The ‘Nocebo’ Impact: Experiencing Sickness When You’re Not

  • Non-adherence to medications, loss of trust among patients in their doctors, high re-switching rates, discontinuation, and wastage of medication are some of the adverse effects of nocebo effect.
  • Patients counseling can be an effective approach in addressing the nocebo effect.
  • Although the biosimilars pipeline is progressing rapidly, the nocebo effect is a real risk that may lead to low adoption of biosimilars.

The word nocebo has its origin in Latin from nocere, which means ‘to harm’. The nocebo effect may lead to treatment failures upon nonmedical switching from an originator to a biosimilar drug. However, this alone is not the only factor that may induce the nocebo effect. Nocebo effects may also be induced by exposure to drug advertisements and advertised descriptions or warnings about health-related conditions that are shared online and on social media. Non-adherence to medications, loss of trust among patients in their doctors, high re-switching rates, discontinuation, and wastage of medication are some of the adverse effects of nocebo effect.

Several studies have highlighted three major factors that may trigger the nocebo effect: negative information leading to long-lasting negative clinical effects, lack of knowledge about biosimilars, and a lack of coherence in communication between patients and healthcare professions about biosimilars.

Although the nocebo effect is not as widely studied as the placebo effect, several universities and institutes are conducting studies to determine the causes of the effect. In 2018, the researchers at the University of Copenhagen and Lund University studied the non-pharmacological effects in switching medication. The team suggested three main strategies to reduce the nocebo effect in clinical practice when switching patients from reference biologic to biosimilar: positive framing, increasing patient and healthcare professionals’ understanding of biosimilars and utilizing a managed switching program.

Effective Approach In Addressing The Nocebo Effect

Patients counseling can be an effective approach in addressing the nocebo effect. This can be done through workshops in which patients may engage with health care providers to develop personalized communications strategies related to switching from an originator to a biosimilar. Moreover, explicit communication is also recommended in case patients harbor doubts regarding the transmission (from originator to a biosimilar). This may include, definition of biosimilars and information about the evidence/clinical trials required for biosimilar approval and similarities between originator biologics and biosimilars.

Nocebo effects may also be induced by exposure to drug advertisements and advertised descriptions or warnings about health-related conditions that are shared online and on social media.

Biosimilars Pipeline

Although the biosimilars pipeline is progressing rapidly, the nocebo effect is a real risk that may lead to low adoption of biosimilars. Several studies have highlighted three major factors that may trigger the nocebo effect: negative information leading to long-lasting negative clinical effects, lack of knowledge about biosimilars, and a lack of coherence in communication between patients and healthcare professions about biosimilars. However, these factors can be addressed through a unified approach to patient communication.  This can be achieved by reporting clinical and observational results that support the use of biosimilars. Other resources such as the Dutch Hospital Pharmacists and Medical Specialist Biosimilars Toolbox can also be an effective tool. Mitigation strategies may also be effective against nocebo effects. This may include use of electrical and histaminic itch stimuli to induce positive expectations by conditioning with verbal suggestion. Enhanced communication strategy may also increase the acceptance and persistence rates of biosimilars.

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