Rhinitis, sinusitis, and upper airway disease
Real-life compliance and persistence among users of subcutaneous and sublingual allergen immunotherapy

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Background

Subcutaneous allergen immunotherapy (SCIT) and sublingual allergen immunotherapy (SLIT) are safe and effective treatments of allergic rhinitis, but high levels of compliance and persistence are crucial to achieving the desired clinical effects.

Objective

Our objective was to assess levels and predictors of compliance and persistence among grass pollen, tree pollen, and house dust mite immunotherapy users in real life and to estimate the costs of premature discontinuation.

Methods

We performed a retrospective analysis of a community pharmacy database from The Netherlands containing data from 6486 patients starting immunotherapy for 1 or more of the allergens of interest between 1994 and 2009. Two thousand seven hundred ninety-six patients received SCIT, and 3690 received SLIT. Time to treatment discontinuation was analyzed and included Cox proportional hazard models with time-dependent covariates, where appropriate.

Results

Overall, only 18% of users reached the minimally required duration of treatment of 3 years (SCIT, 23%; SLIT, 7%). Median durations for SCIT and SLIT users were 1.7 and 0.6 years, respectively (P < .001). Other independent predictors of premature discontinuation were prescriber, with patients of general practitioners demonstrating longer persistence than those of allergologists and other medical specialists; single-allergen immunotherapy, lower socioeconomic status; and younger age. Of the persistent patients, 56% were never late in picking up their medication from the pharmacy. Direct medication costs per nonpersistent patient discontinuing in the third year of treatment were €3800, an amount that was largely misspent.

Conclusion

Real-life persistence is better in SCIT users than in SLIT users, although it is low overall. There is an urgent need for further identification of potential barriers and measures that will enhance persistence and compliance.

Section snippets

Patients and setting

Using the World Health Organization (WHO) Anatomical and Therapeutic Class code for allergen immunotherapy, V01A, we identified all patients aged 18 years or older in the PHARMO Record Linkage System who first started immunotherapy between January 1, 1994, and December 31, 2009 (n = 7851). No prescription of immunotherapy in the 3 years preceding the start of the first course (the index course) of immunotherapy was allowed to avoid any role of long-term effects of previous courses of

Patient and treatment characteristics

Immunotherapy users were, on average, in their fourth decade of life, with a slight predominance of female sex. Users had a slightly higher SES than the general population (P < .001), as displayed in Table I. Sixty-eight percent of SCIT prescriptions and 83% of SLIT prescriptions came from general practitioners, whereas 14% of SCIT prescriptions and 1% of SLIT prescriptions came from allergologists (P < .001). SCIT was more frequently prescribed for GP allergy, whereas SLIT was more frequently

Discussion

The main conclusion from this study is that real-life persistence and compliance with immunotherapy for the most commonly treated allergens in The Netherlands is low. Median treatment duration is far less than the 3 years that are recommended to achieve long-term health benefits. Even the persistent patients, who do reach at least 3 years of treatment, frequently have late pharmacy visits. Persistence and compliance were better in SCIT users than in SLIT users, in patients treated by general

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    Supported by the Dutch Medical and health research council (ZonMW; grant 170995002).

    Disclosure of potential conflict of interest: E. Röder has received research support from ZonMw (NWO), and her thesis was financially supported by ALK-Abelló, GlaxoSmithKline, HAL, Meda Pharma, Novartis, Phadia, and Stallergenes. R. Gerth van Wijk has received consultancy fees from Allergopharma, has received research support from ZonMw (NWO), and has participated in European Academy of Allergology and Clinical Immunology immunotherapy task forces. The rest of the authors declare they have no relevant conflicts of interest.

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