Ustekinumab

Treatment noncompliance represents a significant challenge for both healthcare professionals and their patients with chronic diseases. In discussing noncompliance, it is important to understand the subtleties of relevant terminology. Compliance is patient behavior that results in following the instructions given by their healthcare provider. In contrast, adherence refers to meeting therapeutic goals set mutually by patient and provider. The need for this similar yet distinct term arose from the understanding that individual patient needs and characteristics impact their ability to meet treatment goals. Treatment noncompliance can be unintentional when instructions are misunderstood or forgotten, or deliberate. While it may at first be difficult to understand why patients seek medical advice for these chronic conditions to which they ultimately fail to comply, numerous factors contribute to deliberate treatment noncompliance. Broadly speaking, variables that affect this type of noncompliance include the doctor-patient relationship, patient beliefs about their condition and medications, and medication side effects (Richards et al. 1999).

Maximizing compliance and adherence in psoriasis patients is of particular importance because it is a chronic, highly prevalent systemic inflammatory condition with numerous medical and psychiatric comorbidities including arthritis, depression, and cardiovascular and metabolic diseases (Augustin et al. 2011). Poor compliance is associated with decreased patient satisfaction, reduced quality of life, and unfavorable treatment outcomes. In fact, for every 10% decrease in adherence, there is an associated 1-point deterioration of psoriasis on a 9-point scale (Carroll et al. 2004). Poor adherence also has economic implications such as increased medication costs, increased utilization of resources, inadequate usage of healthcare professionals’ time, and increased sickness-related work absences (Vangeli et al. 2015).

In psoriasis studies, noncompliance rates range between 8 and 73%. The rate reported varies based on both objective and subjective measures used to determine compliance. For example, studies that measure prescription redemption may underestimate noncompliance because they do not account for actual usage of medication. The same applies to studies that use direct patient interviews or patient-to-provider reports because patients may misrepresent their compliance in order to avoid disappointing their provider or negatively impacting future treatment prospects. Conversely, the highest rates of noncompliance are seen in studies that use very stringent criteria for compliance. One study that used the weight of unused medication as a proxy for noncompliance found a rate of 60%. Several studies using anonymous surveys in both Europe and the USA found noncompliance rates of ~40% (Richards et al. 1999; Brown et al. 2006).

In the anonymous survey-based study by Richards et al., non-compliers were significantly younger, had a younger age of psoriasis onset, and had higher self-rated disease severity than compliers. Noncompliant patients also rated both psoriasis and its associated treatments as having a greater impact on their daily lives than did compliant ones, although their overall well-being was not significantly different (Richards et al. 1999). There is conflicting data regarding the association between gender, marital status, smoking, and employment on compliance. Interestingly, there is a positive association between higher levels of education and treatment compliance (Gokdemir et al. 2008; Zaghloul and Goodfield 2004). The distribution and extent of psoriatic lesions also affect compliance. Noncompliance is more likely in patients with facial lesions, higher numbers of lesions, and greater body surface area involved by lesions (Zaghloul and Goodfield 2004). Depression is a significant comorbidity of psoriasis, occurring in 10–62% of patients, and it is also correlated with noncompliance. Similarly, resignation or feelings of having “had enough” correlate negatively, while optimism and a lack of “why me?” thinking correlate positively with compliance (Zalewska et al. 2007).

Many treatment-related factors affect compliance in psoriasis patients. In selecting therapy for patients, it is important to consider that compliance can be negatively impacted by the belief that dependency on or late side effects of medication often outweigh the patients’ subjective assessment of their need for the medication. Of note, it is primarily fear of side effects that affects compliance, not their actual occurrence (Brown et al. 2006). Interestingly, compliance is more likely when patients are treated with a drug for the first time, when the drug is used long term (as opposed to less than 2 months), when the drug is used only once per day, and when the drug has a rapid onset of action (Zaghloul and Goodfield 2004; Atkinson et al. 2004; Uhlenhake et al. 2010). A survey of 1281 patients in Europe showed that the main reasons for noncompliance are low efficacy, poor cosmetic properties, time-consuming use, and occurrence of side effects (Fouéré et al. 2005). There are a number of concerns specific to topical therapies including not only cosmetics but also galenic properties and smell of the preparation. Furthermore, the lower efficacy and longer amount of time needed for application of topical medications compared to systemic agents negatively impact compliance with this treatment modality, which can be as low as 27% (Fouéré et al. 2005). In their survey of 120 patients, Richards et al. found that treatment preference was as follows: 44% systemic, 26% creams, 17% ointments, 3% phototherapy, and 10% no preference.