I read with great interest the study reported by Mioto e Silva et al. 1 The investigators developed a relevant self-administered tool to assess adherence to medical and non-medical treatment in pediatric autoimmune chronic rheumatic diseases (PARDs). A pilot study evaluated a Pediatric Rheumatology Adherence Questionnaire, applied to caregivers, in two instances: diagnosis (the first four months of disease) and after six months. The four most important PARDs was included. Poor global adherence, defined as adherence <95%, was observed in 7/33 (21%) patients, poor adherence to medical treatment in 8/33 (24%), and a trend to correlation between socioeconomic factors and poor adherence was evidenced.
There are many factors associated with non/poor adherence to drug treatment in children and adolescents with PARDs, particularly low socioeconomic status, psychological stress of parents/patients, family dysfunction, drug unavailability, insurance type and coverage, unwanted adverse events and concomitant use of more than three different types of drugs daily. 2 , 3 , 4 , 5
In addition, non/poor adherence to drug treatment and appointments in PARDs are more relevant issues, particularly in the second decade of life. 3 , 4 , 5 Indeed, adolescents have a set of biological, psychosocial and brain maturation developments, becoming more independent, with caregiver autonomy, peer connection, beginning of sexual and romantic relationships. 3 , 4 These findings may be delayed, exacerbated or impaired in adolescents with PARDs, contributing to low adherence to the use of immunosuppressive and biologic agents.
A recent web-based survey study evaluated epidemiology and management practices about childhood-onset systemic lupus erythematosus, including reports of 170/288 (59%) Latin American Pediatric Rheumatologists from 16 countries. Non-adherence to medications was the most important issue described by 97% of respondents, in spite of high frequencies of availability of glucorticosteroid, antimalarials and immunosuppressive drugs (>80%). 5
Therefore, assessing and preventing low adherence poses a great challenge in clinical practice. Direct and indirect methods may help measure poor treatment adherence and should be regularly evaluated: self-administered questionnaires, structured interviews with patients/parents, electronic monitoring devices, adherence history and measurement of serum/drug metabolite levels. 2 , 4 Specific programs for this purpose should be developed to improve compliance. Behavior and education strategies about the disease and treatments, through constructive dialogue at individual/group level with multidisciplinary teams may help PARDs patients improve adherence. 2 , 4
Funding
The author has been supported by grants from National Council for Scientific and Technological Development (CNPq; 303422/2015-7 to CAS), São Paulo Research Foundation (FAPESP; 2015/03756-4 to CAS) and by the “Núcleo de Apoio à Pesquisa em ‘Saúde da Criança e do Adolescente’” Research Support Center of University of São Paulo (NAP-CriAd) to CAS.
REFERENCES
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