Background/Purpose: Nonadherence to treatment in rheumatoid arthritis (RA) has been shown to negatively impact on treat to target goals and disease outcomes. Identifying and targeting potential factors influencing nonadherence is therefore crucial in optimising patient management. This review aims to determine factors associated with nonadherence in patients with RA.

Methods: An electronic search was performed by two independent reviewers using MEDLINE and focusing on articles published from inception to January 2017. The search strategy combined the thesaurus (MeSH) and expanded keyword searches of two concepts: RA and treatment adherence.  Inclusion criteria included observational studies and clinical trials examining potential factors associated with nonadherence. Exclusion criteria included articles not in English or without online access and those with a focus on forms of therapy other than medication. Agreement between raters at the screening stage was high (94.6%, kappa=.88).

Results: The primary search yielded 1411 papers, from which 70 were eventually identified as suitable for full review (Figure). Of the 70 papers, 62 were based on observational studies and eight on clinical trials.  Factors associated with nonadherence were broadly categorized into patient-related factors (demographics, socioeconomic factors, patient perceptions[beliefs/knowledge/attitudes]), disease-related factors (disease duration, disease activity, comorbidities, functional disability) and treatment-related factors (drug type, method of administration, concurrent treatment, side effects, cost). Many studies (74.3%) looking at beliefs, attitudes and patient knowledge reported significant associations between these factors and nonadherence. Adherence was found to be positively associated with stronger beliefs in the necessity of treatment, positive outlooks on disease control and medication, greater knowledge as well as greater self-efficacy. Studies reported greater comorbidities (n=8) including poorer mental health (n=5) to be implicated in nonadherence. Disease duration was largely non-significant in treatment adherence, although a few studies reported a negative correlation (n=3).  The use of biologics was significantly associated with greater adherence. One study identified polypharmacy to be negatively associated with adherence.  Drug side effects were associated with nonadherence (n=3). 

Conclusion: Patient-related factors including personal perceptions were among key contributors to nonadherence to medication in RA patients.  This highlights the need for addressing patient-driven perceptions, along with disease and treatment related factors as part of individualised patient care, to minimise the risk of nonadherence.

Figure showing flowchart of study selection process