Clinical Investigation
Inadequate Therapy Behavior Is Associated to Disease Flares in Patients With Rheumatoid Arthritis Who Have Achieved Remission With Disease-Modifying Antirheumatic Drugs

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Abstract

Objectives

(1) To determine 6-month follow-up adherence and persistence with disease-modifying antirheumatic drugs in patients with early rheumatoid arthritis with disease under control. (2) To compare disease flares across adherent, nonadherent, persistent and nonpersistent patients. (3) To identify differences in adherent and persistent rates among therapeutic regimens. (4) To identify baseline prognosticators of poor compliance.

Methods

Ninety-three patients (86% female) had 4 consecutive 2-month apart evaluations during which the 28-joint disease activity score and the Health Assessment Questionnaire were scored, comorbidities and treatment recorded and a compliance questionnaire and a drug record registry applied. Descriptive statistics, Student t and χ2 tests and logistic regression analysis were used.

Results

At the study entry, patients had mean ± standard deviation age of 40.8 ± 13.9 years, the 28-joint disease activity score of 2.1 ± 1.1, the Health Assessment Questionnaire of 0.09 ± 0.2, and 68 of them (73.1%) had remission. During follow-up, 47 patients (50.5%) were adherent and 51 (54.8%) persistent; 14 of 68 patients (20.6%) who achieved remission had a disease flare. Incidence rate and individual risk of a disease flare were significantly greater in nonadherent and nonpersistent patients. Compared with methotrexate monotherapy, therapeutic regimens with >3 disease-modifying antirheumatic drugs had increased risk of nonadherence and nonpersistence (P ≤ 0.02). Higher previous serial erythrocyte sedimentation rate was associated to nonadherence (as was a shorter follow-up at the Clinic) and to nonpersistence (odds ratio: 1.03; 95% confidence interval: 1.01–1.05 for both, P = 0.05 and P = 0.001, respectively).

Conclusions

Therapy behavior of patients with rheumatoid arthritis with mild/no disease activity and disability was poor and translated into disease flares. Higher serologic activity was associated to poor compliance with therapy.

Section snippets

Setting and Study Population: The Early Arthritis Clinic (February 2004 to Till Date)

All the patients (n = 96) currently attending up to September 2007 the Early Arthritis Clinic of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador-Zubirán, a referral centre for Rheumatic Diseases in México City, and receiving DMARDs (n = 94) were invited to participate. One patient denied. Patients had disease duration of less than a year when first evaluated at the Clinic and no specific rheumatic diagnosis but with RA. Patients were evaluated by the same rheumatologist every 2 

Adherence and Persistence With Therapy Over Study Follow-Up

The 93 patients enrolled had mean ± standard deviation (SD) follow-up at the Clinic of 25 ± 12.2 months and neither disease activity nor disability. At study entry, their mean ± SD DAS28 was of 2.1 ± 1.1, HAQ of 0.09 ± 0.22, ESR of 14.2 ± 13 mm/hr and C-reactive protein of 0.54 ± 0.82 mg/dL. All the patients were receiving DMARDs, 2 patients (2.15%) were receiving tumor necrosis factor α antagonists and 26 patients (28%) were receiving corticosteroids.

The whole population completed study

DISCUSSION

The study was prospectively developed in a cohort of patients with early RA who had achieved reasonable disease control after intensive treatment with DMARDs. Adherence and persistence with therapy were defined and measured separately as 2 different constructs6., 31. during a 6-month period, and their impact on disease flares was analyzed.

A substantial proportion of our patients did not take their medication as directed, and adherence and persistence progressively decreased over follow-up.

REFERENCES (40)

  • CramerJ.A.

    Partial medication compliance: the enigma in poor medical outcomes

    Am J Manag Care

    (1995)
  • de KlerkE. et al.

    Patient compliance in rheumatoid arthritis, polymyalgia rheumatica, and gout

    J Rheumatol

    (2003)
  • DeyoR.A. et al.

    Noncompliance with arthritis drugs: magnitude, correlates, and clinical implications

    J Rheumatol

    (1981)
  • TuncayR. et al.

    Factors affecting drug treatment compliance in patients with rheumatoid arthritis

    Rheumatol Int

    (2007)
  • García-GonzálezA. et al.

    Treatment adherence in patients with rheumatoid arthritis and systemic lupus erythematosus

    Clin Rheumatol

    (2008)
  • LorishC.D. et al.

    Missed medication doses in rheumatic arthritis patients: intentional and unintentional reasons

    Arthritis Care Res

    (1989)
  • LorishC.D. et al.

    Perspective of the patient with rheumatoid arthritis on issues related to missed medication

    Arthritis Care Res

    (1990)
  • VillerF. et al.

    Compliance to drug treatment of patients with rheumatoid arthritis: a 3 year longitudinal study

    J Rheumatol

    (1999)
  • VillerF. et al.

    Compliance with drug therapy in rheumatoid arthritis. A longitudinal European study

    Joint Bone Spine

    (2000)
  • GrijalvaC.G. et al.

    Assessment of adherence to and persistence on disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis

    Med Care

    (2007)

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