Effect of Smart Pill Box on Improving Adherence to 6-Mercaptopurine Maintenance Therapy in Pediatric ALL

Abstract

Abstract Introduction 6-Mercaptopurine (6-MP) forms the backbone of maintenance chemotherapy for acute lymphoblastic leukemia (ALL). A Children's Oncology Group study found 3.9-fold increased risk of relapse in children with 6-MP adherence less than 90%. Objective This article estimates the impact of smart pill box in improving adherence to 6-MP during maintenance phase chemotherapy in children with ALL. Material and Methods It is a prospective interventional study done at pediatric oncology clinic of a tertiary care hospital. Participants being 40 newly diagnosed children with ALL. Baseline adherence was assessed and impact of smart pill box was estimated after using it for 60 days. Subjective and objective assessment of baseline adherence and adherence after intervention was done by subjecting the parents of the children to Morisky Medication Adherence Score 8 (MMAS-8) and measurement of patient's red blood cells (RBC) 6-MP metabolites (6-thioguanine [TGN] and 6-methylmercaptopurine [MMP]) levels, respectively, pre- and postintervention. Results The mean age was 7.39 ± 4.29 years. NUDT15*3 polymorphism was present in 10.26%, and none had TPMT polymorphism. Baseline assessment of adherence to 6-MP by MMAS-8 revealed low, medium, and high adherence in 7.5, 35, and 57.5%, respectively. Baseline 6-TGN and 6-MMP levels by cluster analysis revealed poor adherence in 10%. Following intervention, mean MMAS-8 improved from 7.34 ± 0.78 to 7.66 ± 0.55 (p-value < 0.015) and the median 6-TGN level improved from 150 to 253 pmol/8 × 108 RBCs (p-value < 0.001). Conclusion Nonadherence to 6-MP is widely prevalent in Indian children. Simple measures like smart pill box can improve adherence.