Importance of Adherence to and Persistence with Prescribed Treatments in Patients with Multiple Sclerosis

Importance of Adherence to and Persistence with Prescribed Treatments in Patients with Multiple Sclerosis

Bianca Weinstock-Guttman, Frederick E Munschauer
Published: US Neurology Review 2005
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Multiple sclerosis (MS) is a chronic, progressive disease of the central nervous system (CNS), characterized by cognitive dysfunction and increasing physical disability. The pathogenesis of MS is mediated by T-cells and other immune factors, including antibodies, complement, and mediators of the innate immune responses.1 Environmental triggers are thought to influence the onset of MS in genetically susceptible individuals.1

In the US, it has been estimated that MS affects 250,000 to 350,000 people, and more than one million people worldwide.2,3 MS is typically diagnosed during early adulthood, with a median onset age of 28.4 The early age of onset, the chronic nature of the disease, and the accumulation of physical disability contribute to devastating economic and personal burdens in patients with MS. Fifty per cent of patients with MS require an assistive walking device by 15 years from diagnosis, and 83% after 30 years.5,6

The current treatment of MS consists of lifelong disease and symptom management. Disease-modifying therapies (DMTs), including intramuscular (IM) interferon beta-1a (IFNß-1a), subcutaneous (SC) IFNß-1a, SC IFNß-1b, and glatiramer acetate, form the basis of treatment of relapsing MS. DMTs cannot cure MS; however, they can reduce the frequency and severity of relapses and resulting disability. Over two years, patients who receive DMTs can expect a 30% decrease in relapse rate 7–10 and those who receive IFNß may experience a slowing of sustained disability progression.7,9 In general, the IFNß products are equally effective in reducing disability in the shortterm; however, based on available data, glatiramer acetate does not affect disability and has a mild and delayed effect on disease parameters assessed by magnetic resonance imaging (MRI). Considering these therapeutic benefits, eligible patients should receive a DMT as soon as possible after a diagnosis of relapsing MS. Other treatments, such as corticosteroids and immunosuppressants, are used concomitantly with DMTs during stages of breakthrough or continued breakthrough disease.11,12

To achieve the maximum benefit from DMTs, patients with MS must adhere closely to their prescribed therapeutic regimen (adherence), and they must continue treatment throughout the course of the disease (persistency).As with other pharmacological treatments, DMTs cannot be effective in patients who do not adhere to them over a reasonable length of time.13 Promoting high levels of adherence and persistency should therefore be major aims of therapy. It is interesting to note that discontinuation rates within the first six months of treatment range from 9% to 20% in clinical practice,13,14 whereas rates reported during clinical trials of MS ranged from 7% to 15%.7,9,10 This difference may be partly due to the fact that patients in clinical trials receive a more intense follow-up than patients seen in clinical practices.

Treatment Barriers in Patients with MS
The first step toward improving adherence to DMTs is to gain a clear understanding of the complex and diverse patient-related, treatment-related, and disease-specific barriers to adherence.15,16 Special challenges associated with adherence in patients with MS include an unpredictable disease course,physical disability, feelings of hopelessness, and cognitive impairment. Furthermore, because DMTs do not produce immediate results, treatment adherence can be more challenging than adherence to a therapy that does produce immediate results (e.g. insulin for diabetes).

Patient-related treatment barriers vary among patients. The principal barriers include communication problems, knowledge deficits, physical impairment, social or cultural variables, financial concerns, emotional distress, psychological disorders, and cognitive deficits. For example, physical impairment may result in poor hand to eye coordination or tremor, which can be an obstacle to self-injection. Cognitive deficits may interfere with a person’s ability to understand treatment rationale, and emotional distress and depression are strong impediments to taking medications.17 Knowledge deficits can cause unrealistic treatment expectations. A study of patients beginning treatment with IFNß-1b reported that unrealistic expectations were highly predictive of treatment non-adherence.14

Other barriers of adherence to DMTs relate to the frequency of dosing, injection-related side effects, and other treatment-related side effects. The literature clearly shows that factors such as drug regimen complexity (e.g. frequent administration) and adverse effect intensity or frequency can have an unfavorable impact on adherence.18–22 Furthermore, administration of high-dose IFNß products may be associated with a higher rate of adverse events.

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