There’s no question that coping with rheumatoid arthritis (RA) involves difficult challenges. For one, the prospect of taking disease-modifying antirheumatic drugs (DMARDs) with aggressive-sounding names such as methotrexate for the rest of their life can be daunting for some patients. Other patients may propose using holistic or naturopathic treatments instead of medications that they believe are unnatural and harmful.

The reality, however, is that current rheumatology guidelines advise "treating to target"—that is, treating RA with DMARDs to achieve low disease activity or remission. Fear of DMARDs among patients, or a desire to go “natural” with treatment, represent obstacles to adherence that clinicians need to understand and address head-on. 

 

Patient resistance to DMARDs

“One contributing factor to this is when patients resist (refuse to adopt, avoid initiating/implementing, or discontinue) DMARD medication regimens recommended or prescribed by physicians,” wrote the authors of a qualitative study published in Arthritis Care & Research.

Shaw Y, Metes ID, Michaud K, et al. Rheumatoid arthritis patients' motivations for accepting or resisting disease-modifying antirheumatic drug treatment regimens. Arthritis Care Res (Hoboken). 2018;70(4):533-541.

 

In the study, US researchers interviewed 48 RA patients. Overall, 91.7% were taking DMARDs at the time of the study, but 29% of participants had resisted medication at some point.

The investigators identified five themes that described patients’ motivations for resisting DMARDs:

• Fear of medications

• Desire to maintain control over health

• Denying “sick” identity

• Disappointment with treatment

• Feeling overwhelmed due to the cognitive burden of deciding 

Austrian researchers provided additional insights into why some patients object to RA therapy. Among the 131 patients they interviewed, 43 were non-adherent. Results from the study were published in Arthritis Research & Therapy.

Ritschl V, Lackner A, Boström C, et al. I do not want to suppress the natural process of inflammation: New insights on factors associated with non-adherence in rheumatoid arthritis. Arthritis Res Ther. 2018;20(1):234.

 

Some patients simply had strong opinions, based on beliefs or values that they accepted without question. One such belief was that pain was an indicator of the hard work (usually manual) they had done during their life, and therefore something to be proud of. Another belief held that inflammation was a natural process that shouldn’t be suppressed.

In explaining why it is important for physicians to understand and address patients’ resistance to RA treatment, the Arthritis Care & Research authors summed it up this way: “Patients’ resistance to DMARD treatment regimens can increase the risk of suboptimal treatment, prolong time spent with painful symptoms, and lead to progression of joint damage, diminishing patients’ current and future quality of life.”

 

Addressing the problem

A number of approaches have been studied for their effectiveness in counteracting nonadherence. 

Patient education. When presented with intentional nonadherence, physicians should try to educate the patient.

Increasing the patient’s knowledge about the disease and its treatment, and addressing any concerns or fears about potential side effects from medication, may help to provide solutions for intentional nonadherence, according to the authors of a review published in Patient Preference and Adherence.

Hugtenburg JG, Timmers L, Elders PJ, et al. Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions. Patient Prefer Adherence. 2013;7:675–682.

 

Motivational interviewing. Motivational interviewing can be used to help uncover the patient’s barriers to adherence. This patient-centered form of communication supports the patient in examining their ambivalence and then coming up with their own solutions to the problem.

[Motivational interviewing is] is a balance between directing, advising, and supporting the patient on the one hand and encouraging the patient to find possible solutions on the other.

Addressing negative feelings. Authors of the qualitative study published in Arthritis Care & Research had the following take on improving adherence.

 “Our findings suggest the need for interventions that better address negative feelings arising during patients’ decision process. Such interventions may promote acceptance of recommended therapies and develop patients’ confidence in navigating treatment decisions. Physicians, as patients’ trusted advisors regarding illness and treatment, are in an ideal position to provide such emotional support,” they wrote.

Providing appropriate information. The researchers writing in Arthritis Care & Research noted that information overload could contribute to patients’ deciding to delay treatment for fear of making the “wrong” choice. Too much information can leave patients overwhelmed and uncertain about the decision process.

To this end, physicians can provide decision aids that explain benefits and risks in a nonthreatening and balanced way. These decision aids can help to put things in perspective. 

Applying stratified interventions. Authors of the study published in Arthritis Care & Research recommended the use of stratified and multicomponent interventions when addressing nonadherence in RA.

“Personalized medicine claims that we need stratified interventions relevant to subgroups of patients based on biomarkers. In addition to biomarkers, psycho-social markers, including personal attitudes, strong opinions, cultural values and norms, environmental factors, and so forth, derived from qualitative data such as from our study, could be used to further stratify patients,” the authors wrote.