Adherence to Treatment of Multiple Sclerosis: How to Enhance It and What Interesting Insights Emerged from Current Research?
Therapeutic options for patients with multiple sclerosis (MS) utilizing disease-modifying drugs (DMDs) have continued to expand in recent years. However, achieving their full benefit is critically dependent on adherence to treatment. Nonadherence is demonstrably linked to an increased risk of relapses, faster progression of disability, higher treatment costs, and higher mortality. We present a summary of factors affecting adherence to treatment in MS patients, including the influence of the chosen therapy from a 2022 review and subsequent studies.
Systematic Review of Published Literature
According to a systematic review of relevant literature1 published between 2008 and 2021 (from the MEDLINE and Google Scholar databases), adherence to MS treatment ranges from 41 to 93%. This review indicated that longer disease duration and higher severity of disability negatively affect adherence. Lack of information about the disease also reduces adherence. Satisfaction with therapy, which is associated with higher adherence, is significantly influenced by the doctor-patient relationship, trust, shared decision-making regarding treatment considering patient preferences, explaining the benefits and risks of individual therapeutic options, and forming a treatment plan. Adherence also improves with more frequent contact with a doctor or nurse, including telephone consultations or emails.
Adherence, according to this review, is significantly influenced by the type of medication administered. For injectable DMDs, published studies show adherence between 41 and 88%. Patients with i.m. IFN-β-1a showed significantly higher adherence compared to those with s.c. formulations (GA, IFN-β-1a, IFN-β-1b). If patients completely stop injectable treatment, it typically happens shortly after starting it. The main reasons include fear of needles, injection site reactions (skin reactions and pain), and difficulties with self-administering injections. Higher adherence and less frequent discontinuation of treatment were found with p.o. DMDs, although even these medications do not entirely resolve adherence to MS treatment. Nonadherence to p.o. DMDs administered 1-2 times daily was identified in 20% of patients, with 25% discontinuing treatment within one year. Reasons for discontinuation included side effects (diarrhea, gastrointestinal issues, and hot flashes). One study concluded that p.o. treatment is not a predictor of adherence compared to self-administered injectable therapy.
This review also showed that reasons for nonadherence include cognitive decline, presence of depression, perceived insufficient effectiveness of treatment, forgetfulness, or dissatisfaction with the regimen. Patients who experience good efficacy from initial therapy have a higher chance of good adherence.
Cross-Sectional Study
A study conducted in Spain between 2020 and 20214 among 152 patients using DMDs for at least six months found 73% adherence to pharmacological treatment of MS according to the Morisky-Green questionnaire. The most common cause of nonadherence was forgetfulness (80.5%). Adherence was 88.4% for patients receiving i.v. treatment, 69.8% for those with self-administered injectable treatment, and 62.5% for patients using p.o. formulations. Surprisingly, adherence was not related to beliefs about the necessity of the therapy or concerns about treatment.
Prospective Study
In this cohort study2, adherence to MS pharmacotherapy was evaluated over five years (from 2015) in 288 previously untreated adult patients with relapsing-remitting MS (RRMS). Adherence was 82.5%. The main reason for nonadherence was fatigue from continued long-term treatment (in 42.5% of cases). The authors found a significant correlation between adherence and higher education level, marital status, and specific DMDs (highest adherence was observed with glatiramer acetate, rituximab, and fingolimod). A significant difference in average EDSS (Expanded Disability Status Scale) scores was found after five years between adherent patients (0.92) and nonadherent patients (1.76).
Conclusion
Measures to improve adherence to pharmacotherapy by healthcare providers include explaining the nature of the disease, principles, and significance of treatment and its possible side effects. It is also crucial to answer patient's questions, alleviate their concerns, enhance motivation, regularly monitor treatment results and adherence, and choose a therapeutic approach based on shared decision-making with the patient within the treatment plan. Time devoted to this issue will surely be rewarded with better outcomes and, ultimately, an improvement in patients’ prognosis.5
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Sources:
1. Kołtuniuk A., Chojdak-Łukasiewicz J. Adherence to therapy in patients with multiple sclerosis − review. Int J Environ Res Public Health 2022 Feb 15; 19 (4): 2203, doi: 10.3390/ijerph19042203.
2. Bawand R., Ghiasian M., Fathoallahi N., Moradi A. Effects of disease-modifying treatments discontinuation in patients with relapsing-remitting multiple sclerosis: a 5 year prospective cohort study. Mult Scler Relat Disord 2022 Jul; 63: 103857, doi: 10.1016/j.msard.2022.103857.
3. Rabadi M. H., Just K., Xu C. Impact of adherence with disease-modifying therapies on all-cause mortality rates among veterans with multiple sclerosis. Med Sci Monit 2022 Sep 22; 28: e938116, doi: 10.12659/MSM.938116.
4. Soria C., Prieto L., Lázaro E., Ubeda A. Factors associated with therapeutic adherence in multiple sclerosis in Spain. Patient Prefer Adherence 2023 Mar 14; 17: 679−688, doi: 10.2147/PPA.S401962.
5. Vrablík M. Adherence and possibilities to influence it. Medicine for Practice 2013; 10 (11−12): 369−371.
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