Points to consider to promote adherence in people with RMDs

Prevent non-adherence by building trust, overcoming barriers, and tailoring the solution to the problem.

Rheumatic and musculoskeletal diseases (often shortened to RMDs) are a group of diseases that affect the joints and muscles. There are lots of different treatments available that can both treat symptoms, and stop some of the underlying disease processes. Most of these medicines need to be taken regularly for a long period of time.

Not taking medicines, not performing exercises, or not following advice regarding activities and functioning in daily life as prescribed or advised is called non-adherence. People may be non-adherent if they take a different dose than their doctor stated, take the medicine on a different schedule, or use it wrongly. The same applies to non-pharmacological methods.

Adherence is influenced by many different factors. These include the costs of medicines and supplies, the availability of facilities or treatment options, or having the skills needed to do an exercise or take a medicine properly – for example, if it needs to be injected. Adherence can also change over time in the same person. Some people may choose to be non-adherent, and others may just forget to take their medicine or perform their exercises.

Being non-adherent can stop medicines or other treatments working in the way they are supposed to, and
may stop you achieving a good outcome from your treatment. Non-adherence is very common in people with chronic diseases. It is estimated that between 30% and 80% of people with RMDs do not adhere to the agreed treatment.

The authors wanted to write a set of points to consider that could help screen people for non-adherence. They also wanted to be able to give some ideas about how to manage non-adherence.

This was a systematic review done by a group of healthcare providers followed by a consensus of representative experts. The group included rheumatologists, nurses, pharmacists, psychologists, physiotherapists, occupational therapists, and patient representatives from 12 European countries. A series of points to consider were drafted based on published evidence, and then the group voted anonymously to say how much they agreed with each of the points.

The group developed four overarching principles and nine points to consider. The overarching principles are designed to help understand how and why the points were included. These acknowledge that adherence has an impact on outcomes for people with RMDs, and is influenced by multiple factors. Shared decision making is important, since adherence is a behaviour and people may be more likely to follow a prescription if they were involved in setting it. Adherence is also a dynamic process that needs continuous evaluation.

Yes. Other groups have issued recommendations to reduce non-adherence in people with RMDs, but they dealt specifically with medication and just one specific RMD (rheumatoid arthritis). These are the first broad points to consider that have been written in this area. They are also novel in that they include non-pharmacological interventions, such as exercise, activity pacing, and give advice on healthy lifestyle.

1. All healthcare providers looking after people with RMDs should take responsibility
for promoting adherence.

2. Good communication should be used to enhance adherence.

3. Every person may have individual factors that stop them adhering to their prescription.

4. All people with RMDs should be offered health education as part of their standard

5. Prescriptions should take into account an individual’s preferences and goals.

6. Discuss adherence regularly using open questions – especially when a person’s disease
is not well controlled.

7. Explore which factors might negatively influence adherence. These might include
opportunity (such as availability or cost), capability (for example, could be affected by
memory problems), and motivation.

8. Together with the patient, tailor the approach to overcome individual barriers to
adherence, for example, by simplifying the regimen, using reminders, providing
education, and discussing a person’s beliefs about their treatment.

9. When specific expertise or interventions for adherence are needed, they should be
made available to people with RMDs.

One of the limitations is that the points to consider were written as an expert consensus. This means they are based on the opinions of the group. However, all the points were drafted using published evidence. In the paper, the authors gave each item a score from 1 to 5 based on the quality of the evidence used to support it.

The points will be shared with healthcare providers to help identify and support people with RMDs who are non-adherent. More research is needed in this area to test the ideas, and well-designed clinical studies would be helpful.

If you have an RMD, your treatment should be tailored to your personal symptoms and circumstances. Decisions on medicines should be made between you and your doctor. It is a good idea to stay well-informed about your disease. This can help you stay motivated to keep on top of your treatment. It may also help you be more active and make lifestyle changes that could help.

If you have any concerns about your disease or its treatment, you should talk to your doctor.

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Date prepared: May 2021
Summary based on research article published on: 18 December 2020
From: Ritschl V, et al. EULAR points to consider for the prevention, screening, assessment and management of non-adherence to treatment in people with rheumatic and musculoskeletal diseases for use in clinical practice. Ann Rheum Dis 2021;80:707–713. doi:10.1136/annrheumdis-2020-218986

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