Reasons for nonadherence and response to treatment in an adherence intervention trial for relapsing-remitting multiple sclerosis patients

Patient and Physician Perspectives of Treatment Burden in Multiple Sclerosis

The number of disease-modifying therapies (DMTs) approved for the treatment of multiple sclerosis (MS) has greatly increased in recent decades, leading to higher treatment complexity. DMTs can differ in mode and frequency of administration, benefit-risk profile, and associated costs. Patients with MS contend not only with the burden of their chronic disease but also with the treatment burden of their MS therapy. Adhering to dosing schedules and infusion appointments can be difficult for busy, working-age patients or those with limited access to transportation. Patients and healthcare professionals (HCPs) may have differing priorities, concerns, and preferences when selecting treatment, potentially affecting treatment satisfaction and, importantly, adherence. Additionally, patients face direct and indirect costs related to treatment. These factors can all contribute to a high treatment burden on patients, impacting their quality of life and potentially leading to worse patient outcomes. HCPs, patients, and caregivers must work together to alleviate treatment burden through effective communication, shared decision-making, appreciating each other's perspectives, and additional HCP support. Consideration of treatment burden into clinical guidelines is also warranted. In this review, we examine key factors impacting treatment burden for patients with MS, with a focus on the patient perspective as provided by our patient authors, and provide strategies to minimize treatment burden.

Peer support impact on therapeutic adherence in patients with multiple sclerosis: a mixed-methods pilot trial protocol

INTRODUCTION

Patient partnership is a key component of patient-centred care. One form of partnership is individual peer support, which can improve patients' quality of life and adherence to treatment. Patient with multiple sclerosis could benefit from this type of support, but such an intervention has not been explored in the literature.We propose in this article a pilot study protocol to assess the feasibility and acceptability of healthcare-integrated individual peer support, and the feasibility of a large-scale efficacy trial.

METHODS AND ANALYSIS

The PAIR-SEP study is a mixed-methods pilot clinical trial combining quantitative and qualitative approaches. Sixty patients with relapsing-remitting multiple sclerosis undergoing drug therapy from the Neurology centre of Nantes University Hospital (France) will be randomised on a 1:1 ratio to receive either usual care only or usual care combined with peer support (three individual sessions at 1, 3 and 5 months with a peer helper).We will evaluate clinical outcomes in preparation of the large-scale trial: therapeutic adherence 6 months after baseline, therapeutic compliance, quality of life, anxiety and depression, social support. All dimensions will be assessed using validated health questionnaires at baseline and at 6 months.Intervention's acceptability and feasibility will be evaluated using qualitative methods: undirected interviews with patients from the intervention group and separate focus-groups with the peer helpers the healthcare team.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the local ethics committee on 1 October 2022. This study was designed in collaboration with multiple sclerosis peer helpers.The trial findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05519553.

Using an Intervention Mapping Approach to Improve Adherence to Disease-Modifying Treatment in Multiple Sclerosis

BACKGROUND

Up to 50% of individuals with multiple sclerosis (MS) who are prescribed disease-modifying treatments (DMTs) do not take them as advised. Although many studies report on DMT adherence rate, few studies report on interventions involving individuals with MS. The current paper describes the development of an intervention aimed at improving adherence to DMTs among identified nonadherent individuals with MS.

METHODS

An intervention was developed using an Intervention Mapping approach, recommendations from reviews on medication adherence, and input from individuals with MS. Its content was determined by theories of health behavior (specifically, a perceptions and practicalities approach), empirical evidence collected among the specific target population (an observational "needs assessment" stage [n = 186]), and other studies.

RESULTS

A personalized intervention was tailored to the reasons for nonadherence, uncovered during the observational needs assessment stage, to be delivered sequentially by a neurologist and a psychologist. After the intervention objectives were identified, components of the intervention were set: psychoeducation and ways of coping with adverse effects; modification of unhelpful treatment beliefs (such modifications were found predictive of adherence in the observational phase of the study); improving confidence and self-efficacy; and developing strategies for remembering to take DMTs. These components were embedded within motivational interviewing.

CONCLUSIONS

Intervention Mapping was useful in developing an intervention grounded both in the theoretical approach of perceptions and practicalities and in empirical evidence from the literature and the target sample; concurrently, identifying determinants that the intervention did not address. The effectiveness of the intervention-which could potentially improve adherence among individuals with MS-needs to be examined.

Impact of adherence to disease modifying therapies on long-term clinical and economic outcomes in multiple sclerosis: A claims analysis of real-world data

BACKGROUND

Multiple sclerosis (MS) is a chronic neurodegenerative inflammatory disease that requires long-term commitment to treatment for optimal outcomes. A variety of disease-modifying therapies (DMTs) are now available that reduce relapses and delay disease progression in people with MS. However, adherence remains a significant issue, with a variety of mental, physical, and emotional factors contributing to non-adherence. In a large number of studies, non-adherence has been associated with worse clinical outcomes (relapses and disease severity), a higher economic burden, and loss of work productivity. However, many of these studies were short-term (1-2 years) or cross-sectional studies; thus, more data are needed on the long-term clinical and economic impacts of DMT non-adherence. The objective of this study was to determine the longer-term impact of adherence to DMTs on disease activity and healthcare resource utilization (HCRU) in people with MS. The study hypothesis was that non-adherence to DMTs would be associated long-term with worse clinical outcomes and a higher economic burden.

METHODS

A retrospective administrative claims analysis of the US MarketScan® Commercial database (2011-2017) in individuals (18-65 years) with MS (based on International Classification of Disease coding) was conducted. Adherence was classified by proportion of days covered (PDC) ≥0.8 and non-adherence by PDC <0.8; sensitivity analyses helped further categorize as moderately (PDC ≥0.6-<0.8) or highly (PDC <0.6) non-adherent. Cohorts were matched using propensity score matching. Time to first relapse, annualized relapse rate (ARR), time to use of assistive devices (cane/walker or wheelchair), and annual HCRU (inpatient, emergency room [ER], outpatient, and MRI visits and costs) were compared between cohorts.

RESULTS

10,248 MS cases were identified; 58% met adherence criteria, and 42% met non-adherence criteria. Mean follow-up from diagnosis or first DMT claim was 5.3 years. Adherent individuals had a longer time to first relapse (hazard ratio [HR] 0.83; 95% confidence interval [CI]: 0.77-0.90; p<0.0001), a lower ARR (0.13 vs. 0.18, respectively; rate ratio [RR] 0.75 [95% CI: 0.71-0.79]; p<0.0001), and longer lag times to cane/walker use (HR 0.79 [95% CI: 0.66-0.94]; p=0.0067) and wheelchair use (HR 0.68 [95% CI: 0.55-0.83]; p=0.0002) than non-adherent individuals. Adherent individuals had fewer annual inpatient and ER visits and lower total costs than those who were non-adherent (p<0.0001). Sensitivity analyses showed that differences in disease activity and HCRU were generally more pronounced between matched adherent and highly non-adherent pairs than between matched adherent and moderately non-adherent pairs.

CONCLUSION

Significant differences in MS disease activity and HCRU were observed based on adherence to DMTs. Our study underscores the negative impact of non-adherence to DMTs on long-term clinical and economic outcomes in MS.

Medication habits among persons with multiple sclerosis

BACKGROUND

Though habitual behavior is part of medication-taking behavior, studies of adherence to medication among persons with relapsing remitting multiple sclerosis (PwRRMS) have not prospectively examined habit in relation to disease-modifying treatments (DMTs).

OBJECTIVES

1. Examine habit dimensions - repetition, lack of awareness, and lack of control - across time and route of administration (oral vs. injectable). 2. Examine the association (prospective and cross sectional) of the dimension of repetition and the habit index with adherence and persistence in medication taking and to medication perceptions.

METHODS

PwMS (n = 140), in their first year of treatment with a DMT, were prospectively assessed at three time points: at baseline, 6 months later (Time 1), and 12 months later (Time 2). Clinical and demographic information were obtained in-person, as were patient-reported medication habits and medication perceptions. Adherence and persistence were assessed with a combination of self-reporting and retrospective review of medication claims.

RESULTS

Repeated measures analysis of variance (ANOVA), with dimension as the within-subject factor at each time point, indicated that the repetition dimensions at all points were significantly higher than lack of awareness and lack of control dimensions. Repeated measures ANOVA, with time as the within-subject factor and route of administration as between-subject factor, yielded a significant time effect in repetition and lack of awareness dimensions so that they increased across time but not in lack of control; administration route effects were found to be nonsignificant in all dimensions. Repetition at Time 1 was positively associated with patient-reported adherence at this time point (r_s = 0.33, p = 0.002) but this was not consistently found at other time points . Likewise, reported repetition at Time 1 was higher among PwRMS who persisted with their medication a year later than among those who did not persist. Perceptions of medication (concern, harm, and overtreatment) were significantly negatively associated with reported repetition.

CONCLUSIONS

Over time, PwRMS reported an increase in two habit dimensions, repetition and lack of awareness, in medication taking. No significant differences in habit by administration modality were found. The habit dimension of repetition was significantly associated with perceptions of medication, adherence, and prospectively predicted persistence. However, the low values obtained for lack of awareness and lack of control, compared with the higher levels of repetition, indicate that the habit is not well ingrained. Hence, intervention to target habit formation and maintenance, to be tailored to the individual, are a promising venue for enhancing medication adherence and improving disease outcomes.

Disease-modifying therapy prescription patterns in people with multiple sclerosis by age

Background

Disease-modifying therapies (DMTs) for multiple sclerosis (MS) are approved for their ability to reduce disease activity, namely clinical relapses and signal changes on magnetic resonance imaging (MRI). Disease activity appears age dependent. Thus, the greatest benefit would be expected in younger people with MS (PwMS) whereas benefits in the elderly are uncertain.

Methods

Real-world data were obtained from PwMS from the North American Research Committee on Multiple Sclerosis (NARCOMS) registry and the US Department of Veterans Affairs Multiple Sclerosis Surveillance Registry (MSSR).

Results

6948 PwMS were surveyed from NARCOMS, and the MSSR had 1719 participants. In younger adult PwMS 40-years old or less, 183 (61.4%) in NARCOMS and 179 (70.5%) in the MSSR were prescribed DMTs. Among PwMS over age 60, 1575 (40.1%) in NARCOMS and 239 (36.3%) in the MSSR were prescribed DMTs. More PwMS in the age group of 31-40 (p = 0.035) and 41-50 (p = 0.001) in the MSSR were using DMTs compared with PwMS of the same age groups in NARCOMS.

Conclusion

These findings suggest that DMTs are under-utilized in the younger population and continue to be commonly prescribed in the elderly. Broader access may explain the higher prescription rate of DMTs in US veterans.

Beliefs about medication as predictors of medication adherence in a prospective cohort study among persons with multiple sclerosis

BACKGROUND

Though adherence to disease-modifying therapies (DMTs) among persons with multiple sclerosis (PwMS) varies and is often below 80%, only few prospective studies on adherence examined predictors beyond demographic and clinical characteristics.

OBJECTIVES

Identify antecedents to adherence and persistence to DMT in a prospective design among PwMS.

METHODS

PwMS (n = 186) were prospectively assessed at three time points: baseline, 6 (Time 1) and 12 months later (Time 2). Clinical, demographic information and patient-reported medication beliefs, illness perceptions, medication habits, perceived health and affect were surveyed in-person. Adherence and persistence were assessed by a combination of self-reports and retrospective review of medication claims.

FINDINGS

PwMS were 69.9% (Time 1) and 71% (Time 2) adherent to their DMTs and 64.5.9% were persistent. Beliefs about Medications were consistently predictive at both time points (baseline to Time 1 and Time 1 to Time 2) of medication adherence and persistence whereas other perceptions were predictive in some analyses; clinical and demographic characteristics were mostly not predictive of adherence nor persistence. The prospective association of beliefs about medication with adherence held also in multivariate analyses (OR = 0.88, 95% CI 0.78-0.99, p = 0.029).

CONCLUSIONS

Adherence and persistence are predicted by medication beliefs of PwMS. As medication beliefs are modifiable, they should be assessed periodically and targeted as a focus of tailored interventions aimed to improve adherence and consequently health outcomes in PwMS.

REGISTRATION

Clinical trials registry # NCT02488343 , date: 06/08/2015.

Patient needs and preferences in relapsing-remitting multiple sclerosis: A systematic review

BACKGROUND

Considering the multiple treatments approved for multiple sclerosis (MS) by the Food and Drug Administration (FDA) and European Medicines Agency (EMA), determining a treatment strategy for patients with clinically isolated syndrome (CIS) and relapsing-remitting MS (RRMS) can be challenging. To date, an overview of the needs and preferences of patients at each treatment decision-making moment is lacking. Therefore, the aim of this systematic review is to examine the existing literature about the needs and preferences of patients with CIS and RRMS when making treatment decisions.

METHODS

A systematic search was done using Embase, Medline, PsychINFO, Web of Science and Google Scholar. Eligibility criteria included whether the article described a study of adults with CIS/RRMS and reported patient needs or preferences regarding first-line disease modifying treatment (DMT) decisions. Publications were categorized by treatment decision: initiation of first DMT (D1), DMT adherence/discontinuation (D2a/D2b), and switch to a second DMT (D3). A separate category was created for stated preference studies such as discrete choice experiment methods to examine the relative importance of different treatment attributes. Publications were compared to identify key factors.

RESULTS

The search yielded 2789 articles after removal of duplicates and 434 full-text publications were reviewed for eligibility. Twenty-four articles fulfilled all criteria: n = 5 (D1), n = 12 (D2a), n = 13 (D2b), and n = 3 (D3); six articles studied more than one treatment decision. The need for social support is important during D1. The most commonly reported reasons for adherence/discontinuation/switch included forgetfulness, side-effects, and injection-related reasons. Eight articles described preference studies; the most important DMT attributes were efficacy, mode and frequency of administration, and side-effect profile.

CONCLUSIONS

Understanding the needs and preferences of CIS/RRMS patients regarding DMT attributes and non-treatment related attributes are important to improve treatment decision-making and reduce non-adherence. Studies are needed to understand patient preferences upon treatment initiation. Furthermore, preference studies should include attributes based on the patient perspective.