Factors Associated with Medication Non-adherence in Patients with End-Stage Liver Disease

Abstract

Background Low medication adherence is known to contribute to worse health outcomes in the general population. Aim We aimed to evaluate the medication regimen and determine the adherence levels among patients with end-stage liver disease. Methods We measured adherence in patients awaiting liver transplantation at a single center using the 8-item Morisky Medication Adherence Scale (MMAS-8), with a score <8 classified as low-adherence. Medication regimen complexity was assessed using the Medication Complexity Regimen tool (MRCI). Factors associated with low-adherence were identified by logistic regression. Results Of 181 patients, 33% were female, median age was 62, and Model for end-stage liver disease (MELD) score was 13. The median (IQR) number of medications was 10 (7–13) and the MRCI was 19 (13–27). 54 (30%) were high adherers, and 127 (70%) were low-adherers. 42% reported sometimes forgetting to take their medication and 22% reported intermittent adherence within the past 2 weeks. The most common reasons for low-adherence were: forgetfulness (27%), and side effects (14%). Compared to high adherence, low-adherence was associated with higher number of medications, medication complexity, and diabetes, but lower rates of hepatocellular carcinoma and self-perceived health. In univariable logistic regression, total medication number (OR 1.08), MRCI (OR 1.04), diabetes (OR 2.38), HCC (OR 0.38) and lower self-perceived health (OR 1.37), were statistically significant factors associated with non-adherence. In multivariate analysis, only medication number without supplements (OR 1.14) remained significantly associated with medication non-adherence. Conclusion A majority of patients awaiting liver transplantation demonstrate low medication adherence. Total number of medications and regimen complexity were strong correlates of adherence. Our data underscore the need for chronic liver disease management programs to improve medication adherence in this vulnerable population.

Optimizing medication management for patients with cirrhosis: Evidence‐based strategies and their outcomes

“…One missed dose may cause a downward spiral of progressive confusion, leading to further missed doses and worsening HE. Furthermore, lactulose is associated with abdominal cramping, and frequent loose stools (a desired effect) which contribute to poor adherence . Rifaximin, a poorly absorbable antibiotic, is well‐tolerated and has been shown to reduce hospital readmissions .…”

“…Patients with cirrhosis including some with compensated cirrhosis are on multiple medications with an average between 3 and 10 medications . Volk et al showed that in patients with cirrhosis, the number of medications at discharge can predict time to readmission .…”

“…Furthermore, lactulose is associated with abdominal cramping, and frequent loose stools (a desired effect) which contribute to poor adherence. 13 Rifaximin, a poorly absorbable antibiotic, 12 is well-tolerated and has been shown to reduce hospital readmissions. 14,15 Still, only 60% of patients with overt HE are prescribed rifaximin.…”

“…Patients with cirrhosis including some with compensated cirrhosis are on multiple medications with an average between 3 and 10 medications. 13,28,29 Volk et al showed that in patients with cirrhosis, the number of medications at discharge can predict time to readmission. 29 In addition to the number of medications, dosing frequency and the need to actively titrate by symptom and effect make medication regimens for patients with cirrhosis complex.…”

“…High medication burden was associated with non-adherence, while high MELD (Model for End-Stage Liver Disease) or Child-Pugh scores were not associated with adherence in multivariate analysis. 13…”