Nonadherence to treatment in lung transplant recipients: a matter of life and death

Falta de adesão ao tratamento em pacientes submetidos a transplante pulmonar: uma questão de vida ou morte Lung transplantation is a complex intervention, requiring strict adherence to a very specific medical regimen, which involves not only drug taking but also a fairly restrictive daily routine. The extent to which patients adhere to the prescribed regimen plays a key role in achieving optimal transplantation outcomes. Therefore, adherence to treatment is of great importance in the care of lung transplant recipients. The concept of adherence implies active participation by patients, who must understand their disease and the proposed treatment and strictly follow the recommendations of the health care team. The World Health Organization proposes a close partnership among physicians, multidisciplinary staff, and patients, in order to improve treatment adherence. Institute), located in the city of São Paulo, Brazil, and who died because of treatment nonadherence raised great concern about this issue, leading us to revise our multidisciplinary approach to patients and review the current knowledge of treatment adherence. An 18-year-old female patient underwent double lung transplantation for end-stage cystic fibrosis. Initial immunosuppressive therapy included basiliximab and methylprednisolone, being followed by maintenance treatment with cyclosporine (adjusted to blood levels), mycophenolate, and prednisone. The patient remained stable for a period of one year and five months, after which she presented with acute progressive shortness of breath, hypoxemia, loss of lung function, and diffuse ground-glass opacities on HRCT scans. Although her outpatient prescription drugs included cyclosporine, mycophenolate, prednisone, itraconazole, and trimethoprim-sulfamethoxazole, her cyclosporine blood levels were far below the minimum target. When queried, her caregiver admitted that, despite his efforts, she had not been taking her medication as prescribed in the past month and had been smoking narghile in her spare time. An open lung biopsy revealed grade A3 acute rejection, chronic airway rejection or bronchiolitis obliterans (C1), chronic vascular rejection (D), and organizing pneumonia. She was treated with rabbit antithymocyte globulin and corticosteroids but died as a result of alveolar hemorrhage and multiple infectious complications. Recent studies have shown that as many as 25-50% of chronic disease patients can be considered nonadherers, nonadherence being temporary in some and permanent in others. Among transplant recipients, nonadherence rates can be as high as 80%, especially in adolescent patients. Although different methods and definitions of nonadherence (e.g., missed medication doses, delayed medication use, and dose modification) can influence the aforementioned rates, (1,4) nonadherence is undoubtedly an issue …