Adherence to immunosuppressant drugs in patients with connective tissue diseases

Sir, We read with interest the Editorial by Chambers et al. [1] regarding treatment adherence in systemic lupus erythematosus (SLE). It has been estimated that up to 50% of patients who suffer from chronic diseases do not adhere to treatment recommendations [2]. We have recently reviewed our experience of compliance with immunosuppressive treatment amongst patients with connective tissue diseases (CTDs) at The Royal London Hospital. We used a physician-designed questionnaire, which was distributed to consecutive patients attending the CTD clinic. The questionnaires were filled anonymously. Data collected included age, sex, ethnicity, immunosuppressant prescribed, clinic attendance and degree and reasons for non-adherence. Our catchment area in East London has a large ethnic-minority group from the Asian subcontinent. One hundred questionnaires were given. All were filled but 10 were subsequently discarded as eight patients were on no immunosuppressants and two had a diagnosis of rheumatoid arthritis. Ninety questionnaires were analysed. Seventy per cent of patients had SLE. The remainder had other CTDs including polymyositis and Sjögren's syndrome, or vasculitides including Churg–Strauss and Wegener's granulomatosis. The studied group comprised 41 white Caucasians, 27 Afro-Caribbeans, 19 Asians and 3 Orientals. Fifty patients were on long-term steroids, 43 on hydroxychloroquine (HCQ), 15 on azathioprine (AZA), 9 on mycophenolate (MMF), 5 on methotrexate (MTX), 3 on lefluomide (LEF), 2 on sulphasalazine (SSZ) and 1 on cyclophosphamide (CYC). Fifteen (17%) patients missed their medication more often than a few times each month; 28 (31%) missed tablets less often than a few times a month; 1 patient failed to take medication at all. Overall, 43 (48%) admitted to failure of strict adherence to their immunosuppressive agent. Non-adherence was more common among non-English-speaking patients; thus Asians and Orientals reported missing tablets far more frequently compared with English-speaking Afro-Caribbean and Caucasian patients (Table 1). Analysis of poor compliance according to drug taken showed patients were least compliant with HCQ (53.5%) followed by AZA (47%), steroids (42%) and MMF (30%). Non-compliance was not reported with other immunosuppressants. Patients taking only HCQ tended to have the mildest disease and this may have been a factor in their lack of adherence. The main reasons given for not taking medication were: forgetting (70%), side-effects (14%), concerns about side-effects (14%), feeling well (5%), prescription problems (5%) and not enough explanation (5%). Our data highlight the problem of treatment adherence to long-term medications in patients with CTDs. We would reinforce the call from Chambers et al. to engage in measures aimed at improving compliance amongst this group of patients. Ethnicity distribution and adherence to immunosuppressants Ethnicity distribution and adherence to immunosuppressants Disclosure Statement: The authors have declared no conflicts of interest.