Download Clinical Management and Adherence Issues in IBD

Clinical Management
and Adherence Issues
in IBD
Illness-Related Factors
Affecting Adherence in IBD

Severity, extent, duration of disease

Frequency, duration, intensity of flare-ups

Type and severity of complications

Patients with well-controlled disease and
few flares are most likely to discontinue
maintenance therapy
Treatment-Related Factors
Affecting Adherence in IBD

Convenience
– Dosage/dosing
regimen
– Formulation
– Method of
administration
– Pill size

Cost/reimbursement

Choice of medication
– Sulfasalazine, corticosteroids
• Need to balance efficacy
vs safety
• Start with low doses, titrate
slowly upward
– Mesalamine
• Dose-related efficacy but
not toxicity
• Initiate and maintain
treatment with high doses
• Induction dose =
maintenance dose
Patient-Related Factors
Affecting Adherence
1Martin

Inadequate education1; inadequate skills/knowledge
to follow regimen2

Patients’ main concerns
– Uncertain nature of IBD
– Effects of medications3

Patients’ belief systems (treatment will not help,
side effects outweigh benefits)2

Psychiatric disorders4

Male, unmarried, younger age5,6

Patterns of nonadherence7
A, et al. Ital J Gastroenterol. 1992;24:477-480. 2Levy RL, Field AD. Am J Gastroenterol. 1999;94:1733-1742.
3Drossman DA, et al. Psychosom Med. 1991;53:701-712. 4Nigro G, et al. J Clin Gastroenterol. 2001;32:66-68.
5Kane S. Am J Gastroenterol. 2001;96:2929-2932. 6Kane S. Am J Gastroenterol. 2001;96(suppl):S296. 7Kane S. In:
Bayless TM, Hanauer SB, eds. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: BC Decker,
2001:9-11.
Prevalence of Nonadherence
to IBD Maintenance Therapy
1Blackwell

Failure to take medication by patients with
other illnesses: 25%–50%1

41% of patients on maintenance sulfasalazine
do not take prescribed dosages2

Clinical research protocols overestimate
drug adherence
B. Clin Pharmacol Ther. 1972;13:841-848. 2van Hees PAM, van Tongeren JHM. J Clin Gastroenterol.
1982;4:333-336.
Impact of Nonadherence
on Outcomes in IBD
% of Patients With
Quiescent UC Remaining
in Remission
100
90
Adherent to
5-ASA therapy
(Asacol®)
80
70
60
Nonadherent to
5-ASA therapy*
(Asacol®)
50
40
30
20
10
0
0
5
10
15
20
25
30
Time (months)
*P=.001.
Adapted with permission from Am J Med., Vol 114, Kane S, Huo D, Aikens J, Hanauer S. Medication
nonadherence and the outcomes of patients with quiescent ulcerative colitis, pages 39-43, Copyright 2003 with
permission from Excerpta Medica.
Strategies for Optimizing
Patient Adherence

IBD is a chronic, lifelong illness

Induce then maintain remission

Reciprocal patient:clinician relationship

Educate patient and family

Individualize therapy/simplify regimen

Promote emotional/psychological support

Obtain patient’s commitment to
therapeutic objectives
Guided Self-Management
in UC
Intervention Group
n=101

Personalized, guided
self-management regimen

Single 15-30-minute session
– Relapse recognition
– Treatment protocols

Patients given written protocols

Copy to primary MDs
Robinson A, et al. Lancet. 2001;358:976-981.
Control Group
n=102

Routine treatment
and follow-up
Relapses Are Treated Earlier
in Self-Managed Patients
Proportion Untreated (%)
100
90
80
70
60
Control
group
50
40
30
20
Intervention
group
10
0
0
2
4
6
Time (days)
Reprinted with permission from Elsevier (The Lancet. 2001;358:976-981).
8
10
12
Patient Self-Management

Trends in self-management group (vs controls)
– Fewer relapses (1.53 vs 1.93; P=NS)
– Shorter duration of relapse if treated in first
24 h (17.7±17.1 d vs 25.5±37.4 d; P=.16)
– 82% preferred self-management
– 95% of controls said they were adopting
self-management
Robinson A, et al. Lancet. 2001;358:976-981.