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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Editor-in-Chief
    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
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Assessment of Medication Adherence and Pharmacist Intervention Are Important for the Care of Patients with Inflammatory Bowel Disease

Eun Sil Kim1 , Ben Kang2

1Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, and 2Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea

Correspondence to: Ben Kang
ORCID https://orcid.org/0000-0002-8516-9803
E-mail benkang@knu.ac.kr

See “Improvement in Medication Adherence after Pharmacist Intervention Is Associated with Favorable Clinical Outcomes in Patients with Ulcerative Colitis” by Jae Song Kim, et al. on page 736, Vol. 16, No. 5, 2022.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2022;16(5):665-666

Published online September 15, 2022, Published Date September 15, 2022 https://doi.org/10.5009/gnl220358

Copyright © Gut and Liver.

Considering the requirement of life-long management in patients with inflammatory bowel disease (IBD), adherence to medication is a crucial factor in the management of patients with ulcerative colitis (UC) and Crohn’s disease.1 Previous studies have demonstrated that non-adherence affects 40% to 60% of patients with UC, and has a substantial impact on the course of the disease.2,3 Non-adherence to treatment in patients with IBD may negatively influence patient outcomes, such as increased risk of flares or hospitalization, leading to increased healthcare resource use and costs.3-6 Thus, improving medication adherence in the treatment of IBD is a significant challenge for clinicians.

Three factors create barriers to medication adherence; patients, clinicians and health care system factors.7 Patient factors include inadequate participation in the decision-making process during treatment, previous unpleasant experiences with drugs, poor medical knowledge about their underlying disease, and misbeliefs regarding medication efficacy. Clinician factors include complex prescription and insufficient explanation regarding the effectiveness and side effects of medications. Health care system factors include insurance and accessibility. Taking into account of these factors, it is possible to increase treatment adherence by the intervention of a multidisciplinary team including pharmacists.

Investigating the relationship between medication adherence and clinical outcomes after pharmacist intervention in patients with UC is essential for improving the therapeutic strategy of IBD. Kim et al.8 demonstrated that pharmacist intervention had a significant impact on medication adherence and disease outcome in UC. In this study, the clinical outcomes were compared by dividing non-adherers into the control and intervention groups. The authors found that the non-adherence rate significantly decreased from 60.6% to 30.3% after 6 months in the pharmacist intervention group. In addition, pharmacist intervention affected time-related partial Mayo score, which decreased by 0.094 every month. Moreover, pharmacist intervention (adjusted odds ratio [OR], 0.370; 95% confidence interval [CI], 0.0145 to 0.945; p=0.038) as well as factors associated with disease severity such as baseline partial Mayo score (adjusted OR, 1.333; 95% CI, 1.039 to 1.710; p=0.024) and history of 1-year prior corticosteroid use (adjusted OR, 3.312; 95% CI, 1.035 to 10.597; p=0.044) were independent factors influencing flare up-free survival.

Special interest should also be focused on the assessment of medication adherence. The assessment of medication adherence can be divided into direct and indirect methods.7,9 Direct methods refer to the measurement of drug or metabolite levels, which is capable of revealing whether the patient has been adherent to not to a specific medication. In the treatment of IBD, thiopurine metabolite monitoring is currently used to assess adherence in patients taking thiopurines. However, its use is currently limited in many centers worldwide. Meanwhile, indirect methods include patient questionnaires, patient diaries, pill counts, rates of prescription refills, assessment of patient’s clinical response, electronic medication monitors or measurement of physiologic markers. While self-reported questionnaires or patient diaries are subjective and are inclined to a certain degree of bias, objective measures such as pill counts or electronic medication monitors including medication possession ratio or proportion of days covered are simple and possess the apparent potential to best measure treatment adherence. In this point of view, Kim et al.8 used an indirect, however objective method, by investigating medication possession ratio to assess medication adherence in patients. It is now time for IBD specialists to focus on assessing medication adherence in real-world practice.

As IBD treatment requires patient-centered treatment and multidisciplinary team approach, there is a need for increased awareness of assessing medication adherence, and subsequent pharmacist intervention to improve medication adherence and disease outcomes in patients with IBD. A collaborative approach among gastroenterologists and pharmacists in treating patients with IBD is required to improve medication adherence and furthermore possibly help reach the target and eventually modify the natural course of disease in the era of treat-to-target.10

No potential conflict of interest relevant to this article was reported.

  1. Michetti P, Weinman J, Mrowietz U, et al. Impact of treatment-related beliefs on medication adherence in immune-mediated inflammatory diseases: results of the Global ALIGN Study. Adv Ther 2017;34:91-108.
    Pubmed KoreaMed CrossRef
  2. Kane SV, Cohen RD, Aikens JE, Hanauer SB. Prevalence of nonadherence with maintenance mesalamine in quiescent ulcerative colitis. Am J Gastroenterol 2001;96:2929-2933.
    Pubmed CrossRef
  3. Kane SV, Robinson A. Review article: understanding adherence to medication in ulcerative colitis: innovative thinking and evolving concepts. Aliment Pharmacol Ther 2010;32:1051-1058.
    Pubmed CrossRef
  4. Kane S, Huo D, Aikens J, Hanauer S. Medication nonadherence and the outcomes of patients with quiescent ulcerative colitis. Am J Med 2003;114:39-43.
    Pubmed CrossRef
  5. Kane SV, Chao J, Mulani PM. Adherence to infliximab maintenance therapy and health care utilization and costs by Crohn's disease patients. Adv Ther 2009;26:936-946.
    Pubmed CrossRef
  6. Mitra D, Hodgkins P, Yen L, Davis KL, Cohen RD. Association between oral 5-ASA adherence and health care utilization and costs among patients with active ulcerative colitis. BMC Gastroenterol 2012;12:132.
    Pubmed KoreaMed CrossRef
  7. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-497.
    Pubmed CrossRef
  8. Kim JS, Geum MJ, Son ES, Yu YM, Cheon JH, Kwon KH. Improvement in medication adherence after pharmacist intervention is associated with favorable clinical outcomes in patients with ulcerative colitis. Gut Liver 2022;16:736-745.
    Pubmed CrossRef
  9. Anghel LA, Farcas AM, Oprean RN. An overview of the common methods used to measure treatment adherence. Med Pharm Rep 2019;92:117-122.
    Pubmed KoreaMed CrossRef
  10. Turner D, Ricciuto A, Lewis A, et al. STRIDE-II: an update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD. Gastroenterology 2021;160:1570-1583.
    Pubmed CrossRef

Article

Editorial

Gut and Liver 2022; 16(5): 665-666

Published online September 15, 2022 https://doi.org/10.5009/gnl220358

Copyright © Gut and Liver.

Assessment of Medication Adherence and Pharmacist Intervention Are Important for the Care of Patients with Inflammatory Bowel Disease

Eun Sil Kim1 , Ben Kang2

1Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, and 2Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea

Correspondence to:Ben Kang
ORCID https://orcid.org/0000-0002-8516-9803
E-mail benkang@knu.ac.kr

See “Improvement in Medication Adherence after Pharmacist Intervention Is Associated with Favorable Clinical Outcomes in Patients with Ulcerative Colitis” by Jae Song Kim, et al. on page 736, Vol. 16, No. 5, 2022.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Considering the requirement of life-long management in patients with inflammatory bowel disease (IBD), adherence to medication is a crucial factor in the management of patients with ulcerative colitis (UC) and Crohn’s disease.1 Previous studies have demonstrated that non-adherence affects 40% to 60% of patients with UC, and has a substantial impact on the course of the disease.2,3 Non-adherence to treatment in patients with IBD may negatively influence patient outcomes, such as increased risk of flares or hospitalization, leading to increased healthcare resource use and costs.3-6 Thus, improving medication adherence in the treatment of IBD is a significant challenge for clinicians.

Three factors create barriers to medication adherence; patients, clinicians and health care system factors.7 Patient factors include inadequate participation in the decision-making process during treatment, previous unpleasant experiences with drugs, poor medical knowledge about their underlying disease, and misbeliefs regarding medication efficacy. Clinician factors include complex prescription and insufficient explanation regarding the effectiveness and side effects of medications. Health care system factors include insurance and accessibility. Taking into account of these factors, it is possible to increase treatment adherence by the intervention of a multidisciplinary team including pharmacists.

Investigating the relationship between medication adherence and clinical outcomes after pharmacist intervention in patients with UC is essential for improving the therapeutic strategy of IBD. Kim et al.8 demonstrated that pharmacist intervention had a significant impact on medication adherence and disease outcome in UC. In this study, the clinical outcomes were compared by dividing non-adherers into the control and intervention groups. The authors found that the non-adherence rate significantly decreased from 60.6% to 30.3% after 6 months in the pharmacist intervention group. In addition, pharmacist intervention affected time-related partial Mayo score, which decreased by 0.094 every month. Moreover, pharmacist intervention (adjusted odds ratio [OR], 0.370; 95% confidence interval [CI], 0.0145 to 0.945; p=0.038) as well as factors associated with disease severity such as baseline partial Mayo score (adjusted OR, 1.333; 95% CI, 1.039 to 1.710; p=0.024) and history of 1-year prior corticosteroid use (adjusted OR, 3.312; 95% CI, 1.035 to 10.597; p=0.044) were independent factors influencing flare up-free survival.

Special interest should also be focused on the assessment of medication adherence. The assessment of medication adherence can be divided into direct and indirect methods.7,9 Direct methods refer to the measurement of drug or metabolite levels, which is capable of revealing whether the patient has been adherent to not to a specific medication. In the treatment of IBD, thiopurine metabolite monitoring is currently used to assess adherence in patients taking thiopurines. However, its use is currently limited in many centers worldwide. Meanwhile, indirect methods include patient questionnaires, patient diaries, pill counts, rates of prescription refills, assessment of patient’s clinical response, electronic medication monitors or measurement of physiologic markers. While self-reported questionnaires or patient diaries are subjective and are inclined to a certain degree of bias, objective measures such as pill counts or electronic medication monitors including medication possession ratio or proportion of days covered are simple and possess the apparent potential to best measure treatment adherence. In this point of view, Kim et al.8 used an indirect, however objective method, by investigating medication possession ratio to assess medication adherence in patients. It is now time for IBD specialists to focus on assessing medication adherence in real-world practice.

As IBD treatment requires patient-centered treatment and multidisciplinary team approach, there is a need for increased awareness of assessing medication adherence, and subsequent pharmacist intervention to improve medication adherence and disease outcomes in patients with IBD. A collaborative approach among gastroenterologists and pharmacists in treating patients with IBD is required to improve medication adherence and furthermore possibly help reach the target and eventually modify the natural course of disease in the era of treat-to-target.10

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Michetti P, Weinman J, Mrowietz U, et al. Impact of treatment-related beliefs on medication adherence in immune-mediated inflammatory diseases: results of the Global ALIGN Study. Adv Ther 2017;34:91-108.
    Pubmed KoreaMed CrossRef
  2. Kane SV, Cohen RD, Aikens JE, Hanauer SB. Prevalence of nonadherence with maintenance mesalamine in quiescent ulcerative colitis. Am J Gastroenterol 2001;96:2929-2933.
    Pubmed CrossRef
  3. Kane SV, Robinson A. Review article: understanding adherence to medication in ulcerative colitis: innovative thinking and evolving concepts. Aliment Pharmacol Ther 2010;32:1051-1058.
    Pubmed CrossRef
  4. Kane S, Huo D, Aikens J, Hanauer S. Medication nonadherence and the outcomes of patients with quiescent ulcerative colitis. Am J Med 2003;114:39-43.
    Pubmed CrossRef
  5. Kane SV, Chao J, Mulani PM. Adherence to infliximab maintenance therapy and health care utilization and costs by Crohn's disease patients. Adv Ther 2009;26:936-946.
    Pubmed CrossRef
  6. Mitra D, Hodgkins P, Yen L, Davis KL, Cohen RD. Association between oral 5-ASA adherence and health care utilization and costs among patients with active ulcerative colitis. BMC Gastroenterol 2012;12:132.
    Pubmed KoreaMed CrossRef
  7. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-497.
    Pubmed CrossRef
  8. Kim JS, Geum MJ, Son ES, Yu YM, Cheon JH, Kwon KH. Improvement in medication adherence after pharmacist intervention is associated with favorable clinical outcomes in patients with ulcerative colitis. Gut Liver 2022;16:736-745.
    Pubmed CrossRef
  9. Anghel LA, Farcas AM, Oprean RN. An overview of the common methods used to measure treatment adherence. Med Pharm Rep 2019;92:117-122.
    Pubmed KoreaMed CrossRef
  10. Turner D, Ricciuto A, Lewis A, et al. STRIDE-II: an update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD. Gastroenterology 2021;160:1570-1583.
    Pubmed CrossRef
Gut and Liver

Vol.16 No.5
September, 2022

pISSN 1976-2283
eISSN 2005-1212

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