Immunosuppressive therapy after solid-organ transplantation: does the INTERMED identify patients at risk of poor adherence?

Abstract

Background:Lack of adherence to medication is a trigger of graft rejection in solid-organ transplant (SOT) recipients.Objective:This exploratory study aimed to assess whether a biopsychosocial evaluation using the INTERMED instrument before transplantation could identify SOT recipients at risk of suboptimal post-transplantation adherence to immunosuppressant drugs. We hypothesized that complex patients (INTERMED>20) might have lower medication adherence than noncomplex patients (INTERMED≤20).Methods:Each patient eligible for transplantation at the University Hospital of Lausanne, Switzerland, has to undergo a pre-transplantation psychiatric evaluation. In this context the patient was asked to participate in our study. The INTERMED was completed pre-transplantation, and adherence to immunosuppressive medication was monitored post-transplantation by electronic monitors for 12 months. The main outcome measure was the implementation and persistence to two calcineurin inhibitors, cyclosporine and tacrolimus, according to the dichotomized INTERMED score (>20 or ≤20).Results:Among the 50 SOT recipients who completed the INTERMED, 32 entered the study. The complex (N=11) and noncomplex patients (N=21) were similar in terms of age, sex and transplanted organ. Implementation was 94.2% in noncomplex patients versus 87.8% in complex patients (non-significant p-value). Five patients were lost to follow-up: one was non-persistent, and four refused electronic monitoring. Of the four patients who refused monitoring, two were complex and withdrew early, and two were noncomplex and withdrew later in the study.Conclusion:Patients identified as complex pre-transplant by the INTERMED tended to deviate from their immunosuppressant regimen, but the findings were not statistically significant. Larger studies are needed to evaluate this association further, as well as the appropriateness of using a nonspecific biopsychosocial instrument such as INTERMED in highly morbid patients who have complex social and psychological characteristics.

Prevalence and Patient-Level Correlates of Intentional Non-Adherence to Immunosuppressive Medication After Heart-Transplantation—Findings From the International BRIGHT Study

“…This sample’s IS non-persistence rate (i.e., discontinuation of the regimen) was very low ( N = 7, 0.5%). This finding echoed those of other studies, all of which reported very small prevalence (0.6%–3.1%) of medication non-persistence [ 17 , 18 , 49 ]. In all cases, including cases with a high relative rate of missing information on INA—e.g., Spain, Italy, Germany—, the number of cases involved were too low to allow in-depth analyses.…”

“…To date, though, INA to IS (which we will refer to simply as INA) has received only limited attention in the HTx populations and has not been well-substantiated due to inconsistent definition and measurement and large international variability. INA has not been directly studied, and estimated prevalence of drug holidays or non-persistence to IS vary widely, respectively 0%–7.1% and 0.6%–3.1% [ 16 – 18 ].…”

Quality of life associated with immunosuppressant treatment adherence in liver transplant recipients: A cross-sectional study

“…While studies have mentioned the impacts of pre-transplant depression in non-adherence of liver and kidney transplant recipients (Scheel et al, 2018;Golfieri et al, 2019), they have suggested the positive impact of psychological interventions in adherence. It is also noticeable that in some studies, poor psychological scores before transplantation did not significantly modify patient adherence to immunosuppressive regimens when compared with psychologically stable patients (Michaud et al, 2016). This suggests further attention to considering the causal relationship between non-adherence and poor psychological scores.…”

A complexidade das necessidades de saúde na atenção básica avaliada pelo INTERMED

“…Estudos de confiabilidade interavaliadores apresentaram os seguintes resultados: Posteriormente, foi validado para diversas patologias -dor lombar, diabetes, pacientes em cuidados paliativos, esclerose múltipla, e com traumas ortopédicos. (MICHAUD et al, 2016;SCERRI et al, 2006;VOUILLOZ et al, 2011). Também para pacientes urológicos (quanto à versão auto aplicável) (DI GANGI HERMS et al, 2003;WILD et al, 2011); com pacientes espanhóis com câncer, problemas pulmonares e internados em enfermarias hospitalares (KOCH et al, 2001;LOBO et al, 2007LOBO et al, , 2008LOBO et al, , 2013; no contexto de urgência e emergência na Áustria (MATZER et al, 2012); e nos Estados Unidos no contexto terciário para uso de Gerentes de Caso (KATHOL; HOBBS MELLLER et al, 2015), no Canadá na versão pediátrica (NADER, 2020), e na versão autoaplicável para idosos na Holanda No Brasil, a pesquisa de validação do INTERMED teve início através da pesquisadora Bernadete Weber (WEBER et al, 2012), no contexto hospitalar e com pacientes idosos (GUTIERREZ; SILVA; SHIMIZU, 2014), sendo realizado um estudo de tradução, adaptação transcultural e validação, cujo processo será descrito a seguir.…”