Combating Nonadherence in Diabetes

Troy Trygstad, PharmD, MBA, PhD; Tripp Logan, PharmD; Richard Wynn, MD; Steven Peskin, MD, MBA; and Dhiren Patel, PharmD, share their insights into the complexity of nonadherence in diabetes and discuss ways to overcome barriers that patients may face.

Troy Trygstad, PharmD, MBA, PhD: Tripp, what is the most challenging nonadherence patient circumstance you’ve come across? How did you address it?

Tripp Logan, PharmD: The most challenging? Each one is equally challenging, correct? I don’t know that I’d give you a specific example. The challenge is so personal to each person. That is the challenge: coming up with whatever, for that particular patient, the reason is for the nonadherence. When I hear nonadherence in a community pharmacy, we think of so many claims of a prescription that are being filled over a certain amount of time and the proportion of days covered. But really, adherence, to me, is adherence of the care plan to be at goal. And so, understanding what those barriers are, that’s the No. 1 thing. Specifically, for that patient, ask, “What are your barriers, and what can we help you overcome?”

Troy Trygstad, PharmD, MBA, PhD: Dr. Wynn, one that sticks out in your mind?

Richard Wynn, MD: Mental health issues, probably. Sometimes, you’re negotiating with a patient and their illness. A schizophrenic or a bipolar patient has medications that tend to increase their blood sugars and increase their resistance to insulin. So, controlling their mental health, or improving their mental health, means the worst thing in diabetes. You have to find a balance and have a different goal for this patient. Sometimes you have to talk with the psychiatrist. Sometimes you talk with the patient. And sometimes it’s health beliefs that are based on their mental illness that you have to negotiate with. “This shot doesn’t have bad spirits” or those kinds of things. International patients have health beliefs that are completely different from Americans. Their assumptions about what health is may be different.

Troy Trygstad, PharmD, MBA, PhD: So, meeting the patient where they’re at?

Richard Wynn, MD: Yes.

Troy Trygstad, PharmD, MBA, PhD: Behavioral health makes it more challenging to meet the patient where they’re at.

Richard Wynn, MD: You have a lot of different options and ways to treat them. You have to negotiate the way that works for them and gives the best outcome that they can deal with.

Troy Trygstad, PharmD, MBA, PhD: Steven, do you have a specific adherence circumstance that you can think of, in your mind?

Steven Peskin, MD, MBA: Well, since I’m a systems person, I absolutely am going with what you just said—meeting the patient where you’re at. So, the nonadherence issue around understanding the health literacy, the health numeracy, or lack thereof, or the person. Sometimes it’s economic. Sometimes it’s not. From a system level, where we see the gap is in that inability to meet the persons where they are and where the persons fall through the proverbial cracks.

Dhiren Patel, PharmD: I would say that I don’t have one, but a common theme that I see, where I sit in endocrinology, is when it comes to initiation of injectables—specifically, around insulin. And so, over the years, there are 2 things that I’ve noticed and been very successful with for patients who need to be on therapy. First, it’s explaining what it is and how it works, which is usually never the case. I have patients that I also pick up after 10, 15 years. I’ll say, “Do you know what this is or why you’re actually taking it, other than that it is just for diabetes?“ You actually explain it and discuss how it’s an endogenous hormone that is there. And then the other is actually doing the first injection in clinic.

Those are the 2 things that I found to be extremely helpful in converting a patient, talking to them, and overcoming those adherence issues. Typically, the common theme that we’ll see is that patients are unwilling to inject. “Help me figure out what else I can do if the patient’s sitting at an A1C of 10% or 11%.” But you peel back a few of the layers and you quickly figure out that they’re not resistant to or afraid of needles. Everyone is just inherently afraid because they don’t deal with it.

Tripp Logan, PharmD: They’re afraid of the unknown.

Dhiren Patel, PharmD: That’s it.