Table 1
Factors Influencing Patient Adherence
Category Factors
  • Patients’ knowledge/beliefs
  • Demographic characteristics
  • Emotional/coping style
  • Psychosocial support
  • Patient’s lifestyle/preferences
  • Extent of disability
  • Lose self-esteem
  • Cognition
  • Forgetfulness
  • Symptoms
  • Treatment plan
  • Patient’s prior experience
  • Illness severity
  • Clinician’s knowledge/beliefs
  • Clinician’s role
  • Clinician’s communication style
Healthcare setting/systems-related
  • Primary or specialist care
  • Access to care
  • Economics/cost
  • Side effects
  • Fear of needles
  • Unrealistic treatment expectations
  • Ease of use/administration factors
  • Polypharmacy
  • Regimen complexity
  • Summer associated with greater nonadherence
Saiz et al. Neurologia. 2015 May;30(4):214-22.8
Rieckmann et al. Mult Scler Relat Disord. 2015 May;4(3):202-18.9
Costello et al. Medscape J Med. 2008;10(9):225.10

Table 2
Enhancing Clinician-Patient Communication
Category Technique
Conversational/listening skills
  • Sitting down during consultation
  • Attending to patient comfort
  • Listening without interrupting
  • Showing attention by using nonverbal cues
  • Being silent while patients search for words
  • Acknowledging/legitimizing feelings
  • Explaining/reassuring
  • Asking for areas of concern
  • Motivational interviewing
  • Asking direct but nonconfrontational questions
Use of “prompt sheets”
  • Increases patients’ asking of questions
  • May increase patients’ knowledge/understanding
  • May empower patients
  • Does not necessarily increase length of consultation
Rieckmann et al. Mult Scler Relat Disord. 2015 May;4(3):202-18.9
Costello et al. Medscape J Med. 2008;10(9):225.10

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Table 3
Interventions to Promote Adherence
Factor Affecting Adherence Intervention
Forgetting medication dose(s)
  • Perform cognitive assessment, including assessment for memory problems
  • Adjust frequency/complexity of regimen
  • Arrange for telephone or text support/reminders
  • Incorporate family, significant others into treatment plan
  • Consider switching to DMT with less frequent dosing
Flu-like symptoms
  • Explain to patients that medication is not actually “giving them the flu”
  • Educate patients about pattern/duration of symptoms
  • Gradual dose titration from low initial dose to full dose
  • Concomitant use of antipyretic or NSAID
  • Evening administration of injections to allow patient to sleep through symptoms
  • Schedule injections on days when symptoms will be least disruptive
  • Treat with NSAIDs or acetaminophen pre-and post-injection
  • Consider low-dose oral steroids at treatment initiation
  • Incorporate use of sleep aids
  • Consider dose reduction
Injection site reactions and pain Prevention

  • Site rotation
  • Thorough washing of hands
  • Clean injection site
  • Room temperature medication
  • Allow alcohol to dry before injection
  • Replace alcohol swab with soap/water
  • Avoid vigorous rubbing of site
  • Hold needle upward to keep it dry pre-injection
  • Pretreat site with ice for 1 minute
  • Some patients find it helpful to apply heat rather than ice to injection site before injection
  • Ensure complete needle penetration below skin surface before injecting intradermally
  • Use an autoinjector to help achieve appropriate needle depth
  • Use ethyl chloride spray or topical anesthetics (eg, lidocaine)
  • Enlist support of injection-training nurses from pharmaceutical company


  • Apply ice or cold compress to reduce swelling
  • Apply warmth is swelling persists > 1 day
  • Use hydrocortisone cream for swelling/rash
  • Try EMLA cream

Avoid injections

  • Consider initiating therapy with oral agent
Injection-related fear/anxiety
  • Assess patient’s self-efficacy
  • Enlist support of family, significant others
  • Use motivational interviewing
  • Consider mindfulness training and guided imagery
  • Consider thinner gauge or shorter needle
  • Switch to autoinjector
  • Consider CBT
  • Consider initiating therapy with oral agent
Fatigue/tiring of injections
  • Consider mindfulness/CBT for fatigue
  • Adjust frequency and complexity of regimen
  • Consider switch to DMT with less frequent dosing
  • Consider treatment for depression or other psychosocial factors
  • Consider initiating therapy with oral agent
Economic/financial challenges
  • Enlist support of social worker
  • Facilitate contact with medication assistance programs for DMTs
Lack of motivation
  • Use motivational interviewing
  • Recommend telephone counseling and help lines
  • Provide education regarding the illness
  • Facilitate shared decision-making
DMT = Disease modifying therapies; NSAID = Nonsteroidal anti-inflammatory drugs;
EMLA = Eutectic mixture of local anesthetics; CBT = Cognitive behavioral therapy
Remington et al. Int J MS Care. 2013;15:36-45.4
Rieckmann et al. Mult Scler Relat Disord. 2015 May;4(3):202-18.9
Costello et al. Medscape J Med. 2008;10(9):225.10
Kim W, Zandoná ME, Kim S-H, Kim HJ. J Clin Neurol. 2015 Jan; 11(1): 9-19.14
Torkildsen Ø, Myhr KM, Bø L. Eur J Neurol. 2016 Jan;23 Suppl1:18-27.15
Mohr et al. J Behav Ther Exp Psychiatry. 2002 Mar;33(1):39-47.16