In some cases, medications are perceived as being ineffective. Many RA medications take months to reach full efficacy. Patients in remission sometimes stop their medications. It’s incumbent on us to outline the time line for a sufficient trial of medication and to teach that remission is not synonymous with cure.
Initiation of urate-lowering therapy is another time that anticipatory counseling can make a difference: It may be hard to convince a patient who flares after starting allopurinol that this is a medicine that really treats gout! Preemptive discussion of the potential to have flares may prevent self-discontinuation of the medication.
Importantly, patients are less likely to take medications if they hold beliefs or have concerns that conflict with the provider’s beliefs and concerns. Factors that drive rheumatologists to change medication regimens in rheumatoid arthritis are what we expect—swollen joint counts, physician global assessment, worsening erosions and increased disease activity compared with the prior visit. In contrast, when patients were asked what may lead them to escalate care, they cite painful joint counts, current physical functioning, satisfaction with current DMARDs and trust in their rheumatologist.8 Exploration of patient values and preferences around illness and medication can help tease out if patients are likely to be taking a prescribed regimen.
What Can We Do about It?
Improving adherence in chronic disease is challenging. Interventions that have been studied and found helpful almost all require a substantial amount of effort and resources. These interventions have to be continued indefinitely, because there is no evidence that low adherence can be “cured.”9
One step that can be taken is to simplify dosage regimens when possible. Are there any medications that can be discontinued? Is a long-acting version available to decrease the dosing frequency?
Also, we should spend time on the front end to elicit patient concerns and make sure we are connected to the patient so they can share their fears and concerns.
Employing the teach-back method at the end of a visit is an excellent way to ensure patient understanding. One might say to the patient at the end of a visit, “What are you going to tell your spouse about our conversation and what medications you will be taking?” This technique can reveal important gaps in patient understanding.
Writing down the diagnosis highlights and medicine regimens may also improve education and retention.
Communication is at the heart of the adherence issue. The best predictor of adherence is the clinician–patient relationship. You need to understand the patient’s own belief about their illness. You need to show empathy by using good body language and by voicing concern about how the disease is affecting the patient.