When Adherence Is the Challenge: Matching Treatment Administration to the Patient

In this installment of Discourses in Dermatology, Steven Feldman, MD, discusses adherence as a multifactorial component of psoriasis management and considers how treatment administration may factor into individualized biologic selection. Drawing on experiences from clinical practice, he illustrates how adherence challenges can extend beyond whether a patient simply remembers to take a medication.

When the right treatment is not enough

Early in his career, Dr Feldman recalls thinking that successful psoriasis management would largely come down to making the correct diagnosis and prescribing an effective treatment. Clinical experience quickly demonstrated that treatment selection was only part of the equation.

This was particularly apparent among patients with limited disease who were prescribed topical therapies but did not improve as expected. Poor adherence to topical treatment is well recognized, and Dr Feldman emphasizes the importance of making treatment as manageable as possible for patients. In some difficult-to-treat cases, this may contribute to the decision to consider systemic therapy rather than relying on a topical regimen that a patient may struggle to maintain.

Adherence remains relevant with biologic therapy

Although adherence to systemic injectable therapies may be better than adherence to topical treatment, it is not necessarily perfect. When a patient with moderate to severe psoriasis does not achieve the anticipated response to a biologic, or initially responds and later loses efficacy, Dr Feldman argues that adherence should remain among the factors clinicians consider before concluding that the therapy itself has failed.

With self-administered biologics, adherence can also encompass more than receiving the prescribed dose on schedule. Proper delivery, storage, handling, and administration all become part of the equation.

A medication delivered to a patient's home, for example, must be stored according to its prescribing information. Dr Feldman notes that clinicians may assume these instructions are being followed correctly, but medications may be inadvertently exposed to inappropriate temperatures or undergo repeated changes in storage conditions.

When instructions do not translate into practice

Dr Feldman shares memorable examples that illustrate how differently patients may interpret seemingly straightforward instructions. In one case, a patient who had been taught injection technique using an orange subsequently injected the medication into an orange and ate it. In another, a patient instructed to inject into an area without psoriasis chose the scalp because it was the only unaffected area, repeatedly hitting bone and bending the needle.

While unusual, these examples reinforce a broader point: prescribing a treatment and explaining how to use it do not guarantee that it will be administered as intended. Misunderstandings, treatment logistics, storage, and administration technique can all introduce variability between the regimen clinicians prescribe and the treatment patients actually receive.

Reducing adherence-related variability

For some patients, in-office administration offers an opportunity to remove several of these variables. Dr Feldman explains that he favors IL-23 inhibitors in his approach to psoriasis and considers the availability of an in-office treatment option particularly relevant when adherence or medication handling is a concern.

Among IL-23 inhibitors, tildrakizumab is administered by a health care provider. This allows the clinical team to oversee storage, handling, and administration and provides greater certainty that scheduled doses are being given as intended.

Dr Feldman considers this approach particularly useful when a patient's treatment history raises questions about adherence, including situations in which therapies appear to work initially and then repeatedly lose effectiveness. Rather than viewing an inadequate response solely as pharmacologic failure, he encourages clinicians to consider whether factors surrounding medication use or handling could be contributing to the outcome.

Looking beyond efficacy when selecting treatment

Adherence is influenced by behavioral, logistical, and treatment-related factors, all of which can ultimately affect outcomes. Dr Feldman's examples illustrate why evaluating treatment response may require looking beyond the efficacy of the medication itself to consider what happens between prescribing a therapy and the patient actually receiving it.

For patients in whom self-administration or medication handling presents a concern, provider-administered therapy may offer one way to reduce that uncertainty. Incorporating these considerations into biologic selection can help clinicians match not only the medication, but also its mode of administration, to the individual patient.