
Mohr et al., Mult Scler 1999
The consequences
The consequences
“To the extent that treatment response is related to the dose and schedule of a therapy, non-adherence reduces treatment benefits and can bias assessment of the efficacy of treatments” Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000011. DOI: 10.1002/14651858.CD000011.pub3.
The consequences
“... Increasing the effectiveness of adherence
interventions may have a far greater impact on
the health of the population than any
improvement in specific medical treatments”..”
(Haynes RB. Interventions for helping patients to follow prescriptions for medications.
Cochrane Database of Systematic Reviews, 2001, Issue 1.)
http://www.who.int/chp/knowledge/publications/adherence_report/en/print.html
The consequences
Key points
Manage expectations: efficacy
Authors n* Follow-up Stopping** Reasons for stopping (% of n)
Lack of Efficacy Side effects Other
Portaccio et al. 225 / -- 50mo (5%) / 45% 28.9% 14.7% 2.2%
Río et al. 488 / 134 47mo 17% / (22%) 9% 2.7% 5.3%
O’Rourke et al. 246 / 148 49mo 28% / -- 13.8% 14.2% 0%
Mohr et al. -- / 939 8.3mo 7.35% / -- -- -- --
Clerico et al. 162 / 31 -- 19% 12% 3% 4%
Tremlett et al. 844 23mo (13%) / 33% 10% 17% 6%
* Relapsing-Remitting / Secondary Progressive
** Stoppers / Stoppers plus switchers
PREVENT MISPLACED EXPECTATIONS
Make sure patients know:
1. They may still suffer relapses
2. Disability will not improve
3. Symptoms will not improve
4. Side effects are not severe but frequent and unsettling
5. The best available way to manage side effects
Manage expectacions
PREVENT MISPLACED EXPECTATIONS
Before educational sessions
Unrealistically optimistic expectations are common
• Regarding attack rate reduction - 57% of patients
• Regarding functional improvement - 34% of patients
Mohr et al., Mult Scler 1996
Manage expectations: efficacy
Manage side effects
Authors n* Follow-up Stopping** Reasons for stopping (% of n)
Lack of Efficacy Side effects Other
Portaccio et al. 225 / -- 50mo (5%) / 45% 28.9% 14.7% 2.2%
Río et al. 488 / 134 47mo 17% / (22%) 9% 2.7% 5.3%
O’Rourke et al. 246 / 148 49mo 28% / -- 13.8% 14.2% 0%
Mohr et al. -- / 939 8.3mo 7.35% / -- -- -- --
Clerico et al. 162 / 31 -- 19% 12% 3% 4%
Tremlett et al. 844 23mo (13%) / 33% 10% 17% 6%
* Relapsing-Remitting / Secondary Progressive
** Stoppers / Stoppers plus switchers
Manage side effects
Cohen BA. Int J Clin Pract 2007:1922-30
Co-medication to reduce flu-like symptoms
Auto-injection devices to make self-injection easier
New formulations of interferons
Emphasis on induction training by skilled nurses
Ongoing reinforcement of adherence
Manage side effects
Co-medication to reduce flu-like symptoms.
Manage side effects
MS Nurse Team at Cemcat, Barcelona
Manage side effects
TEAMWORK
Manage side effects and expectations
Clinical Neuroimmunology Unit
Neurorehabilitation Unit
Doctors and patients don't agree: cross sectional study of patients' and doctors' perceptions and assessments of disability in multiple sclerosis. P M Rothwell, et al. BMJ 1997
Understanding patients needs
Respect for their choice
Respect for their choice
Take home
Some words from WHO
http://www.who.int/chp/knowledge/publications/adherence_report/en/print.html
Poor adherence to treatment of chronic diseases is a worldwide problem of striking magnitude
The impact of poor adherence grows as the burden of chronic disease grows worldwide
The consequences of poor adherence are poor health outcomes and increased health care costs
Improving adherence also enhances patients’ safety
Health systems must evolve to meet new challenges
Patients need to be supported, not blamed
Adherence is simultaneously influenced by several factors
Patient-tailored interventions are required
Adherence is a dynamic process that needs to be followed up
Health professionals need to be trained in adherence
Family, community and patients’ organizations: a key factor for success
A multidisciplinary approach towards adherence is needed
Many thanks to all of you for your kind attention
To all my colleagues at CEM-Cat
And specially to María Jesús Arévalo, Jordi Río & Xavier Montalban
UNiC 2010
UNeR 2008
CARM 2010
Jaume Sastre-Garriga
Unitat de Neuroimmunologia Clínica
Centre d’Esclerosi Múltiple de Catalunya – CEMCat
Hospital Universitari Vall d’Hebron, Barcelona
Adherence in multiple sclerosis: Neurologist’s view