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Adherence Issues in IBD

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Adherence Issues in IBD Sunanda Kane MD MSPH Professor of Medicine Mayo Clinic Rochester Topics for Discussion Thoughts in this new era of practice Data from primary ... – PowerPoint PPT presentation

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Title: Adherence Issues in IBD


1
Adherence Issues in IBD
  • Sunanda Kane MD MSPH
  • Professor of Medicine
  • Mayo Clinic Rochester

2
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

3
Perspective
4
Evidence ? Practice

Glasziou and Haynes ACP JC 2005
5
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
6
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.
7
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.
8
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.
9
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
10
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.
11
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.
12
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.
13
  • 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

14
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.
15
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16
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17
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

18
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