Patients’ Adherence in the Maintenance Therapy of Children and Adolescents with Acute Lymphoblastic Leukemia

Abstract

Background: Acute lymphoblastic leukemia (ALL) is the most common form of paediatric cancer. Maintenance therapy as last treatment phase includes oral chemotherapy with methotrexate (MTX) and mercaptopurine (6-MP), self- or parent-administered at home, given for about 1 ½ years, and qualified as decisive for an optimum therapy outcome. The aim of our study was to analyze factors influencing the adherence of patients with ALL undergoing maintenance therapy and their families.

Methods: A multi-method study was undertaken between 11/2011 and 10/2014 with patients surveyed by the Hannover Medical School outpatient clinic, including a questionnaire survey and qualitative interviews with parents as well as blood samples of the patients.

Results: 33 questionnaires, 27 interviews and blood samples of 26 patients could be analyzed. Only one third of the blood samples showed concentrations of the 6-MP active metabolite within the therapeutic reference range. Parents named the clinical doctor as their main advisor on medication intake. 36% (12/33) of the participants stated that medication intake has not always occurred the way medication was prescribed. Drug formulation and drug intake information could be identified as determinants of adherence. Parents’ problems to obtain information are partly caused by different study results concerning the correct timing of the drug intake and drug interactions with milk products.

Conclusion: Parents’ information on drug therapy should be more consistent and the pharmaceutical formulations have to be adapted to patients’ needs to improve adherence and thereby the chance of long-term remission.

Zusammenfassung

Hintergrund: Die akute lymphoblastische Leukämie (ALL) ist die häufigste Krebserkrankung im Kindesalter. Die Erhaltungstherapie als letzte Behandlungs-Phase umfasst eine orale Chemotherapie mit Methotrexat (MTX) und Mercaptopurin (6-MP) über etwa 1 ½ Jahre und gilt als entscheidend für ein optimales Therapie-Ergebnis; die Einnahme organisieren die Patienten oder Familien zu Hause selbst. Ziel vorliegender Studie war die Analyse von Einflussfaktoren auf die Adhärenz der Patienten und ihrer Familien in der ALL-Erhaltungstherapie.

Methode: Von 11/2011 bis 10/2014 wurde eine Mixed Methods-Studie an der Medizinischen Hochschule Hannover durchgeführt, die Eltern-Fragebogen und -Interviews sowie Blutentnahmen der Patienten umfasste.

Ergebnisse: 33 Fragebogen, 27 Interviews und Blutproben von 26 Patienten wurden ausgewertet. Nur ein Drittel der Blutproben zeigte Konzentrationen des aktiven Metaboliten von 6-MP im therapeutischen Zielbereich. Die Eltern benannten den Klinikarzt als wichtige Informationsquelle für die Medikamenteneinnahme. 36% (12/33) der Befragten gaben an, dass die Medikamenteneinnahme nicht immer exakt nach Plan erfolgte. Die Arzneiform und Informationen über die Einnahme konnten als Einflussfaktoren auf die Adhärenz identifiziert werden. Probleme der Eltern, konsistente Informationen zur Erhaltungstherapie zu bekommen, begründen sich u. a. in divergierenden Studienergebnissen zum Einfluss des Einnahmezeitpunkts sowie Arzneimittelinteraktionen mit Milchprodukten.

Schlussfolgerung: Informationen der Eltern zur Arzneimitteltherapie sollten konsistenter sein und die Arzneiformen an die Patientenbedürfnisse angepasst werden, um die Adhärenz und damit die Wahrscheinlichkeit einer Langzeitremission zu erhöhen.

Key words

acute lymphoblastic leukemia - paediatrics - adherence - maintenance therapy - mixed methods

Schlüsselwörter

akute lymphoblastische Leukämie - Pädiatrie - Adhärenz - Erhaltungstherapie - Mixed methods

^* Contributed equally

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