Adherence Issues in IBD

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Adherence Issues in IBD

• Sunanda Kane MD MSPH
• Professor of Medicine
• Mayo Clinic Rochester

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Topics for Discussion

• Thoughts in this new era of practice
• Data from primary care
• Data on oral IBD meds
• Data on biologics (anti-TNF)
• Data on non-therapeutic areas

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Perspective
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Evidence ? Practice

Glasziou and Haynes ACP JC 2005
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Where Are We?

• Educational intervention (1)
• Behavioral intervention (2)
• Cognitive behavioral intervention (1)
• Altering thinking as well as other behaviors
• Multi-component interventions (6)
• None have been shown to increase adherence gt 6
  months

Greenley R. Inflamm Bowel Dis 2013 191534-1545
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Primary Non-adherence with Prescriptions in
Primary Care

• Canadian primary care network of 15,961
• Primary non-adherence not filling an incident
  prescription within 9 months
• 31.3 of 37,506 prescriptions not filled
• Upper quartile of cost, those for dermatologic,
  gastrointestinal and autonomic conditions less
  likely to be filled compared with antibiotics
• Older age, co-pay coverage and more visits with
  MD protective of non-adherence

Tamblyn R. Ann Intern Med 2014 160441-450.
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Appearance Does Matter

• UnitedHealth database queried for medication use
  following MI
• 4573 single episodes of non-persistent medication
  use
• OR if pill color changed 1.34 (1.12-1.59)
• OR if pill shape changed 1.66 (1.43-1.94)
• These effects did not change even in multivariate
  analysis

Kesselheim A et al. Ann Internal Med 2014
16196-103.
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Burden of Comedications

• Polypharmacy of growing concern in chronically
  ill for several reasons
• IBD pts from Thomson Reuters MarketScan databases
  compared to HC
• Narcotics 48 vs 34
• Non-narcotic analgesics 12.8 vs 8
• Antidepressants 28.3 vs 19.4
• Psychiatric meds 25.8 vs 16.7

Buckley J et al. Inflamm Bowel Dis 2013
19(13)2725-2736.
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Attitudes to Mesalamine Questionnaire

• Validation study of survey to predict
  non-adherence to mesalamine for UC
• Responses correlated with MMAS-8, MPR at 12 mo
  and urine levels of salicylates
• Patient belief in importance of maintenance when
  in remission and concerns about side effects were
  the 2 items that correlated best with all metrics
• Could be easily administered in clinic

Moss A. Am J Gastroenterol 2014 Jun Epub ahead
of print
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Systematic Review of Adherence to Anti-TNF Therapy

• 13 studies identified 93,998 patients
• Pooled adherence 82.6 (range 37-96)
• Overall 83 for ADA
• Overall 71 IFX
• Pts with CD gt UC for either therapy
• Most reliable predictor of non-adherence was
  female gender, followed by smoking and
  psychological disease

Lopez A. Inflamm Bowel Dis 2013 191528-1533.
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Strategies to Reduce Costs Associated with
Biologic Use

• Eliminate Episodic Dosing
• Accurately Determine Indication for Escalating
  Dose
• Shorten Infusion Times
• What Still Needs to be Worked Out
• SQ really cheaper?
• Combination therapy
• Monitoring drug levels
• Do we really need complete mucosal healing?

Park K. Inflamm Bowel Dis 2014 20(5)946-51.
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Self Efficacy Survey

• SE beliefs have significant effect on how a
  person will persist in performing a task over
  time, how much effort a person will expend and
  how engaged the persons coping behavior when a
  skill is mastered
• Cannot do at all to Highly certain I can do
• 20-item survey for surveillance colonoscopy
• Refined survey 11 items, then 8
• Adherence correlated well with all 3 surveys,
  accuracy was 74

Friedman S. Inflamm Bowel Dis 2014 201602-1610.
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• Accept the news its time for procedure
• Schedule procedure
• Take the prep
• Tolerate the prep
• Avoid eating solid foods prior
• Drink enough clear fluids
• Recover from side effects
• Enjoy the rest of the day after procedure

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Adherence and Efficacy of DEXA Screening for IBD

• Nationwide VA population those exposed to
  steroids with IBD
• Of 5736 patients, 1.4 had fragility fx
• Adherence to AGA guidelines was 23
• Those who had DEXA were half as likely to develop
  fragility fracture
• HR 0.5 (0.3-0.9)

Khan N. Am J Gastroenterol 2014 109572-78.
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Summary

• Non-adherence prevalent
• Still no good, reliable, cheap way to change
  long-term behavior
• Knowing this, take small frequent steps
• Not all meds have same issues
• Not all patients have same issues

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