SPIN2019

Conference summaries


PSORIASI & ADHERENCE

How can we support optimal medication adherence?

Presented by: Rachael Thorneloe, MD
Centre for Behavioural Science & Applied Psychology, Sheffield Hallam University, South Yorkshire, UK
  • Non-adherence to treatment and medical recommendations is one of the leading causes of treatment failure, poor clinical outcomes, and increased healthcare utilization.
  • Although non-adherence is observed across all medical specialties, adherence to treatment in dermatology deserves special attention given the multiple different routes of treatment.
  • Medications do not work in people who do not take them.
  • Non-adherence is actually the norm, and across many chronic conditions around 50% of medications are not taken as prescribed.
  • Non-adherence can be intentional or un-intentional and these need to be differentiated because they are driven by different factors.
  • Psoriasis (PsO) is a complex systemic condition and is associated with high levels of psychological and social morbidity and impaired quality of life.
  • Comorbidities are also common, including PsO arthritic disease and increased cardiac risk.
  • When considering medication adherence, we need to consider it in the context of all these other challenges.
  • Topical therapies can be time-consuming [1].
  • Can stain clothing and bedding [1].
  • Patients are often unsure how much topical therapy to use, when to use it, and how often they should be using it [1].
  • Unpredictable flares can make patients uncertain whether topical therapies are managing symptoms [1].
  • Reported lack of support from clinicians [1].
  • Concerns about potential adverse effects [1].
    • Short-term effects (e.g. skin irritation) / Long-term effects (e.g. organ damage in biologics).
  • High levels of uncertainty [1].
    • Will my treatments stop working? / What will happen if they stop working?
  • Distress associated with therapy taking can influence adherence (33-78% of PsO patients do not use their therapy as prescribed) [2].
  • Adherence to treatment is a complex behaviour, especially for PsO and many patients report making strategic judgements about how they use topical therapies, even though not discussed with their clinician (both over and under-use).
  • Treatment overuse has important implications for drug side-effects.
  • The iMAP study surveyed 811 with moderate to severe PsO patients treated across 35 dermatology centres around England [3].
  • Non-adherence can occur with all drugs, and this study found rates of almost 30% for conventional systemic therapies and 16% for biologic therapies [3].
  • People who reported the strongest concerns about their systemic therapy were more likely to be classified as non-adherent, than those who reported weaker concerns and medication beliefs were not associated with unintentional non-adherence (e.g. forgetting) [3].
  • The most important, potentially modifiable, factors influencing adherence was found to be belief about PsO treatment and medicines in general and mood drive intentional non-adherence (see Figure 1).
  • People who reported weaker medication-taking habits/routines for taking their systemic therapy were more likely to be classified as non-adherent, than those who reported stronger habits/routines.

Think-feel-do cycle – Identify patterns in thoughts, feelings and behavior

  • This is the first step to understand and therefore change the ways in which we can help cope better with medications and adherence to a long-term therapy.
  • The loop can become a vicious cycle, see example Figure 2.
  • Physicians need to work with patients to identify unhelpful behaviour patterns that can occur in response to thoughts and feelings, it is an important step in supporting medication adherence.
  • People are often unaware of these patterns BUT when they are able to identify them, they can often intervene early to stop them.
  • Identifying these patterns can provide targets for behaviour change.

Maintaining new behaviour – Helping to develop good routines and habits.

  • Action planning – contextual cues (‘when, what, how will I know’ framework to aid habit formation), for example “I will take my tablets before I brush my teeth”
  • By tying the behaviour to a contextual cue, stress and demands of that behaviour are reduced and the behaviour becomes automatic and unconscious.

What question do I need to ask to identify non-adherence?

  • Most patients do not want to admit to non-adherence, so they need to know that it is common, and it is not their fault.
  • By opening up a discussion about their beliefs and concerns, an open and honest conversation can help.
  • Sometimes the nurse is more able to have the patient admit to non-adherence from the patient than a doctor.
  • Pharmacists could be used better to assist in medication adherence – and in the future it may be useful to train pharmacists in this role.


References

References


  1. 1. Thorneloe RJ, Bundy C, Griffiths CE, et al. Adherence to medication in patients with psoriasis: a systematic literature review. Br J Dermatol. 2013;168:20-31.
  2. 2. Thorneloe RJ, Bundy C, Griffiths CE, et al. Nonadherence to psoriasis medication as an outcome of limited coping resources and conflicting goals: findings from a qualitative interview study with people with psoriasis. Br J Dermatol. 2017;176:667-76.
  3. 3. Thorneloe RJ, Griffiths CEM, Emsley R, et al.; British Association of Dermatologists Biologic Interventions Register; Psoriasis Stratification to Optimise Relevant Therapy Study Groups. Intentional and unintentional medication non-adherence in psoriasis: The role of patients’ medication beliefs and habit strength. J Invest Dermatol. 2018;138:785-94.

Presenter disclosure(s): [none provided]

Written by: Johanna Chester, BA

Reviewed by: Martina Lambertini, MD


All report

Welcome to the SPIN 2019 Highlights

Jo Lambert, MD, PhD

With this collection of summaries from selected presentations at SPIN 2019, and interviews with international experts, we hope to share with you some of the highlights of this year’s congress. The international network met … [ Read all ]

SUMMARIES

ATOPIC DERMATITIS & PSORIASIS

Atopic dermatitis and psoriasis: On a spectrum?

Presented by: Emma Guttman-Yassky, MD, PhD

INFLAMMATORY SKIN DISEASES

PSORIASIS

Which drug for which patient?

Presented by: Emilie Sbidian, MD, PhD

PSORIASIS

Effects of biotherapy on vascular disease in psoriasis

Presented by: Nehal N. Mehta, MD, MSCE, FAHA

SYSTEMIC THERAPIES

Classical systemic therapies – Methotrexate

Presented by: Rolland Gyulai, MD, PhD, DSc

SMALL MOLECULES

Small molecules, apremilast, and beyond

Presented by: Richard G.B. Langley, MD

PSORIASIS

Treatment goals in psoriasis

Presented by: Ulrich Mrowietz, MD

PSORIASIS

Combined therapy in psoriasis

Presented by: Pablo Coto-Segura, MD, PhD

MEASURING OUTCOMES

PSORIASIS & ADHERENCE

How can we support optimal medication adherence?

Presented by: Rachael Thorneloe, MD