Understanding Nonadherence with Hydroxychloroquine Therapy in Systemic Lupus Erythematosus

Abstract

Objective.Hydroxychloroquine (HCQ) is a cornerstone to managing systemic lupus erythematosus (SLE), yet adherence to medication is poor. We sought to measure the association of adherence with 5 “dimensions of adherence” as articulated by the World Health Organization for chronic conditions: the patient’s socioeconomic status, and patient-, condition-, therapy-, and healthcare system–related factors. Our longterm goal is to generate evidence to design effective interventions to increase adherence.Methods.The retrospective cohort study included Kaiser Permanente Northern California patients ≥ 18 years old during 2006–2014, with SLE and ≥ 2 consecutive prescriptions for HCQ. Adherence was calculated from the medication possession ratio and dichotomized as < 80% versus ≥ 80%. Predictor variables were obtained from the electronic medical record and census data. We used multivariable logistic regression to estimate adjusted OR and 95% CI.Results.The study included 1956 patients. Only 58% of patients had adherence ≥ 80%. In adjusted analyses, socioeconomic variables did not predict adherence. Increasing age (65–89 yrs compared with ≤ 39 yrs: OR 1.44, 95% CI 1.07–1.93), white race (p < 0.05), and the number of rheumatology visits in the year before baseline (≥ 3 compared with 0 or 1: OR 1.47, 95% CI 1.18–1.83) were positively associated with adherence. The rheumatologist and medical center providing care were not associated with adherence.Conclusion.At our setting, as in other settings, about half of patients with SLE were not adherent to HCQ therapy. Differences in adherence by race/ethnicity suggest the possibility of using tailored interventions to increase adherence. Qualitative research is needed to elucidate patient preferences for adherence support.

Unexpectedly, low hydroxychloroquine concentration enhances DNA-induced immune stimulation in vitro: potential implication in non-compliant patients with SLE

“…1 Their study adds to the number of papers stressing the correlation of low HCQ blood level and increased risk of disease exacerbation, due mainly to lack of treatment adherence. [2][3][4] The paper is in agreement with other clinical studies showing that blood HCQ concentration above 500 ng mL -1 improves clinical activity of SLE. 2 In vitro studies have demonstrated that, at such concentrations, HCQ inhibits MHC-class II antigen presentation and Toll-like receptor 9 (TLR9) signaling in response to DNA containing CpG motifs, 5 an important pathway in the production of type-1 interferons thought to play a role in the pathogenesis of SLE.…”

“…1 Their study adds to the number of papers stressing the correlation of low HCQ blood level and increased risk of disease exacerbation, due mainly to lack of treatment adherence. 2–4…”

Cardiovascular Safety of Hydroxychloroquine in US Veterans With Rheumatoid Arthritis

“…Adherence to HCQ therapy in patients with rheumatic diseases, including RA, is generally low (51,52). It has been reported that adherence may be further lowered due to perceived concerns surrounding its adverse cardiovascular effect in patients with COVID‐19 (9).…”

Possible Consequences of a Shortage of Hydroxychloroquine for Patients with Systemic Lupus Erythematosus amid the COVID-19 Pandemic

“…Since then, multiple studies have shown high levels of very poor adherence, generally ranging from 20% to 50% of patients 38,39,40,41,42 . Common reasons for poor adherence cited by patients include fear of adverse effects and lack of understanding of the benefits 32,43 .…”