Don’t Underestimate the Role of Pharmacists: Your Patient Won’t

Why don’t patients always adhere to taking their biologics as prescribed? Paradoxically, one reason may be that the drugs don’t always work as well as expected.

For rheumatologists, the question has burning importance. The treatments can transform a patient’s life. And they’re expensive, so someone – the patient, the government, pharmaceutical company or the insurance company – is making a big investment.

Yet, around a quarter of patients with chronic inflammatory rheumatic diseases stop taking their medicines. For a new study published online February 15 in the Journal of Rheumatology, researchers at University Grenoble-Alpes in Grenoble, France, turned to the people with the most authority on the question:  the patients themselves.

“The idea was to question … the specific reason why people have problems with their treatments,” explains Benoît Allenet, PharmD., Ph.D., a professor of clinical pharmacy.

He and his colleagues posted a questionnaire on the internet and emailed the link to the three major French patient associations for rheumatoid arthritis, anklyosing spondylitis and all other types of chronic inflammatory rheumatic disease.  [[{"type":"media","view_mode":"media_crop","fid":"48195","attributes":{"alt":"©IakobchukViacheslav/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_3362364684430","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5746","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©IakobchukViacheslav/Shutterstock.com","typeof":"foaf:Image"}}]]

Patients responded from all over France. Out of 606, the researchers excluded 25 because they answered twice, gave inconsistent or inadequate data or were under 18 years of age.

Out of the remaining 581 patients, 60.4% had ankylosing spondylitis, 33.7% had rheumatoid arthritis and 5.2% had psoriatic arthritis, affecting 5.2%, with miscellaneous inflammatory rheumatic conditions making up the remainder.

Their mean age was 46. On average, the patients estimated their pain over the previous 8 days as 4.2 on a 0-10 visual analogue scale where 10 is the worst.

The patients reported taking a median of 2 biologics. The most common were etanercept, adalimumab and infliximab in that order.

Most of the patients administered their own biologics, and most reported having had side effects that had disrupted their daily activities. More than have reported using complementary or alternative medicine.

The survey showed that 14.8% of the patients had self-discontinued, meaning they made the decision to stop their biologic on their own. It includes those whose decision was later validated by a physician, but not those who discontinued because of an infection.

The most common reason, given by 38.4%, was “I felt better.” Another 28.6% blamed side effects, while 13.4% said the “treatment didn’t work,” 8.9% said “I was fed up” and 7.1% said “I was afraid about health effects,” and 3.6% gave a variety of other reasons.

The researchers found several other responses on the survey that correlated with self-discontinuation.

The first was a low level of pain. Among patients who discontinued medication, 63.9% rated their pain 4 or below on a 10-point scale, compared to 52.7% of patients who stayed on their medication, a difference that was statistically significant (P = 0.001) on multivariate analysis. “If people feel better they are more willing to stop their treatment,” Dr. Allenet said.

Self-administration is another factor, Dr. Allenet said. “I think some of the treatment failures you have are people who don’t take the drug in the correct way,” he said.

He speculates that people who come to the hospital for intravenous injections get more follow-up from healthcare workers. “It’s less expensive to put people on subcutaneous biologics,” he said. “But we may end up with greater expense because of the bad quality of follow-up.”

Other factors included having tried more than one biologic, negative beliefs about treatment and lack of perceived medical and social support.

Interestingly, although patients who self-discontinued sometimes gave side effects as the reason, they were no more likely to have side effects than the other patients. They were also not more likely to use complementary and alternative medicine in a multivariate analysis.

Given these findings, the researchers concluded that health care workers need to educate patients about the efficacy and side effects of biologics.

Pharmacists could play a key role in this process, Dr. Allenet said. Often his patients express fears that the drugs will cause cancer or some other side effect. He wonders how well his colleagues deal with the question.

In France at least, he thinks they may be better suited than doctors. “I always consider that the physicians are like the daddy for the patient and the patient doesn’t want to tell them the truth,” he said. “Usually they are more keen on talking to the mommy, and the pharmacist in France is more like the mommy.”

The findings might be different in another part of the world, Dr. Allenet said. “The big difference in France compared with the U.S and even Canada is that drugs are subsidized [more completely] by the government or private insurance,” he said. “So people are not aware of the cost.”

References:

Anne-Laure Betegnie, Aurélie Gauchet, et. al.

"Why Do Patients with Chronic Inflammatory Rheumatic Diseases Discontinue Their Biologics? An Assessment of Patients’ Adherence Using a Self-report Questionnaire,"

The Journal of Rheumatology.

 Published online before print February 15, 2016, doi: 10.3899/jrheum.150414