HCPLive Network

ADA 2011: Solving the Challenge of Medication Adherence in Patients with Diabetes


Nonadherent patients with diabetes face severely increased risks of hospitalization and death.

During “The Realities of the Problem—Prevalence and Common Barriers,” part of the “Improving Compliance and Outcomes in the Era of Complex Therapeutic Regimens—What Really Works?” symposium at the ADA 71st Annual Meeting in San Diego, John R. White Jr., PharmD, provided an overview of non-adherence challenges in patients with type 2 diabetes and discussed the scope, predictors, and some solutions for improving adherence.

White said that many providers tend to think, “your patients may not be adherent, but mine are.” The fact is, most providers think their patients are adherent, when many are not. Worldwide, 50% of all patients take medication as prescribed. In the US, one-third to one-half are not taking medications as directed. Non-adherence causes 69% of medication-related hospitalizations versus 33% in those who are adherent. The annual cost of non-adherence-related problems is $290 billion. Specific to diabetes, mortality increases to 12.1% from 6.7%, the risk of hospitalization goes up to 30% from 13%, and the average annual cost nearly doubles, to $16,498 from $8,886 (non-adherent versus adherent, respectively). Quoting C. Everett Koop, White reminded the audience that the basic problem is that “Drugs don’t work in patients that don’t take them.”

Factors contributing most to non-adherence include complexity of the regimen, side effects (actual or perceived), poor provider-patient relationship, the patient’s lack of belief in the benefit of treatment, and cost or insurance reimbursement. In a study conducted in 2005, researchers found that as frequency of medication increases, adherence decreases. Another study found 38% adherence with tid dosing versus 79% adherence with qd dosing. White also cited a study of 37,431 Medicaid type 2 diabetes patients which found 15% adherence for monotherapy versus less than 5% with combination therapy.

Interestingly, and unfortunately, many of the predictors of non-adherence are commonly seen in diabetic patients. Presence of psychological problems such as depression, inadequate follow-up or discharge planning, side effects, patients’ lack of belief in the benefit of treatment, patients’ lack of insight into illness, complexity of treatment, cost, and missed appointments can all contribute to non-adherence in the general patient population, but also in diabetics. “Part of the problem in diabetes is that it is a complex metabolic disease that exists often in the presence of other conditions,” said White. So providers will find many patients taking multiple medications (eg, statins, antihypertensives). And patients have life stressors in addition to medical problems. He said that providers “have to be cognizant of all these other factors that may contribute to adherence problems.”

Putting some of the responsibility on our health care system, White examined whether providers are adherent to practice guidelines. After reviewing the literature, he found few providers who escalated treatment regimens for patients whose A1C was not under control. So clearly it is not just patients who are non-adherent.

Aside from adhering to practice guidelines themselves, providers can help improve patient adherence by implementing various strategies. First and foremost, said White, is to identify patients with poor adherence. Emphasize the value of the treatment regimen, elicit patients’ feelings, listen to patients, reinforce desirable behavior, and incorporate other communication methods for improving the provider-patient relationship. In addition, White suggests providing simple, clear instructions to patients, simplifying the regimen when possible (eg, qd versus tid), and considering more “forgiving” medications (eg, those with better side effect profiles). Finally, providers should seek help from family members or friends.

Although he painted a rather grim picture in terms of adherence, White reminded the audience that “As providers, we should do all we can to improve adherence. Even if we go through all the appropriate steps and patients don’t take their medications, we’re failing.”


Further Reading
In what could be New York City’s first case of Ebola, a doctor identified by the NY Post as Craig Spencer, 33, MD an emergency medicine physician at New York Hospital/Columbia-Presbyterian was rushed to a special Ebola unit at city-run Bellevue Hospital Center in Manhattan. Spencer returned 10 days ago from a stint as a volunteer with Doctors without Borders, caring for Ebola victims in Guinea, one of three West African nations with major outbreaks.
Patients diagnosed with diabetic retinopathy may be able to get a sense of how their condition has progressed without having to leave the comfort of their own home.
Monika Fischer, MD, talks about focusing research on patients with more severe IBD symptoms at 2014 ACG Annual Scientific Meeting in Philadelphia, PA.
Monika Fischer, MD, discusses the outcomes of a study assessing fecal microbiota transplantation for c. difficile infection at the 2014 ACG Annual Scientific Meeting in Philadelphia, PA.
For patients with untreated metastatic colorectal cancer, chemotherapy with fluorouracil, leucovorin, oxaliplatin, and irinotecan plus bevacizumab improves outcome versus fluorouracil, leucovorin, and irinotecan plus bevacizumab, according to a study published in the Oct. 23 issue of the New England Journal of Medicine.
Over the last decade, mortality rates for patients undergoing surgical repair for aortic dissection have improved, according to a study published online Oct. 21 in Circulation: Cardiovascular Quality and Outcomes.
A collaborative effort from researchers at the University of Pennsylvania and University of Florida has yielded plant leaves as a viable treatment for pulmonary hypertension.
More Reading
In what could be New York City’s first case of Ebola, a doctor identified by the NY Post as Craig Spencer, 33, MD an emergency medicine physician at New York Hospital/Columbia-Presbyterian was rushed to a special Ebola unit at city-run Bellevue Hospital Center in Manhattan. Spencer returned 10 days ago from a stint as a volunteer with Doctors without Borders, caring for Ebola victims in Guinea, one of three West African nations with major outbreaks.