Diabetes Care: Adherence to Regimens

Approximately 21 million people have diabetes nationwide.¹ Uncontrolled diabetes in patients with type 1 and type 2 diabetes increases the risk for long-term macrovascular and microvascular complications that may lead to death.^2-4 Unfortunately, unless steps are taken to prevent these serious complications, diabetes may result in 121 million serious diabetes-related adverse events.⁵

Large-scale clinical trials such as the United Kingdom Prospective Diabetes Study and the Diabetes Control and Complications Trial provide support that the achievement of appropriate glycemic, blood pressure, and cholesterol goals dramatically decreases the likelihood of these complications.^2,3 Fortunately, new devices (eg, prefilled insulin pens) are now available to enhance the achievement of these goals.

Treatment Goals for Diabetes

The National Diabetes Education Program has created simplistic ABC treatment goals for diabetes and also steps to take to control diabetes for life.^6,7 Because the achievement of ABC goals lowers the chances of developing chronic diabetic complications, it is vital that patients understand the importance of adherence in order to achieve these goals^6-8 (Table).

Factors Impacting Adherence

Unfortunately, less than half of diabetics meet their goal ABCs. Only 37% achieve goal A1C, 36% achieve goal blood pressure, and 48% achieve goal cholesterol?and only ~7% achieve all 3 goals.⁴

Many factors impact adherence.^9,10 Common oral hypoglycemic agents for type 2 diabetes require special administration and dosing, have frequent side effects, and may be expensive.^11,12 The Cross-National Diabetes Attitudes, Wishes, and Needs study shows that 78% of type 2 diabetics take their medications on a daily basis, and between 30% and 40% maintain a consistent diet and exercise program.¹³ Up to 3 or 4 daily injections of insulin is essential in type 1 diabetes and may be needed in type 2 diabetics for intermittent or continuous glycemic control or in the case of disease progression.^11,12,14 Difficulties with adherence to insulin regimens in all types of diabetes revolve around dosing and administration requirements (timed with meals, numerous daily injections, embarrassment).^9,10,14 Approximately 83% of diabetics take their insulin as recommended, and less than 40% maintain a consistent diet and exercise program.¹³ Complicating adherence patterns is polypharmacy?diabetics average at least 4 medications daily.¹⁵

To help reach glycemic goals, self-monitoring of blood glucose (SMBG) and health care provider follow-up are necessary.⁴ Unfortunately, 30% of diabetics do not perform SMBG or see their health care provider as recommended.¹³ These factors lead to decreased adherence.

Definition of Adherence

A recent review article defines adherence as the "active, voluntary, and collaborative involvement of the patient in a mutually acceptable course of behavior to produce a therapeutic result."¹⁰ For a diabetic patient, adherence means that the patient has the motivation and willpower to take medications on a daily basis, eat a well-balanced diet, and exercise on a regular basis in order to achieve glycemic, blood pressure, and blood cholesterol goals set forth by the health care provider.

Adherence to Diet

It is important to eat the right amount of healthy foods:

• Whole grain breads
• Calcium-rich dairy products
• Fresh fruits and vegetables
• Lean meats, chicken, fish

The Food Pyramid¹⁶ and dietitians can help patients decide what to eat. Pharmacists should recommend avoiding high-salt and high-fat foods. Insulin pens are convenient for use at mealtimes.

Adherence to Exercise

Pharmacists should encourage patients to get at least 30 to 60 minutes of moderate physical activity most days of the week. Regular exercise leads to weight reduction and helps in achievement of ABC goals.⁴

Interdisciplinary Health Care Diabetic Team

Many health care professionals?pharmacists, podiatrists, optometrists, dental professionals, and physicians?coordinate the care of the diabetic patient in order to achieve appropriate goals.⁸ Pharmacists are easily accessible and have long been ranked in the Top Ten Most Trusted Professionals.¹⁷ Patients see their pharmacists 7 times as often as their doctor.¹⁸ By stressing adherence, pharmacists play an important role in helping diabetic patients achieve goal glycemic, blood pressure, and blood cholesterol levels to prevent complications.

Adherence to Medications

Polypharmacy, SMBG, diet, and exercise all impact adherence in diabetic patients. Adherence tools such as medication charts, pill containers, and caregiver prompts often are used in clinical practice. For expensive medications, patient assistance programs are available.

As stated above, new devices are now available to enhance insulin administration and SMBG adherence in patients with type 1 or type 2 diabetes.^19-25 Prefilled insulin pens make insulin administration more convenient,^19-25 and new needles used with the pens are rated by consumers as practically pain-free. For individual doses, patients simply dial the appropriate number of insulin units. Studies in patients with type 1 and type 2 diabetes show that prefilled insulin pens such as the FlexPen are discreet and convenient, easy to handle and use, and accurate, and they provide comparable blood glucose control.^19-25 Adherence may be positively impacted because of the ease of administration of prefilled insulin syringes. Increased adherence leads to fewer physician and hospital visits and lower health care costs.

For More Information

American Diabetes Association

Alexandria, VA

800-342-2383, 888-342-2383

www.diabetes.org

National Diabetes Education Program

Bethesda, MD

800-438-5383

www.ndep.nih.gov

Novo Nordisk

Princeton, NJ

800-727-6500

novonordisk-us.com

insulindevice.com

Dr. Throm is an assistant professor of pharmacy practice at Midwestern University College of Pharmacy-Glendale, Glendale, Ariz.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Rybovic, Pharmacy Times, Ascend Media Healthcare, 103 College Road East, Princeton, NJ 08540; or send an e-mail request to: arybovic@ascendmedia.com.