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Azathioprine and Mycophenolate Mofetil Adherence Patterns and Predictors among Medicaid Beneficiaries with Systemic Lupus Erythematosus

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Feldman CH1, Collins J2, Zhang Z1, Xu C1, Subramanian SV3, Kawachi I3, Solomon DH1, Costenbader KH1. Arthritis Care Res (Hoboken). 2018 Oct 24. doi: 10.1002/acr.23792. [Epub ahead of print]

Abstract

Author information 1 Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Boston, MA. 2 The Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Brigham and Women's Hospital, Boston, MA. 3 Department of Social Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA.

Abstract OBJECTIVE: Azathioprine (AZA) and mycophenolate mofetil (MMF) are frequently used immunosuppressives for moderate-to-severe SLE. We studied longitudinal patterns and predictors of adherence to AZA and MMF in a nationwide U.S. SLE cohort.

METHODS: In the Medicaid Analytic eXtract (2000-2010), we identified SLE patients who initiated AZA or MMF (no use in prior 6 months) with >12 months of continuous follow-up. We dichotomized adherence at 80% with >24/30 days/month considered adherent. We used group-based trajectory models to estimate monthly adherence patterns and multivariable multinomial logistic regression to determine the association between demographic, SLE and utilization-related predictors and the odds ratios (OR) of belonging to a nonadherent vs. the adherent trajectory, separately for AZA and MMF.

RESULTS: We identified 2,309 AZA initiators and 2,070 MMF initiators with SLE. Four-group trajectory models classified 17% of AZA and 21% of MMF initiators as adherent. AZA and MMF nonadherers followed similar trajectory patterns. Black race (OR 1.67, 95% CI 1.20-2.31) and Hispanic ethnicity (OR 1.58, 95% CI 1.06-2.35) increased odds of AZA nonadherence; there were no significant associations between race/ethnicity and MMF nonadherence. Male sex and polypharmacy were associated with lower odds of nonadherence to both medications; lupus nephritis was associated with lower odds of nonadherence to MMF (OR 0.74, 95% CI 0.55-0.99).

CONCLUSIONS: Adherence to AZA or MMF over the first year of use was rare. Race, sex and lupus nephritis were modestly associated with adherence, but the magnitude, direction and significance of predictors differed by medication suggesting the complexity of predicting adherence behavior.