Background Recent meta-analysis established that the efficacy of combination therapy with a biological agent is superior to methotrexate for remission (1). Moreover, superiority of combination of anti-TNFa (aTNF) + nbDMARDs over aTNF monotherapy has been demonstrated. Therefore, non-adherence to nbDMARDs prescribed in combination with biologic therapy (BT) may reduce the benefit obtained with these agents.
Objectives This study investigated both acquisition and adherence to nbDMARDs and BT in real life, in patients treated either in monotherapy (MONO) or in combination (COMBO).
Methods A panel of 1000 French representative (region – turnover – population) retail pharmacies were solicited to collect prescription information on nbDMARDs and/or BT from RA patients purchasing these drugs between Nov 16 - Dec 20, 2012. In France, delivery by pharmacies of RA BT is restricted to the following subcutaneous (SC) BT: etanercept, adalimumab, certolizumab pegol, golimumab and anakinra. A record sheet was systematically assessed during dispensation at pharmacies and each included RA patient was invited to complete a self-administered questionnaire (SAQ). Adherence to nbDMARDs and/or SC BT was assessed by the Morisky Medication Adherence Scale (2). Identification of independent risk factors for a decrease in adherence was performed by multivariate logistic regression analysis including the following covariates: age, gender, disease duration, self-administration, prescription duration, information given on therapy and quality of life (QoL).
Results Of the 1,050 included RA patients, 35% (n=367) received nbDMARDs in MONO, 27% (n=291) received SC BT in MONO, 23% (n=238) were treated in COMBO (SC n=226 and IV n=12) and 15% (n=154) received nbDMARDs with missing data regarding BT IV administration. The latter were excluded from further analyses. 55% (95%CI [42.6-55%]) of patients calling for SC BT (n=291/517), received it on MONO. Of the 628 filled-in SAQ which could be analysed for adherence, similar proportion of patients presenting medium/low adherence (2) to their nbDMARDs (26%, n=101/394) or their BT (27%, n=95/362) was observed, whether they were taken in MONO or COMBO. Patients on COMBO presented the same level of medium/low adherence to their nbDMARD (28%) and BT (19%). Predictive factors of medium/low adherence were identified only for the DMARD MONO population: poor QoL (P= 0.015 OR 5.31 95%CI [0,048-0,726]), information given on therapy by the pharmacist (P = 0.02 OR= 3.24 95%CI [1,201-8,754]). It should be noted that adherence may be overstated as the design of the herein study did not allow us to assess the first-fill failure rate.
Conclusions This study found that, in real world, 49% of RA patients are treated with SC BT and up to 55% received it as MONO. 28% of patients on COMBO had low adherence with nbDMARDs that may be responsible of suboptimal outcome. Better information on therapy may improve adherence.
Kurya B, Arkema EV, Byker VP, Keystone EC Ann Rheum Dis 2010,69:1298-304
Morisky DE, Green LW, Levine DM. Med Care 1986; 24:67-74.
Disclosure of Interest C. Deslandre Consultant for: Pfizer, Roche, J.-C. Balblanc Consultant for: Roche, Orthovisc, Paid instructor for: Pfizer, Genévrier, Wyeth, MSD, E. Desfleurs Employee of: Roche, J. Antheaume Employee of: Roche, P. Dieudé Grant/research support from: Roche, Pfizer, BMS, Consultant for: Roche, Pfizer, BMS