Nonadherence to immunosuppression: challenges and solutions

Figures & data

Table 1 Evaluation of different methods to assess nonadherence to immunosuppression

Method	Advantages	Disadvantages
Direct
Medication intake observation	Verifies adherence	Clinically unpractical
Biological monitoring of drug levels in blood/urine	Reflects degree of immunosuppression. Objective	Drug’s half-life, metabolic rate, white coat adherence
Indirect
Self-reporting	Simple, cheap	Bias (patient honesty, recall)
Collateral reporting	Simple, cheap	Bias (clinicians’ overestimation)
Pharmacy refill	Objective, cheap	Not equivalent to ingestion of medication Requires a closed pharmacy system
Pill counts	Objective, simple, cheap	Discarded or hoarded doses
Electronic monitoring gold standard	Provides insight into patterns of adherence (day, time)	Expensive Discarded or hoarded doses

Table 2 Risk factors associated with nonadherence to immunosuppression

Areas related with nonadherence	Factors related with nonadherence
Socioeconomic	Socioeconomic status Race/culture Poor social support Poor social functioning Illiteracy
Patient related	History of nonadherence Adolescence Psychological disorders (depression) Psychiatric illness Personality disorders Cognitive impairment Substance abuse Negative beliefs in medications Low conscientiousness
Disease related	Longer illness duration, poor disease knowledge/insight
Treatment related	Medication side effects Complex regimen Lack of medication knowledge No pill box/reminder system
Factors related to the healthcare setting and provider	Medication cost/co-pay Poor access to medication Poor aftercare/discharge planning Poor physician–patient relationship Poor physician communication