Nearly One-Third of Patients Didn’t Closely Follow Treatment Regimens
A recent VA study found that 31% of MS patients in the VA system had suboptimal medication adherence. That can especially be an issue for relapsing forms of the disease, which affect 85% of MS patients, because there could be times of partial or complete remission when symptoms are reduced or absent.
Researchers note that recent exacerbations tended to increase adherence, although failing to regularly use disease modifying treatment has been associated with more relapses and exacerbations, a greater likelihood of disease progression and a poorer quality of life.
WEST HAVEN, CT — Just as there are many presentations of multiple sclerosis with myriad symptoms, patients have a range of reasons for failing to adhere to their treatment plans.
The degenerative nature of the disease makes medication nonadherence particularly problematic, and VA is engaged in a number of ways to help patients stick as close as possible to their regimen.
Poorer adherence to an MS treatment regimen has been associated with more relapses and exacerbations, a greater likelihood of disease progression and a poorer quality of life. Not only do patients who fail to adhere to treatment have more disability and a greater impact of the disease on their lives, but healthcare systems also bear higher costs related to increased emergency care and hospital visits.
A VA study published recently in the Archives of Physical Medicine and Rehabilitation looking at MS patients in the VA system found that 31% had suboptimal medication adherence. A team led by VA Connecticut Healthcare System, West Haven, researchers determined that fewer than 70% refilled their medications at least 80% of the time over a two-year span. The risk factors for nonadherence among the 2,939 veterans studied included missed appointments, traumatic brain injury and mood disorders, among others. The study concluded that person-specific interventions are sorely needed for VA’s MS patient population.1
The researchers suggested that patients experienced barriers preventing them from adhering strictly to a disease modifying therapy. Depression and anxiety—both common in MS patients—can cause medication lapses. Treating those conditions has been found to improve adherence. Side effects can be a barrier early in the course of a DMT and can contribute to poor adherence or even discontinuation of treatment.
One particularly troublesome barrier is that the benefits of a medication may not be immediately apparent, causing patients to underestimate its use.
“A DMT’s benefits are not always immediately apparent,” the researchers explained. “They reduce the likelihood of a bad thing happening in the future but provide little immediate and tangible benefit. As a result, patient perceptions of effectiveness are associated with adherence. People take medications when they think they are helpful and don’t when they do not.”
Somewhat paradoxically, the presence of recent exacerbations were associated with better adherence. The researchers hypothesize that the exacerbations act as a reminder to the patient of the dangers of the disease and cause them to adhere more strongly to their treatment.
For patients with relapsing forms of MS, which is the initial diagnosis for about 85% of patients, relapses or exacerbations—clearly defined attacks of new or increasing neurologic symptoms are followed by periods of partial or complete remission. During remissions, all symptoms might disappear, which can exacerbate problems with adherence. On the other hand, analysis of some studies for oral medications has indicated they can significantly reduce risk of relapse, although no treatment eliminates it.
There also is a patient’s general pattern of self-care to consider when tallying treatment barriers. Patients who are more likely to miss medical appointments in general were found to also have more nonadherence, according to the report.
And the type and quantity of the drugs themselves can provide barriers. Medications that require more doses were associated with less adherence, either due to forgetting to take them or dosing fatigue. In general, VA has found self-injected medications to have the poorest adherence—a finding mirrored outside VA, as well. Injection anxiety, researchers have found, can be a very strong, specific barrier to patients taking a medication. At the start of the study, most patients, 95.27%, were on an injectable, disease-modifying therapy, but by the end of the study the percentage on injectable DMTs dropped to 81.11%, with an increasing number using or transitioning to oral medications, the researchers noted.
Improving Adherence
VA has engaged in several studies examining ways to improve MS medication adherence. In a small trial conducted by VA’s MS Centers of Excellence, brief in-person counseling was used to help remind patients of their own perceptions of the benefits of medication. This was combined with telephone support. The combination was found to increase adherence over time. This intervention was considered particularly useful, since the interventions were brief, could be delivered to a veteran anywhere over the phone, and could be tailored to the individual patient.
Another VA study examined what forms of screening could be used to identify patients who would have difficulties adhering to MS medications. The best predictor for adherence was a single, simple question: “How confident are you that you will be taking your prescribed DMT one month from now?”
Most of VA’s interventions seeking to improve adherence are similarly simple. They include regular reminders from nurses and pharmacy staff. The integrated VA system, which allows all providers to see if and when a patient refills their medication, makes it clear when a patient might not be adhering to treatment. Smart phone apps for improving MS medication adherence have also had some limited success.
What medications a patient is prescribed at the start can also have a big impact on whether they take them regularly.
“Initial selection of the medication that best fits each individual’s goals and the understanding of their side effects is essential,” explained officials from the VA MS Centers of Excellence. “Ongoing communication about the frequency of missed doses, encouragement, and reassessment of long-term goals and benefits is also critical.”
Sticking to treatment regimens can have an effect on now long MS patients survive. In a previous interview with U.S. Medicine, Mitchell Wallin, MD, MPH, director of the MS Center of Excellence-East, based in Washington, DC, and associate professor of neurology at George Washington University and the University of Maryland School of Medicine, pointed out that “people are living longer across the board,” adding, “You can see that in the mortality data; the average age of the MS population has gone up.”
Asked why, he responded that the improvement in mortality rates can be “attributed some to new medicines, but we’re also treating infection better and increasing mobility.”
- Gromisch ES, Turner AP, Leipertz SL, Beauvais J, Haselkorn JK. Risk Factors for Suboptimal Medication Adherence in Persons With Multiple Sclerosis: Development of an Electronic Health Record-Based Explanatory Model for Disease-Modifying Therapy Use. Arch Phys Med Rehabil. 2020;101(5):807‐814. doi:10.1016/j.apmr.2019.11.005