Improving treatment adherence in patients with rheumatoid arthritis: what are the options?

Adherence to medication in patients with rheumatoid arthritis is low, varying from 30 to 80%. Improving adherence to therapy could therefore dramatically improve the efficacy of drug therapy. Although indicators for suboptimal adherence can be useful to identify nonadherent patients, and could function as targets for adherence-improving interventions, no indicators are yet found to be consistently and strongly related to nonadherence. Despite this, nonadherence behavior could conceptually be categorized into two subtypes: unintentional (due to forgetfulness, regimen complexity or physical problems) and intentional (based on the patient's decision to take no/less medication). In case of intentional nonadherence, patients seem to make a benefit-risk analysis weighing the perceived risks of the treatment against the perceived benefits. This weighing process may be influenced by the patient's beliefs about medication, the patient's self-efficacy and the patient's knowledge of the disease. This implicates that besides tackling practical barriers, clinicians should be sensitive to patient's personal beliefs that may impact medication adherence.

To investigate beliefs about medications held by people with rheumatoid arthritis (RA), what factors are related to these specific medication beliefs, and whether these beliefs influence adherence. The design was a cross-sectional postal questionnaire survey of people with RA. The Beliefs about Medicines Questionnaire was used to assess beliefs about the necessity of medication and concerns about it. Questionnaires were mailed to 600 out-patients with RA. The response rate was 57.3%. Most (74.3%) respondents agreed or strongly agreed that their arthritis medications are necessary for their health. However, 47.4% were concerned about potential adverse consequences. The overall necessity score (mean 19.2, s.d. 3.13) was higher than the concerns score (mean 15.84, s.d. 3.53; P<0.001). Greater disability was associated with higher necessity scores (r = 0.36; P<0.001). Greater helplessness correlated with higher concerns scores (r = 0.49; P<0.001). There was no association between RA knowledge and beliefs about medications (necessity scale, r = 0.02, P = 0.66; concerns scale, r=-0.08, P = 0.14). Concerns scores for non-adherent participants (mean 17.88, s.d. 3.29) were higher than for the adherent group (mean 15.64, s.d. 3.51; P = 0.002). Most people with RA have positive beliefs about the necessity of their medication. However, levels of concern are high and associate with helplessness and non-adherence. The Beliefs about Medicines Questionnaire may identify people at risk of poor adherence and provide a focus for patients to discuss their beliefs, providing opportunities to improve adherence.