title: Inflammatory bowel disease: adherence to immunomodulators in a biological therapy era.
abstract: BACKGROUND
  Combination therapy, with anti-tumor necrosis factor-α agents and immunomodulators, is the most effective option to induce and maintain remission in inflammatory bowel disease (IBD). Infliximab, with its administration features, determines particular conditions of adherence; the same is not possible with thiopurines. Nevertheless, research on adherence to these treatments is scarce. Nonadherence worsens the prognosis of IBD.
  
  
  OBJECTIVE
  (a) Assess adherence to immunomodulators and (b) determine therapeutic nonadherence predictors.
  
  
  METHODS
  We included all IBD outpatients consecutively evaluated over a 6-month period in our center. Participants completed a study-specific questionnaire on IBD, IBD therapeutic adherence (Morisky Medication Adherence Scale-8-item), Therapeutics Complexity questionnaire, Beliefs about Medication questionnaire, and Hospital Anxiety and Depression Scale.
  
  
  RESULTS
  A total of 112 patients under azathioprine were considered; 49.1% were also under anti-tumor necrosis factor-α. Self-assessed questionnaire showed that 70.5% were adherent to immunosuppression. Similar adherence was found with and without infliximab (68.4%-monotherapy vs. 72.7%-combination therapy; P=0.61). Nonintentional nonadherence was documented in 57.6%; 42.4% reported voluntary nonadherence. Nonadherence was higher in male patients [odds ratio (OR): 3.79; 95% confidence interval (CI): 1.2-11.95; P=0.023], younger patients (OR: 0.93; 95% CI: 0.87-0.98; P=0.01), nonsmokers (OR: 4.90; 95% CI: 1.22-19.73; P=0.025), and those who had depression (OR: 2.22; 95% CI: 1.36-3.62; P=0.001). Most of the IBD patients believed in the necessity of maintaining immunosuppression (86.7%), but 36.6% reported concerns about drugs.
  
  
  CONCLUSIONS
  Nonadherence to thiopurines plays a significant role in IBD. Nonetheless, it does not increase with association with biological agents. Involuntary nonadherence is higher. Male sex, younger age, nonsmoker, and presence of depression were independent predictors of nonadherence to immunomodulators. More than one-third of IBD patients had concerns about drugs. Optimizing the discussion on patients' concerns to overcome perceptual barriers related to drugs may obviate the negative course of IBD related to nonadherence.
authors: aDepartment of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Coimbra bDepartment of Gastroenterology, Hospital de São Teotónio, Viseu, Portugal.
authors: Sara
authors: S
authors: Campos
authors: Francisco
authors: F
authors: Portela
authors: Paula
authors: P
authors: Sousa
authors: Carlos
authors: C
authors: Sofia
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D001379:Azathioprine / Q000009:adverse effects / Q000627:therapeutic use; D003863:Depression / Q000523:psychology; D004359:Drug Therapy, Combination; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007155:Immunologic Factors / Q000009:adverse effects / Q000627:therapeutic use*; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use; D015212:Inflammatory Bowel Diseases / Q000188:drug therapy*; D008297:Male; D055118:Medication Adherence / Q000523:psychology; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D012737:Sex Factors; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D007155:Immunologic Factors; D007166:Immunosuppressive Agents; D014409:Tumor Necrosis Factor-alpha; D001379:Azathioprine