Factors that impact on adherence to treatment and strategies to improve adherence in patients with SLE



Medication non-adherence can be a challenge in many diseases, thus also frequently occurring in patients with SLE, possibly leading to poorer outcomes. Several studies have reported proportions of patients with SLE who are non-adherent to treatment, but these proportions range from 3% to 76% depending on how the assessment has been done [1].  

Medication non-adherence can be total, partial, continuous or intermittent, and intentional or unintentional. The reasons for intentional non-adherence are less straightforward than unintentional and include problems related to taking medications (such as adverse events), inability to pay for the medications, disagreement regarding the need for pharmacological treatment, or other patient-specific issues [2]. Beliefs about medications, treatment in general or particular medications, are likely to be associated with intentional non-adherence [3] 

It has been found that the most common reasons for AMA treatment discontinuation by patient initiative include the perception of AMA not being an effective treatment and apprehension about potential side-effects [4]. A recent post-hoc analysis [5] of two large clinical trials comprising SLE patients with active disease despite standard of care treatment with a high prevalence of mucocutaneous and musculoskeletal involvement, i.e. BLISS-52 [6] and BLISS-76 [7], showed that use of AMA was associated with better HRQoL perceptions in physical aspects of the medical outcome study (MOS) short form-36 (SF-36), particularly regarding patients’ physical functioning. Importantly, GC doses and use of immunosuppressants were not found to impact physical functioning, and the favourable impact of AMA use was independent of the negative impact of age, disease activity and organ damage. 

In another study from Sweden comprising 69 patients with active SLE, selected for treatment with biological agents, i.e. belimumab or rituximab, patients receiving AMA performed better in social functioning and mental health, based on self-reports using the SF-36 health survey [8]. In light of this background, it appears important to improve SLE patients’ adherence to treatment, particularly AMA. Towards this goal, a first step would be to systematically identify influenceable factors that have an impact on medication adherence, and thereafter strategies that could contribute to improved medication adherence.   



Our main objective with this study is to identify influenceable factors that impair adherence to treatment in patients with SLEand suggest strategies that could improve adherence to treatment. 


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    Link: https://pubmed.ncbi.nlm.nih.gov/28086003/  


  1. Atkins L, Fallowfield L. Intentional and non-intentional non-adherence to medication amongst breast cancer patients.European Journal of Cancer. 2006;42(14):2271-6

    Link: https://pubmed.ncbi.nlm.nih.gov/16644208/  


  1. Costedoat-Chalumeau N, Amoura Z, Hulot JS, Aymard G, Leroux G, Marra D, Lechat P, Piette JC. Very low blood hydroxychloroquine concentration as an objective marker of poor adherence to treatment of systemic lupus erythematosus.Annals of the Rheumatic Diseases. 2007 Jun;66(6):821-4

    Link: https://pubmed.ncbi.nlm.nih.gov/17324970/  


  1. Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: The development and evaluation of a new method for assessing the cognitive representation of medication. Psychology & Health. 1999;14(1):1-24

    Link: https://psycnet.apa.org/record/1999-05846-001  


  1. Gomez A,Soukka S, Johansson P, Åkerström E, Emamikia S, Enman Y, Chatzidionysiou K, Parodis  Use of Antimalarial Agents is Associated with Favourable Physical Functioning in Patients with Systemic Lupus Erythematosus. Journal of Clinical Medicine. 2020 Jun 10;9(6):1813

    Link: https://pubmed.ncbi.nlm.nih.gov/32532059/  


  1. Navarra SV, Guzmán RM, Gallacher AE, Hall S, Levy RA, Jimenez RE, Li EK, Thomas M, Kim HY, León MG, Tanasescu C, Nasonov E, Lan JL, Pineda L, Zhong ZJ, Freimuth W, Petri MA; BLISS-52 Study Group. Efficacy and safety of belimumab in patients with active systemic lupus erythematosus: a randomised, placebo-controlled, phase 3 trial. Lancet. 2011 Feb 26;377(9767):721-31

    Link: https://pubmed.ncbi.nlm.nih.gov/21296403/  


  1. Furie R, Petri M, Zamani O, Cervera R, Wallace DJ,Tegzová D, Sanchez-Guerrero J, Schwarting A, Merrill JT, Chatham WW, Stohl W, Ginzler EM, Hough DR, Zhong ZJ, Freimuth W, van Vollenhoven RF; BLISS-76 Study Group. A phase III, randomized, placebo-controlled study of belimumab, a monoclonal antibody that inhibits B lymphocyte stimulator, in patients with systemic lupus erythematosus. Arthritis Research and Therapy. 2011 Dec;63(12):3918-30

    Link: https://pubmed.ncbi.nlm.nih.gov/22127708/  


  1. ParodisI, Lopez Benavides AH, Zickert A, Pettersson S, Möller S, Welin Henriksson E, Voss A, Gunnarsson I. The Impact of Belimumab and Rituximab on Health-Related Quality of Life in Patients With Systemic Lupus Erythematosus. Arthritis Research and Therapy. 2019 Jun;71(6):811-821

    Link: https://pubmed.ncbi.nlm.nih.gov/30055091/