Diabetic Medication Adherence Aids Outcomes

Jenna Herman, DNP, APRN, FNP-BC
Friday February 15, 2019
Diabetes affects about 400 million people internationally and more than 25 million in the United States.1

By 2030, diabetes is predicted to be one of the top 10 causes of morbidity worldwide.Type 2 diabetes (T2D) is the more common type. It is a focal point for many health care organizations and providers because of its cost, frequency, and potential complications that may adversely affect quality of life.3

DIABETES TREATMENT
Treatment options vary for T2D, but they often include increased physical activity, prescriptions (insulin, oral antidiabetic medication), and weight loss.Lifestyle modifications are the cornerstone of T2D treatment. The benefits of 1 kilogram of weight loss have been substantiated in studies.Ongoing monitoring of T2D, however, can be a challenge for both patients and providers, given its complexity. Patients living with the disease are responsible for many of the tasks required to manage their own day-to-day care. These tasks consist of tracking blood sugar, diet and exercise, and sometimes medication administration.Providers partner with patients in treating T2D; they make referrals, manage comorbidities, monitor the evolution of the disease (such as elevated glycated hemoglobin A1c [HbA1c]), and prescribe medication as appropriate.1

In addition to nonpharmacological measures, more than two-thirds of patients with T2D take oral antidiabetic medication or use insulin.Medication adherence to both of these agents is poor. Average adherence rates hover around 60% for insulin and 75% for oral antidiabetic medication.2,6 Other studies report that the nonadherence numbers may be as high as one-third of patients with T2D.7,8 With most patients with T2D taking medication and varying rates of medication adherence, exploring the factors influencing nonadherence is important, given the lifelong changes required to treat the disease.2

FACTORS AFFECTING MEDICATION ADHERENCE
Medication adherence is complicated, as it encompasses several patient behaviors, such as filling the prescription, receiving the medication, remembering and following provider prescription instructions, and taking the medication.Nonadherence may be deliberate or inadvertent. Intentional nonadherence is an active action by the patient to not comply with the recommended treatment plan, whereas unintentional nonadherence is a passive action, such as carelessness or forgetfulness, in following the treatment plan.8,9 Factors that positively affect medication adherence are the patient–provider relationship, self-efficacy, self-esteem, and social support.2,10

Higher rates of nonadherence are present in certain ethnic and racial minorities, females, and those with cormorbidities,high HbA1c levels, and lower levels of education and socioeconomic status.7,8 Additional factors include adverse effects, concern that generic medications are ineffective compared with brand name ones, cost, displeasure when the medication does not have an immediate effect on the patient’s T2D, feeling burned out with diabetic treatment, forgetfulness, inconvenience, and a perceived lack of support from family or the health care provider.1,7,8 Depression has also been studied as an influencer of medication adherence, but more research is needed.10

Medication nonadherence contributes to T2D costly complications that include amputations, heart attacks, mortality, nephropathy, retinopathy, and strokes.Patients with T2D who practice full or partial adherence to their medications had substantially lower complication rates than nonadherent patients.11 Adherence data indicate that diabetes-related morbidity was reduced by about 20%, heart attacks by about 15%, retinopathy complications by more than one-third, and strokes by 10%.Interestingly, however, hypoglycemia is experienced more frequently by adherent patients than nonadherent ones.1

CLINICAL PRACTICE IMPLICATIONS
Diabetes treatment should be guided by a patient’s needs to ensure an individualized plan is developed to address behavioral and lifestyle modifications. Study results show that when interventions were implemented for behavioral, economic, and educational barriers to medication nonadherence, adherence improved by 40%.Patients who have access to primary care also have greater adherence to American Diabetes Association T2D recommendations, including medication.12

Taking a broad focus and perspective on patients’ occupations, relationships, and social support systems is crucial because these areas may influence their opinions and outlooks on their treatment plans. These topics should be discussed before beginning a diabetes treatment plan.

Open-ended questions can be helpful, such as, “Is there a particular concern you would like to discuss today?” or “What challenges are you dealing with related to your diabetes?”Health care providers need to understand that 1 component of complete and thorough care is evaluating medication adherence at each patient visit while simultaneously addressing any health care system or patient barriers, if appropriate. Providers should also alter their evaluation and prescription practices through evidence-based practice to positively affect medication adherence.11

T2D is a common and costly disease. With so many patients taking medication for T2D, it is essential for providers to recognize risk factors for medication nonadherence, educate patients about potential barriers, and follow through in keeping patients as partners in the lifelong treatment.
 

REFERENCES

  1. Gordon J, McEwan P, Idris I, Evans M, Puelles J. Treatment choice, medication adherence and glycemic efficacy in people with type 2 diabetes: a UK clinical practice database study. BMJ Open Diab Res Care. 2018;6(1):e000512. doi: 10.1136/ bmjdrc-2018-000512.
  2. Sapkota S, Brien JA, Greenfield JR, Aslani P. Systematic review of interventions addressing adherence to anti-diabetic medications in patients with type 2 diabetes--components of interventions. PLoS ONE. 2015;10(6):e0128581. doi: 10.1371/ journal.pone.0128581.
  3. McAdam-Marx C, Bellows BK, Unni S, et al. Impact of adherence and weight loss on glycemic control in patients with type 2 diabetes: cohort analyses of integrated medical record, pharmacy claims, and patient-reported data. J Manag Care Spec Pharm. 2014;20(7):691-700.
  4. Bartol T. Improving the treatment experience for patients with type 2 diabetes: role of the nurse practitioner. J Am Acad Nurse Pract. 2012;24(suppl 1):270-276. doi: 10.1111/j.1745-7599.2012.00722.x.
  5. CDC. Age-adjusted percentage of adults with diabetes using diabetes medication, by type of medication, United States 1997-2011. CDC website. cdc.gov/diabetes/sta- tistics/meduse/fig2.htm. Updated November 19, 2013. Accessed December 21, 2018.
  6. McGovern A, Tippu Z, Hinton W, Munro N, Whyte M, de Lusignan S. Systematic review of adherence rates by medication class in type 2 diabetes: a study protocol. BMJ Open. 2016;6(2):e010469. doi: 10.1136/bmjopen-2015-010469.
  7. Nelson LA, Wallston KA, Kripalini S, LeStourgeon LM, Williamson SE, Mayberry LS. Assessing barriers to diabetes medication adherence using the Information- Motivation-Behavioral skills model. Diabetes Res Clin Pract. 2018;142:374-384. doi: 10.1016/j.diabres.2018.05.046.
  8. Jaam M, Mohamed Ibrahim MI, Kheir N, Hadi MA, Diab MI, Awaisu A. Assessing prevalence of and barriers to medication adherence in patients with uncontrolled diabe- tes attending primary healthcare clinics in Qatar. Prim Care Diabetes. 2018;12(2):116- 125. doi: 10.1016/j.pcd.2017.11.001.
  9. Wheeler KJ, Roberts ME, Neiheisel MB. Medication adherence part two: Predictors of nonadherence and adherence. J Am Assoc Nurse Pract. 2014;26(4):225-232. doi: 10.1002/2327-6924.12105.
  10. Adam J, Folds L. Depression, self-efficacy and adherence in patients with type 2 diabetes. J Nurse Pract. 2014;10(9):646-652. doi: 10.1016/j.nurpra.2014.07.033.
  11. Bansilal S, Wei HG, Castellano J, et al; Assessing the impact of medication adherence on long-term outcomes in patients with diabetes. J Am Coll Cardiol. 2015;65(suppl 10). doi: 10.1016/S0735-1097(15)61409-7.
  12. Kuo YF, Goodwin JS, Chen NW, Lwin KK, Baillargeon J, Raji MA. Diabetes mellitus care provided by nurse practitioners vs primary care physicians. J Am Geriatr Soc. 2015;63(10): 1980-1988. doi: 10.1111/jgs.13662.



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