Transcript Imperial College London

Non-adherence to oral CML
therapies
Dr Lina Eliasson
Atlantis Healthcare
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Extent of non-adherence to oral CML therapies1
 IMATINIB
– Belgium: 1/3 of patients non-adherent & only 14% took all
doses1
– UK: 26% of patients took ≤90%2
– US: 31% patients had no imatinib for >30 days3
– US: 41% patients ≤85% MPR4
– US: 30% patients had ≥1 interruption of >1 week5
– IT: 47% of patients report suboptimal adherence (MMAS,
n=413)6
 DASATINIB & NILOTINIB 2nd line7–9
– Few reports & with conflicting results
1Noens
L, et al. Blood 2009;113:5401–1541; 2Marin D, et al. J Clin Oncol 2010;28:2381–2388; 3Darkow T, et al.
Pharmacoeconomics 2007;25:481–496; 4Wu EQ, et al. Curr Med Res & Opin 2010;26(1):61–69; 5Ganesan P, et al. Am J
Hematol 2011;86:471–474; 6Efficace F, et al. Blood (ASH Annual Meeting Abstracts) 2012: Abstract 1026. ;
7Wu EQ, et al. Curr Med Res & Opin 2010;26(12):2861–2869; 8Guerin, et al. Blood (ASH Annual Meeting Abstracts)
2010;116(21): Abstract 3437; 9Ulcickas Yood M, et al. J Clin Oncol 2011;29: Abstract 6589.
© Lina Eliasson 2
Impact of non-adherence to IMATINIB (Gleevec/Glivec)
 Negative impact on response
– Patient with suboptimal response had lower adherence
levels1
– ≤90% no CMR2
– ≤80% no MMR2
– 2-year follow up: Patients taking ≤85% more likely to lose
imatinib response / discontinue treatment3
– Non-adherent patients less likely to reach 5-year EFS
(59.8% vs 76.7%) & less likely to achieve CCyR at any
point (26% vs 44%)4
 Increased health care costs5,6
1Noens
L, et al. Blood 2009;113:5401–1541; 2Marin D, et al. J Clin Oncol 2010;28:2381–2388;
AR, et al. Blood 2011;117(14):3733–3736; 4Ganesan P, et al. Am J Hematol 2011;86:471–474;
5Wu EQ, et al. Curr Med Res & Opin 2010;26(1):61–69; 6Darkow T, et al. Pharmacoeconomics 2007;25:481–496.
© Lina Eliasson 3
3Ibrahim
Predictors of non-adherence to CML therapy
 Side effects of CML treatment1
–
–
–
–
Lack of energy / feeling tired
Feeling sick / vomiting
Muscle cramps
Pain in bones or joints
 Treatment characteristics2
– Duration on imatinib
– Time lag between CML diagnosis and initiation
– Starting dose
 Economical factors
– Patient cost-sharing2
 Presence of co-morbidities (using Charlson Comorbidities Index)3
 Low social support & desire for more information4
1Marin
D, et al. J Clin Oncol 2010;28:2381–2388; 2St Charles M, et al. Blood (ASH Annual Meeting Abstracts) 2009;114(22):
Abstract 2209; 3Fogliatto L, et al. Blood (ASH Annual Meeting Abstracts) 2010;116(21): Abstract 2296. 4Efficace F, et al.
Blood (ASH Annual Meeting Abstracts) 2012: Abstract 1026. ;
© Lina Eliasson
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CML patients’ reasons for non-adherence
 Unintentional non-adherence:





– forgetting / trouble swallowing
Intentional non-adherence:
– dealing with side effects
Drug holidays:
– “detoxing” or reduce side effects
Both Intentional & Unintentional:
– forgot & then decided not to take it
Patients’ views of consequences:
– don’t think it matters to miss the “odd dose” / may feel better
due to reduced side effects
Health care providers influence on patients’ non-adherence:
– HCPs may downplay impact of missing doses
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Identifying Non-adherent Patients
 Open & non-judgemental communication
 Identification of sub-optimal response
 Plasma drug levels
 Self-report measurements
 Electronic monitoring with/without feedback
 Assessing predictive factors
© Lina Eliasson
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Strategies to improve adherence
 People who adhere to imatinib:
– Have fewer side effects1
– Took imatinib with food1
– Kept routines2
– Used prompts2
– Also experienced problems1
I wonder myself whether I am
doing the right thing, taking
these flipping tablets, they
make me feel so ill
1Marin
D, et al. J Clin Oncol 2010;28:2381–2388; 2Eliasson L, et al. Leuk Res 2011;35(5):626–630.
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Strategies to improve adherence
 Be frank about consequences of missing doses and be specific
Missing the odd dose
is OK
If you miss more than
2 doses in a month it
is likely to affect your
response
If I thought there was going to
be any effect on [my response]
then I guess that would make a
big difference
Eliasson L, et al. Leuk Res 2011;35(5):626–630.
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Strategies to improve adherence: Unintentional
 Adherence supporting technologies
 Cost-sharing initiatives1
1Kiarie
GW, et al. East Afr Med J 2009;86(Suppl 12):S106–S107.
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Strategies to improve adherence: Intentional
 Manage side-effects
 Patient “education”
 Support by allied health professionals1
– Specialist nurses
– Onco-psychologists
 Personalised advice by pharmacist2
1Guilhot
F, et al. Blood (ASH Annual Meeting Abstracts) 2010;116(21): Abstract 1514;
S, et al. Pharm World Sci 2006;28(3):165–170.
2Clifford
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The right to not adhere should be respected
 Everyone has the right to manage their own treatment so it fits
their life
 Everyone has the right to not take their medication
 However, it has to be an informed decision!
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Non-adherence to oral CML
therapies
Dr Lina Eliasson
Atlantis Healthcare
12