Adherence in multiple sclerosis: Neurologist s view

Transcription

1 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

2 Adherence

3 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)

4 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)

5 The definition Downloaded from:

6 The definition

7 Outline Non-adherence to treatment in Multiple Sclerosis 1. The magnitude 2. Factors related with non-adherence 3. The consequences 4. Key points

8 The magnitude

9 The magnitude

10 The magnitude 14% Relapsing Remitting MS 23% Secondary Progressive MS

11 The magnitude

12 The magnitude Yeaw et al., J Manag Care Pharm 2009

13 The magnitude

14 The magnitude Authors n* Follow-up Stopping** Portaccio et al. 225 / -- 50mo (5%) / 45% Río et al. 488 / mo 17% / (22%) O Rourke et al. 246 / mo 28% / -- Mohr et al. -- / mo 7.35% / -- Clerico et al. 162 / % Tremlett et al mo (13%) / 33% * Relapsing-Remitting / Secondary Progressive ** Stoppers / Stoppers plus switchers

15 The magnitude From:

16 The magnitude Blaschke, Osterberg, Vrijens, Urquhart, Ann Rev Pharmacol Toxicol 2012

17 Devonshire et al., Eur J Neurol 2011

18 Devonshire et al., Eur J Neurol 2011

19 The magnitude Adherence defined as MPR 80%

20 The magnitude Adherence: 79.2% (never forgot to take an injection in the last four weeks) Fernandez et al., PLOS ONE 2012

21 The magnitude

22 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

23 Factors related with non-adherence

24 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

25 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 / mo 17% / (22%) 9% 2.7% 5.3% O Rourke et al. 246 / mo 28% / % 14.2% 0% Mohr et al. -- / mo 7.35% / Clerico et al. 162 / % 12% 3% 4% Tremlett et al mo (13%) / 33% 10% 17% 6% * Relapsing-Remitting / Secondary Progressive ** Stoppers / Stoppers plus switchers

26 Factors related with non-adherence 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 Mohr et al., Mult Scler 1999

27 The consequences

28 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.: CD DOI: / CD pub3.

29 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.)

30 The consequences

31 Key points

32 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 / mo 17% / (22%) 9% 2.7% 5.3% O Rourke et al. 246 / mo 28% / % 14.2% 0% Mohr et al. -- / mo 7.35% / Clerico et al. 162 / % 12% 3% 4% Tremlett et al mo (13%) / 33% 10% 17% 6% * Relapsing-Remitting / Secondary Progressive ** Stoppers / Stoppers plus switchers

33 Manage expectacions 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

34 Manage expectations: efficacy 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

35 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 / mo 17% / (22%) 9% 2.7% 5.3% O Rourke et al. 246 / mo 28% / % 14.2% 0% Mohr et al. -- / mo 7.35% / Clerico et al. 162 / % 12% 3% 4% Tremlett et al mo (13%) / 33% 10% 17% 6% * Relapsing-Remitting / Secondary Progressive ** Stoppers / Stoppers plus switchers

36 Manage side effects

37 Manage side effects 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 Cohen BA. Int J Clin Pract 2007:

38 Manage side effects Co-medication to reduce flu-like symptoms.

39 Manage side effects MS Nurse Team at Cemcat, Barcelona

40 Manage side effects and expectations TEAMWORK Clinical Neuroimmunology Unit Neurorehabilitation Unit

41 Understanding patients needs 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

42 Respect for their choice

43 Respect for their choice

44 Take home

45 Some words from WHO 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

46 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

47 UNeR 2008 UNiC 2010 CARM 2010

48 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