Self-reported non-adherence to antiretroviral therapy repeatedly assessed by two questions predicts treatment failure in virologically suppressed patients

BACKGROUND: The aim of this study was to explore the predictive value of longitudinal self-reported adherence data on viral rebound. METHODS: Individuals in the Swiss HIV Cohort Study on combined antiretroviral therapy (cART) with RNA <50 copies/ml over the previous 3 months and who were interviewed about adherence at least once prior to 1 March 2007 were eligible. Adherence was defined in terms of missed doses of cART (0, 1, 2 or >2) in the previous 28 days. Viral rebound was defined as RNA >500 copies/ml. Cox regression models with time-independent and -dependent covariates were used to evaluate time to viral rebound. RESULTS: A total of 2,664 individuals and 15,530 visits were included. Across all visits, missing doses were reported as follows: 1 dose 14.7%, 2 doses 5.1%, >2 doses 3.8% taking <95% of doses 4.5% and missing > or =2 consecutive doses 3.2%. In total, 308 (11.6%) patients experienced viral rebound. After controlling for confounding variables, self-reported non-adherence remained significantly associated with the rate of occurrence of viral rebound (compared with zero missed doses: 1 dose, hazard ratio [HR] 1.03, 95% confidence interval [CI] 0.72-1.48; 2 doses, HR 2.17, 95% CI 1.46-3.25; >2 doses, HR 3.66, 95% CI 2.50-5.34). Several variables significantly associated with an increased risk of viral rebound irrespective of adherence were identified: being on a protease inhibitor or triple nucleoside regimen (compared with a non-nucleoside reverse transcriptase inhibitor), >5 previous cART regimens, seeing a less-experienced physician, taking co-medication, and a shorter time virally suppressed. CONCLUSIONS: A simple self-report adherence questionnaire repeatedly administered provides a sensitive measure of non-adherence that predicts viral rebound.

Mean corpuscular volume as a marker for adherence to antiretroviral therapy among HIV infected children and adolescents in Uganda

Mean corpuscular volume, which is an inexpensive and widely available measure to assess, increases in HIV infected individuals receiving zidovudine and stavudine raising the hypothesis that it could be used as a surrogate for adherence.^ The aim of this study was to examine the association between mean corpuscular volume and adherence to antiretroviral therapy among HIV infected children and adolescents aged 0–19 years in Uganda as well as the extent to which changes in mean corpuscular volume predict adherence as determined by virologic suppression.^ The investigator retrospectively reviewed and analyzed secondary data of 158 HIV infected children and adolescents aged 0–19 years who initiated antiretroviral therapy under an observational cohort at the Baylor College of Medicine Children's Foundation - Uganda. Viral suppression was used as the gold standard for monitoring adherence and defined as viral load of < 400 copies/ml at 24 and 48 weeks. ^ Patients were at least 48 weeks on therapy, age 0.2–18.4 years, 54.4% female, 82.3% on zidovudine based regimen, 92% WHO stage III at initiation of therapy, median pre therapy MCV 80.6 fl (70.3–98.3 fl), median CD4% 10.2% (0.3%–28.0%), and mean pre therapy viral load 407,712.9 ± 270,413.9 copies/ml. For both 24 and 48 weeks of antiretroviral therapy, patients with viral suppression had a greater mean percentage change in mean corpuscular volume (15.1% ± 8.4 vs. 11.1% ± 7.8 and 2.3% ± 13.2 vs. -2.7% ± 10.5 respectively). The mean percentage change in mean corpuscular volume was greater in the first 24 weeks of therapy for patients with and without viral suppression (15.1% ± 8.4 vs. 2.3% ± 13.2 and 11.1% ± 7.8 vs. -2.7% ± 10.5 respectively). In the multivariate logistic regression model, percentage change in mean corpuscular volume ≥ 20% was significantly associated with viral suppression (adjusted OR 4.0; CI 1.2–13.3; p value 0.02). The ability of percentage changes in MCV to correctly identify children and adolescents with viral suppression was higher at a cut off of ≥ 20% (90.7%; sensitivity, 31.7%) than at ≥ 9% (82.9%; sensitivity, 78.9%). Negative predictive value was lower at ≥ 20% change (25%; specificity, 84.8%) than at ≥ 9% change (33.3%; specificity, 39.4%).^ Mean corpuscular volume is a useful marker of adherence among children and adolescents with viral suppression. ^

A prospective multicentre study of pharmacist initiated changes to drug therapy and patient management in acute care government funded hospitals

Aims To determine the cost savings of pharmacist initiated changes to hospitalized patients' drug therapy or management in eight major acute care government funded teaching hospitals in Australia. Methods This was a prospective study performed in eight hospitals examining resource implications of pharmacists' interventions assessed by an independent clinical panel. Pharmacists providing clinical services to inpatients recorded details of interventions, defined as any action that directly resulted in a change to patient management or therapy. An independent clinical review panel, convened at each participating centre, confirmed or rejected the clinical pharmacist's assessment of the impact on length of stay (LOS), readmission probability, medical procedures and laboratory monitoring and quantified the resultant changes, which were then costed. Results A total of 1399 interventions were documented. Eight hundred and thirty-five interventions impacted on drug costs alone. Five hundred and eleven interventions were evaluated by the independent panels with three quarters of these confirmed as having an impact on one or more of: length of stay, readmission probability, medical procedures or laboratory monitoring. There were 96 interventions deemed by the independent panels to have reduced LOS and 156 reduced the potential for readmission. The calculated savings was $263 221 for the eight hospitals during the period of the study. This included $150 307 for length of stay reduction, $111 848 for readmission reduction. Conclusions The annualized cost savings relating to length of stay, readmission, drugs, medical procedures and laboratory monitoring as a result of clinical pharmacist initiated changes to hospitalized patient management or therapy was $4 444 794 for eight major acute care government funded teaching hospitals in Australia.

Reasons for non-adherence to antiretroviral therapy:patients' perspectives provide evidence of multiple causes

The objective of the study was to define common reasons for non-adherence (NA) to highly active antiretroviral therapy (HAART) and the number of reasons reported by non-adherent individuals. A confidential questionnaire was administered to HIV-seropositive patients taking proteinase inhibitor based HAART. Median self-reported adherence was 95% (n = 178, range = 60-100%). The most frequent reasons for at least 'sometimes' missing a dose were eating a meal at the wrong time (38.2%), oversleeping (36.3%), forgetting (35.0%) and being in a social situation (30.5%). The mean number of reasons occurring at least 'sometimes' was 3.2; 20% of patients gave six or more reasons; those reporting the lowest adherence reported a significantly greater numbers of reasons (ρ = - 0.59; p < 0.001). Three factors were derived from the data by principal component analysis reflecting 'negative experiences of HAART', 'having a low priority for taking medication' and 'unintentionally missing doses', accounting for 53.8% of the variance. On multivariate analysis only the latter two factors were significantly related to NA (odds ratios 0.845 and 0.849, respectively). There was a wide spectrum of reasons for NA in our population. The number of reasons in an individual increased as adherence became less. A variety of modalities individualized for each patient are required to support patients with the lowest adherence.

Adherence to antiretroviral therapy and its determinants among persons living with HIV/AIDS in Bayelsa state, Nigeria

Background: A high level of adherence is required to achieve the desired outcomes of antiretroviral therapy. There is paucity of information about adherence to combined antiretroviral therapy in Bayelsa State of southern Nigeria. Objectives: The objectives of the study were to determine the level of adherence to combined antiretroviral therapy among the patients, evaluate the improvement in their immune status and identify reasons for sub-optimal adherence to therapy. Methods: The cross-sectional study involved administration of an adapted and pretested questionnaire to 601 consented patients attending the two tertiary health institutions in Bayesla State, Nigeria: The Federal Medical Centre, Yenagoa and the Niger-Delta University Teaching Hospital Okolobiri. The tool was divided into various sections such as socio-demographic data, HIV knowledge and adherence to combined antiretroviral therapy. Information on the patient's CD4+ T cells count was retrieved from their medical records. Adherence was assessed by asking patients to recall their intake of prescribed doses in the last fourteen days and subjects who had 95-100% of the prescribed antiretroviral drugs were considered adherent. Results: Three hundred and forty eight (57.9%) of the subjects were females and 253 (42.1%) were males. The majority of them, 557 (92.7%) have good knowledge of HIV and combined anti-retroviral therapy with a score of 70.0% and above. A larger proportion of the respondents, 441 (73.4%), had > 95% adherence. Some of the most important reasons giving for missing doses include, “simply forgot” 147 (24.5%), and “wanted to avoid the side-effects of drugs” 33(5.5%). There were remarkable improvements in the immune status of the subjects with an increment in the proportion of the subjects with CD4+ T cells count of greater than 350 cells/mm3 from 33 (5.5%) at therapy initiation to 338 (56.3%) at study period (p<0.0001). Conclusion: The adherence level of 73.4% was low which calls for intervention and improvement. The combined antiretroviral therapy has significantly improved the immune status of the majority of patients which must be sustained. “Simply forgot” was the most important reason for missing doses.

Methotrexate polyglutamates as a potential marker of adherence to long-term therapy in children with juvenile idiopathic arthritis and juvenile dermatomyositis:an observational, cross-sectional study

Introduction: Methotrexate (MTX) is a cornerstone of treatment in a wide variety of inflammatory conditions, including juvenile idiopathic arthritis (JIA) and juvenile dermatomyositis (JDM). However, owing to its narrow therapeutic index and the considerable interpatient variability in clinical response, monitoring of adherence to MTX is important. The present study demonstrates the feasibility of using methotrexate polyglutamates (MTXPGs) as a biomarker to measure adherence to MTX treatment in children with JIA and JDM. Methods: Data were collected prospectively from a cohort of 48 children (median age 11.5 years) who received oral or subcutaneous (SC) MTX therapy for JIA or JDM. Dried blood spot samples were obtained from children by finger pick at the clinic or via self- or parent-led sampling at home, and they were analysed to determine the variability in MTXPG concentrations and assess adherence to MTX therapy. Results: Wide fluctuations in MTXPG total concentrations (>2.0-fold variations) were found in 17 patients receiving stable weekly doses of MTX, which is indicative of nonadherence or partial adherence to MTX therapy. Age (P = 0.026) and route of administration (P = 0.005) were the most important predictors of nonadherence to MTX treatment. In addition, the study showed that MTX dose and route of administration were significantly associated with variations in the distribution of MTXPG subtypes. Higher doses and SC administration of MTX produced higher levels of total MTXPGs and selective accumulation of longer-chain MTXPGs (P < 0.001 and P < 0.0001, respectively). Conclusions: Nonadherence to MTX therapy is a significant problem in children with JIA and JDM. The present study suggests that patients with inadequate adherence and/or intolerance to oral MTX may benefit from SC administration of the drug. The clinical utility of MTXPG levels to monitor and optimise adherence to MTX in children has been demonstrated. Trial registration: ISRCTN Registry identifier: ISRCTN93945409. Registered 2 December 2011.

Drug therapy complexity: the importance of pharmacotherapeutic follow-up

Nowadays, the phenomenon of population ageing represents an worldwide problem, which assumes particular significance in Portugal. As they get older, individuals present more comorbidities and consequently consume an increasing number of drugs, which contributes to a growing drug therapy complexity. The institutionalized elders are particularly affected by this occurrence. Drug therapy complexity is defined as the conciliator of several characteristics of the pharmacotherapy and can affect patient’s safety and medication adherence. It can be measured with Medication Regimen Complexity Index (MRCI). This study aims to determine the drug therapy complexity of institutionalized elders in order to assess the need of pharmacotherapeutic follow-up.

Evaluation of factors affecting adherence to asthma controller therapy in chest clinics in a sub-Saharan African setting: a cross-sectional study

Background: Adherence to controller therapy in asthma is a major concern during the management of the disease. Objective: To determine the adherence rate and identify the predictors of low adherence to asthma controller therapy. Methods: A cross-sectional study including asthma patients was conducted from November 1, 2012 to May 31, 2013 in 4 chest clinics in Cameroon. The adherence to asthma treatment was rated using Morisky Medication Adherence Scale. A multivariate logistic regression analysis was performed for the identification of factors associated with adherence to asthma treatment. Results: Among the 201 asthma patients included, 133 (66.2%) were female. The mean age of participants was 41.2 years. Sixty-one (30.3%) of the patients did not visit the chest physician during the last year prior to the study. Asthma was well controlled in 118 patients (58.7%). The prevalence of low adherence rate to asthma controller therapy was 44.8% and the absence of any chest specialist visit within the last 12 months was the only factor associated with the low adherence rate to asthma treatment (OR 5.57 ; 95% CI 2.84–10.93). Conclusion: The adherence rate to asthma controller therapy in Cameroon is low and it could be improved if scheduled visits are respected by patients.

Factors associated with non-adherence to the treatment of vivax malaria in a rural community from the Brazilian Amazon Basin

Abstract: INTRODUCTION We investigated the association between demographic and behavioral factors and non-adherence to antimalarial therapy. METHODS A demographic questionnaire and 5-item self-reported questionnaire regarding non-adherence were completed by 135 patients after treatment for Plasmodium vivax. RESULTS Treatment interruption, but not demographic factors, was significantly associated with non-adherence to therapy. The likelihood of non-adherence was 5.16 times higher when the patients felt better than when they felt worse. The relative risk of parasitic resurgence was 3.04 times higher in non-adherent patients. CONCLUSIONS Treatment interruption is significantly associated with treatment adherence.

Patient adherence and the choice of antihypertensive drugs: focus on lercanidipine.

Despite the development of many effective antihypertensive drugs, target blood pressures are reached in only a minority of patients in clinical practice. Poor adherence to drug therapy and the occurrence of side effects are among the main reasons commonly reported by patients and physicians to explain the poor results of actual antihypertensive therapies. The development of new effective antihypertensive agents with an improved tolerability profile might help to partly overcome these problems. Lercanidipine is an effective dihydropyridine calcium channel blocker of the third generation characterized by a long half-life and its lipophylicity. In contrast to first-generation dihydropyridines, lercanidipine does not induce reflex tachycardia and induces peripheral edema with a lower incidence. Recent data suggest that in addition to lowering blood pressure, lercanidipine might have some renal protective properties. In this review we shall discuss the problems of drug adherence in the management of hypertension with a special emphasis on lercanidipine.

Medication reconciliation and adherence: a call for clinical pharmacist

Introduction and Objectives: With the population ageing, there is a growing number of people who have several comorbidities and make use of a variety of drugs. These factors lead to a greater predisposition to adverse drug events, as well as to medication errors. The clinical pharmacist is the most indicated health professional to target these issues. The aims of this study were to analyze the profile of medication reconciliation and assess the role of the clinical pharmacist regarding medication adherence. Material and Methods: Prospective observational cohort study conducted from Jan-Mar 2013 at the Surgical Clinic of the University Hospital of the University of Sao Paulo. 117 admitted patients - over the age of 18 years, under continuous medication use and with length of hospitalization up to 120h - were included. Discrepancies were classified as intentional/unintentional and according to their risk to cause harm, and interventions were divided into accepted/not accepted. Medication adherence was measured by Morisky questionnaire. Results and Conclusions: Only 30% of hospital prescriptions showed no discrepancies between the medications that the patient was using at home and those which were being prescribed at the hospital and more than one third of those had the potential to cause moderate discomfort or clinical deterioration. One third of total discrepancies were classified as unintentional. About 90% of the interventions were accepted by the medical staff. In addition, about 63% of patients had poor adherence to drug therapy. The study revealed the importance of the medication reconciliation at patient admission, ensuring greater safety and therapeutic efficacy of the treatment during hospitalization, and orienting the patient at discharge, assuring the therapy safety.

Examination of the influence of behavioral, normative and control beliefs on the adherence to a prescribed renal diet among elderly populations with chronic to end-stage renal disease

The 1999-2004 prevalence of chronic kidney disease in adults 20 year or older (15.5 million) is an estimated 7.69%. The risk of developing CKD is exacerbated by diabetes, hypertension and/or a family history of kidney disease. African Americans, Hispanics, Pacific Islanders, Native Americans, and the elderly are more susceptible to higher incidence of CKD. The challenges of aging coupled with co-morbidities such as kidney disease raises the potential for malnutrition among elderly (for the purpose of this study 55 years or older) populations. Lack of adherence to prescribed nutrition guidelines specific to renal failure jeopardizes body homeostasis and increases the likelihood of future morbidity and resultant mortality. The relationship and synergy that exists between diet and disease is evident. Clinical experience with renal patients has indicated the importance of adherence to diet therapy specific to kidney disease. Extension investigation of diet adherence among endstage renal disease patients revealed a sizeable dearth in the current literature. This thesis study was undertaken to help reduce that void. The study design is qualitative and descriptive. Support, cooperation, and collaboration were provided by the University of Texas Nephrology Department, University of Texas Physicians, and DaVita Dialysis Centers. Approximately 105 male and female chronic to end-stage kidney disease patients were approached to participate in elicitation interviews in dialysis treatment facilities regarding their present diet beliefs and practices. Eighty-five were recruited and agreed to participate. Inclusion criteria required individuals to be between 35-90 years of age; capable of completing a 5-10 minute interview; and English speaking. Each kidney patient was asked seven (7) non-leading questions developed from the constructs of the Theory of Planned Behavior. The study presents a descriptive comparison of behavioral, normative, and control beliefs that influence adherence to renal diets by age, race, and gender. The study successfully concluded that behavioral, normative, and control beliefs of chronic to end-stage renal patients promoted execution and adherence to prescribed nutrition. This study provides valuable information for dietitians, technicians, nurses, and physicians to assess patient compliance toward prescribed nutrition and the means to support or improve that performance. ^

Adesão à terapêutica medicamentosa em doentes com Diabetes Mellitus Tipo 2 : um estudo no ACES Almada e Seixal

RESUMO - A (não) adesão à terapêutica é um problema mundial que, para além de afetar diretamente a saúde dos indivíduos, afeta também os recursos económicos e sociais. Apesar da importância em aderir à terapêutica, largamente fundamentada na evidência científica, facto é que, em muitos casos, os doentes não o fazem. Assim, estudar as questões relacionadas com a adesão tem vindo a ganhar cada vez mais relevância e atualmente constitui um desafio para os sistemas de saúde, pois os mecanismos envolvidos no comportamento de adesão dos indivíduos são complexos. Deste modo, com este estudo pretendeu-se caracterizar uma amostra de indivíduos com diabetes mellitus tipo 2 e relacionar o seu nível de adesão à terapêutica medicamentosa com os fatores de não adesão. Este estudo foi desenvolvido no Agrupamento de Centros de Saúde (ACES) Almada e Seixal e nele participaram 151 diabéticos tipo 2. Para a recolha de dados utilizou-se o Questionário de Identificação de Fatores de Não Adesão adaptado de Cabral e Silva (2010) e a Medida de Adesão aos Tratamentos de Delgado e Lima (2001). Os resultados mostraram um perfil de participantes maioritariamente idosos, reformados, do género feminino, casados, com o ensino primário completo, rendimento mensal entre 301-1000 euros e tendencialmente aderentes à terapêutica medicamentosa. O (i) esquecimento, o (ii) preço da medicação, o (iii) número elevado de medicamentos para tomar de uma vez só, não perceber bem o que deve tomar e como e (v) adormecer antes da toma foram os fatores de não adesão relatados com mais frequência. Foram encontradas relações significativas entre o nível de adesão e o esquecimento, o preço da medicação o número elevado de medicamentos para tomar de uma vez só e adormecer antes da toma. Não encontrámos relações significativas entre o nível de adesão e os dados sociodemográficos, os fatores terapêuticos e o fator de não adesão “não perceber bem o que deve tomar e como”. No presente estudo são discutidos os resultados obtidos, consideradas algumas limitações e efetuadas propostas de investigações futuras.