Nonadherence of Oral Antihyperglycemic Medication Will Increase Risk of End-Stage Renal Disease

Clinical efficacy and cost-effectiveness of metformin in different patient populations: A narrative review of real-world evidence

Over the past two decades, diabetes pharmacopoeia has flourished, with new drugs that, on top of their glucose-lowering efficacy, have been shown to protect the heart and the kidney. Despite these new opportunities, metformin retains a pivotal role among glucose-lowering agents. As one of the few available insulin sensitizers, metformin is an effective, safe, and overall well-tolerated drug backed by over 60 years of clinical experience, including evidence for potential benefits beyond glucose reduction across different ages, sexes, genetic backgrounds, geographical areas, and stages of disease. Although there is some discussion of whether metformin offers the most effective front-line option in newly diagnosed type 2 diabetes (T2D), it remains a natural companion to all other glucose-lowering agents. Furthermore, metformin comes at a very low cost and, as such, it has extremely high cost-effectiveness, particularly given the serious economic burden associated with diabetes complications. This financial advantage is particularly relevant in resource-constrained healthcare systems, where the affordability of metformin may be instrumental in implementing an effective treatment in an evergrowing number of individuals. We present here compelling real-world evidence in support of the clinical efficacy and cost-effectiveness of metformin across different patient populations, highlighting areas where more population-based studies are needed to further incorporate and consolidate its use in the pharmacological management of T2D.

Initiation of lipid-lowering therapy as primary prevention of cardiovascular disease in the elderly

AIMS

This study aimed to analyse the initiation adherence phase to lipid-lowering therapy for primary prevention of cardiovascular disease in a Spanish population aged 70 years or older. The secondary objective was to identify the determinants of initiation and early discontinuation.

METHODS

This was an observational study conducted in the CArdiovascular Risk factors for HEalth Service research (CARhES) cohort. People aged 70 and older with a first prescription of a lipid-lowering drug and without a previous major adverse cardiovascular event (MACE) were selected (2018-2021). Data on sociodemographics, clinical conditions, drugs and use of health services were collected from clinical and administrative electronic databases. The study population was classified into: non-initiation, early discontinuation (i.e., discontinuation after the first dispensing) and initiation with more than one dispensing. Their characteristics were compared. Determinants of initiation and early discontinuation were explored.

RESULTS

Among the 15 019 people studied, 80.2% initiated the medication, 11.2% showed an early discontinuation and 8.6% were non-initiators. An older age or conditions such as dementia, diabetes or depression reduced the likelihood of initiation, while obesity and a high pharmacological burden increased it. People over 90 years of age or those prescribed a statin in combination were more likely to have an early discontinuation.

CONCLUSIONS

Non-initiation and early discontinuation are common among older people prescribed lipid-lowering drugs as primary prevention of cardiovascular disease for the first time. The presence of chronic pathologies other than cardiovascular ones should be considered when assessing whether or not to prescribe these drugs in the elderly.

The differential impact of a 6-versus 12-month pharmacist-led interprofessional medication adherence program on medication adherence in patients with diabetic kidney disease: the randomized PANDIA-IRIS study

Background: For every 100 patients with diabetes, 40 will develop diabetic kidney disease (DKD) over time. This diabetes complication may be partly due to poor adherence to their prescribed medications. In this study, we aimed to evaluate the differential impact of a 6- versus 12-month pharmacist-led interprofessional medication adherence program (IMAP) on the components of adherence (i.e., implementation and discontinuation) in patients with DKD, during and after the intervention. Methods: All included patients benefited from the IMAP, which consists in face-to-face regular motivational interviews between the patient and the pharmacist based on the adherence feedback from electronic monitors (EMs), in which the prescribed treatments were delivered. Adherence reports were available to prescribers during the intervention period. Patients were randomized 1:1 into two parallel arms: a 12-month IMAP intervention in group A versus a 6-month intervention in group B. Adherence was monitored continuously for 24 months post-inclusion during the consecutive intervention and follow-up phases. In the follow-up phase post-intervention, EM data were blinded. Blood pressure was measured by the pharmacist at each visit. The repeated measures of daily patient medication intake outcomes (1/0) to antidiabetics, antihypertensive drugs, and statins were modeled longitudinally using the generalized estimated equation in both groups and in both the intervention and the follow-up phases. Results: EM data of 72 patients were analyzed (34 in group A and 38 in group B). Patient implementation to antidiabetics and antihypertensive drugs increased during the IMAP intervention phase and decreased progressively during the follow-up period. At 12 months, implementation to antidiabetics was statistically higher in group A versus group B (93.8% versus 86.8%; Δ 7.0%, 95% CI: 5.7%; 8.3%); implementation to antihypertensive drugs was also higher in group A versus B (97.9% versus 92.1%; Δ 5.8%, 95% CI: 4.8%; 6.7%). At 24 months, implementation to antidiabetics and antihypertensive drugs remained higher in group A versus B (for antidiabetics: 88.6% versus 85.6%; Δ 3.0%, 95% CI: 1.7%; 4.4% and for antihypertensive drugs: 94.4% versus 85.9%; Δ 8.5%, 95% CI: 6.6%; 10.7%). No difference in pharmacy-based blood pressure was observed between groups. Implementation to statins was comparable at each time point between groups. Three patients discontinued at least one treatment; they were all in group B. In total, 46% (16/35) of patients in the 12-month intervention versus 37% (14/38) of patients in the 6-month intervention left the study during the intervention phase, mainly due to personal reasons. Conclusion: The IMAP improves adherence to chronic medications in patients with DKD. The longer the patients benefit from the intervention, the more the implementation increases over time, and the more the effect lasts after the end of the intervention. These data suggest that a 12-month rather than a 6-month program should be provided as a standard of care to support medication adherence in this population. The impact on clinical outcomes needs to be demonstrated. Clinical Trial Registration: Clinicaltrials.gov, identifier NCT04190251_PANDIA IRIS.

Determinants of diabetic nephropathy among adult diabetic patients on follow-up at public hospitals in Addis Ababa, Ethiopia: A case-control study

Background

Diabetic nephropathy is defined as patients with diabetes mellitus who have persistent proteinuria for at least three consecutive measurements per year, a high blood creatinine level (>130 mol/l), or a decrease in glomerular filtration rate (<60 ml/min). Limited studies were done in Ethiopia on determinants of diabetic nephropathy among diabetic patients. Therefore, this study aimed to identify determinants of nephropathy among adult diabetic patients on follow-up at public hospitals in Addis Ababa, Ethiopia, 2022.

Methods

A hospital-based unmatched case-control study design was conducted from 6 September to 9 November 2022, among diabetic patients on follow-up at public health hospitals in Addis Ababa. Using consecutive sampling techniques, a total of 442 (353 controls and 89 cases) were recruited, with a control-to-case ratio of 4:1. The data were collected using a structured and interview-administered questionnaire and variables like high-density lipoprotein, low-density lipoprotein, Glycated hemoglobin, and type of diabetes were extracted from the medical records of the patients using a checklist. The collected data were entered into Epidata 3.1 and analyzed by STATA version 15.0. Variables with a p-value < 0.25 in the bivariable logistic regression were selected for the final model. In multivariable logistic regression model fitting, variables with a p-value < 0.05 with 95% CI adjusted odds ratio have declared statistically significant risk factors of diabetic nephropathy.

Results

In this study, out of 442 study participants, 334 controls and 89 cases were included in the analysis, with a response rate of 94.6% and 100%, respectively. The majority of the study participants were 92.13% of cases and 84.13% of controls; 7.87% of cases, and 15.87% of controls were type 2 diabetes mellitus. Age 65 and above years old (AOR: 2.42; 95% CI: 1.28, 4.57); Smoking cigarette (AOR: 2.22; 95% CI: 1.18, 4.16); Non-adherent to diet (AOR: 2.11; 95% CI: 1.15, 3.84); Drinking alcohols (AOR: 1.95; 95% CI: 1.07, 3.52); Duration with diabetes more than 10 years (AOR: 3.39; 95% CI: 1.76, 6.54); Poor glycemic control (AOR: 2.19; 95% CI: 1.23, 4.28); and Low-density lipoprotein (AOR: 2.97; 95% CI: 1.69, 5.28) were found to be statistically significant risk factors of nephropathy among diabetic patients.

Conclusion

This study found that old age, smoking cigarettes, non-adherence to diet, duration of diabetes, alcohol drinking, Glycated hemoglobin A1C, and high low-density lipoprotein were risk factors for nephropathy. Hence, continuous health education on lifestyle modifications and diabetic-related complications in each follow-up visit via front-line health professionals are very essential to avert the problem.

Diabetes Pay-for-Performance Program Participation and Dialysis Risk in Relation to Educational Attainment: A Retrospective Cohort Study

Pay-for-performance (P4P) programs for diabetes care enable the provision of comprehensive and continuous health care to diabetic patients. However, patient outcomes may be affected by the patient's educational attainment. The present retrospective cohort study aimed to examine the effects of the educational attainment of diabetic patients on participation in a P4P program in Taiwan and the risk of dialysis. The data were obtained from the National Health Insurance Research Database of Taiwan. Patients newly diagnosed with type 2 diabetes mellitus (T2DM) aged 45 years from 2002 to 2015 were enrolled and observed until the end of 2017. The effects of their educational attainment on their participation in a P4P program were examined using the Cox proportional hazards model, while the impact on their risk for dialysis was investigated using the Cox proportional hazards model. The probability of participation in the P4P program was significantly higher in subjects with a junior high school education or above than in those who were illiterate or had only attained an elementary school education. Subjects with higher educational attainment exhibited a lower risk for dialysis. Different educational levels had similar effects on reducing dialysis risk among diabetic participants in the P4P program.

Chronic kidney outcomes associated with GLP-1 receptor agonists versus long-acting insulins among type 2 diabetes patients requiring intensive glycemic control: a nationwide cohort study

BACKGROUND

Effectiveness of glucagon-like peptide-1 receptor agonists (GLP-1RAs) versus long-acting insulins (LAIs) on preventing progressive chronic kidney outcomes is uncertain for type 2 diabetes (T2D) patients requiring intensive glycemic control. This study aimed to evaluate comparative effectiveness of GLP-1RA versus LAI therapies on progressive chronic kidney outcomes among patients having poor glycemic control and requiring these injectable glucose-lowering agents (GLAs).

METHODS

7279 propensity-score-matched pairs of newly stable GLP-1RA and LAI users in 2013-2018 were identified from Taiwan's National Health Insurance Research Database and followed until death or 12/31/2019 (intention-to-treat). Subdistributional hazard model was utilized to assess the comparative effectiveness on a composite renal outcome (i.e., renal insufficiency [eGFR < 15 mL/min/1.73 m2], dialysis-dependent end-stage renal disease [ESRD], or renal death) and its individual components. Sensitivity analyses with the as-treated scenario, PS weighting, high-dimensional PS techniques, using cardiovascular diseases (CVDs) as positive control outcomes, and interaction testing were performed.

RESULTS

In primary analyses, subdistribution hazard ratios (95% CIs) for initiating GLP-1RAs versus LAIs for the composite renal outcome, renal insufficiency, dialysis-dependent ESRD, and renal death were 0.39 (0.30-0.51), 0.43 (0.32-0.57), 0.29 (0.20-0.43), and 0.28 (0.15-0.51), respectively. Sensitivity analysis results were consistent with the primary findings. CVD history and the medication possession ratio of prior oral GLAs possessed modification effects on GLP-1RA-associated kidney outcomes.

CONCLUSION

Using GLP-1RAs versus LAIs was associated with kidney benefits in T2D patients requiring intensive glycemic control and potentially at high risk of kidney progression. GLP-1RAs should be prioritized to patients with CVDs or adherence to prior oral GLAs to maximize kidney benefits.

Adherence to Oral Antidiabetic Drugs in Patients with Type 2 Diabetes: Systematic Review and Meta-Analysis

Poor adherence to oral antidiabetic drugs (OADs) in patients with type 2 diabetes (T2D) can lead to therapy failure and risk of complications. The aim of this study was to produce an adherence proportion to OADs and estimate the association between good adherence and good glycemic control in patients with T2D. We searched in MEDLINE, Scopus, and CENTRAL databases to find observational studies on therapeutic adherence in OAD users. We calculated the proportion of adherent patients to the total number of participants for each study and pooled study-specific adherence proportions using random effect models with Freeman-Tukey transformation. We also calculated the odds ratio (OR) of having good glycemic control and good adherence and pooled study-specific OR with the generic inverse variance method. A total of 156 studies (10,041,928 patients) were included in the systematic review and meta-analysis. The pooled proportion of adherent patients was 54% (95% confidence interval, CI: 51-58%). We observed a significant association between good glycemic control and good adherence (OR: 1.33; 95% CI: 1.17-1.51). This study demonstrated that adherence to OADs in patients with T2D is sub-optimal. Improving therapeutic adherence through health-promoting programs and prescription of personalized therapies could be an effective strategy to reduce the risk of complications.

Impact of Medication Adherence and Glycemic Control on the Risk of Micro- and Macrovascular Diseases in Patients with Diabetes

PURPOSE

Our purpose in the research was to clarify the impact of medication adherence to oral hypoglycemic agents during a 1-year period and subsequent glycemic control on the risk of micro- and macrovascular diseases.

METHODS

Examined was a nationwide claims database on 13,256 individuals with diabetic eye disease without requiring prior treatment, 7,862 without prior initiation of dialysis, 15,556 without prior coronary artery disease, 16,243 without prior cerebrovascular disease, and 19,386 without prior heart failure from 2008 to 2016 in Japan. Medication adherence was evaluated by the proportion of days covered. Patients were considered to have poor adherence if the proportion of days covered was <80%. Multivariate Cox regression model identified risks of micro- and macrovascular diseases.

RESULTS

In each group, mean age was 53 to 54 years, HbA1c was 7.1% to 7.2%, and median follow-up period was 4.6 to 5.1 years, and the percentage of poor adherence was approximately 30%. During the study period, 532 treatment-requiring diabetic eye disease, 75 dialysis, 389 coronary artery disease, 316 cerebrovascular disease, and 144 heart failure events occurred. Multivariate Cox regression model revealed that the hazard ratio (95% confidence interval) of dialysis in the poor adherence group was 2.04 (1.27-3.30) compared with the good adherence group. The hazard ratios in the poor adherence/poor glycemic control group were 3.34 (2.63-4.24) for treatment-requiring diabetic eye disease, 4.23 (2.17-8.26) for dialysis, 1.69 (1.23-2.31) for coronary artery disease, and 2.08 (1.25-3.48) for heart failure compared with the good adherence/good glycemic control group.

CONCLUSIONS

Poor medication adherence was an independent risk factor for the initiation of dialysis, suggesting that clinicians must pay close attention to these patients.

Derivation and Validation of a Prediction Model of End-Stage Renal Disease in Patients With Type 2 Diabetes Based on a Systematic Review and Meta-analysis

OBJECTIVES

To develop and validate a model for predicting the risk of end-stage renal disease (ESRD) in patients with type 2 diabetes.

METHODS

The derivation cohort was from a meta-analysis. Statistically significant risk factors were extracted and combined to the corresponding risk ratio (RR) to establish a risk assessment model for ESRD in type 2 diabetes. All risk factors were scored according to their weightings to establish the prediction model. Model performance is evaluated using external validation cohorts. The outcome was the occurrence of ESRD defined as eGFR<15 ml min^-1 1.73 m^-2 or received kidney replacement therapy (dialysis or transplantation).

RESULTS

A total of 1,167,317 patients with type 2 diabetes were included in our meta-analysis, with a cumulative incidence of approximately 1.1%. The final risk factors of the prediction model included age, sex, smoking, diabetes mellitus (DM) duration, systolic blood pressure (SBP), hemoglobin A1c (HbA1c), estimated glomerular filtration rate (eGFR), and triglyceride (TG). All risk factors were scored according to their weightings, with the highest score being 36.5. External verification showed that the model has good discrimination, AUC=0.807(95%CI 0.753-0.861). The best cutoff value is 16 points, with the sensitivity and specificity given by 85.33% and 60.45%, respectively.

CONCLUSION

The study established a simple risk assessment model including 8 routinely available clinical parameters for predicting the risk of ESRD in type 2 diabetes.

Vaccination Against Receptor for Advanced Glycation End Products Attenuates the Progression of Diabetic Kidney Disease

Effective treatment of diabetic kidney disease (DKD) remains a large unmet medical need. Within the disease's complicated pathogenic mechanism, activation of the advanced glycation end products (AGEs)-receptor for AGE (RAGE) axis plays a pivotal role in the development and progression of DKD. To provide a new therapeutic strategy against DKD progression, we developed a vaccine against RAGE. Three rounds of immunization of mice with the RAGE vaccine successfully induced antigen-specific serum IgG antibody titers and elevated antibody titers were sustained for at least 38 weeks. In addition, RAGE vaccination significantly attenuated the increase in urinary albumin excretion in streptozotocin-induced diabetic mice (type 1 diabetes model) and leptin-receptor-deficient db/db mice (type 2 diabetes model). In microscopic analyses, RAGE vaccination suppressed glomerular hypertrophy and mesangial expansion in both diabetic models and significantly reduced glomerular basement membrane thickness in streptozotocin-induced diabetic mice. Results of an in vitro study indicated that the serum IgG antibody elicited by RAGE vaccination suppressed the expression of AGE-induced vascular cell adhesion molecule 1 and intracellular adhesion molecule 1 in endothelial cells. Thus, our newly developed RAGE vaccine attenuated the progression of DKD in mice and is a promising potential therapeutic strategy for patients with DKD.

Interprofessional Medication Adherence Program for Patients With Diabetic Kidney Disease: Protocol for a Randomized Controlled and Qualitative Study (PANDIA-IRIS)

Background

Despite effective treatments, more than 30% of patients with diabetes will present with diabetic kidney disease (DKD) at some point. Patients with DKD are among the most complex as their care is multifactorial and involves different groups of health care providers. Suboptimal adherence to polypharmacy is frequent and contributes to poor outcomes. As self-management is one of the keys to clinical success, structured medication adherence programs are crucial. The PANDIA-IRIS (patients diabétiques et insuffisants rénaux: un programme interdisciplinaire de soutien à l’adhésion thérapeutique) study is based on a routine medication adherence program led by pharmacists.

Objective

The aim of this study is to define the impact of the duration of this medication adherence program on long-term adherence and clinical outcomes in patients with DKD.

Methods

This monocentric adherence program consists of short, repeated motivational interviews focused on patients’ medication behaviors combined with the use of electronic monitors containing patients’ medications. When patients open the electronic monitor cap to take their medication, the date and hour at each opening are registered. In total, 73 patients are randomized as 1:1 in 2 parallel groups; the adherence program will last 6 months in the first group versus 12 months in the second group. After the intervention phases, patients continue using their electronic monitors for a total of 24 months but without receiving feedback. Electronic monitors and pill counts are used to assess medication adherence. Persistence and implementation will be described using Kaplan-Meier curves and generalized estimating equation multimodeling, respectively. Longitudinal adherence will be presented as the product of persistence and implementation and modelized by generalized estimating equation multimodeling. The evolution of the ADVANCE (Action in Diabetes and Vascular disease: Preterax and Diamicron Modified-Release Controlled Evaluation) and UKPDS (United Kingdom Prospective Diabetes Study) clinical scores based on medication adherence will be analyzed with generalized estimating equation multimodeling. Patients’ satisfaction with this study will be assessed through qualitative interviews, which will be transcribed verbatim, coded, and analyzed for the main themes.

Results

This study was approved by the local ethics committee (Vaud, Switzerland) in November 2015. Since then, 2 amendments to the protocol have been approved in June 2017 and October 2019. Patients’ recruitment began in April 2016 and ended in October 2020. This study was introduced to all consecutive eligible patients (n=275). Among them, 73 accepted to participate (26.5%) and 202 (73.5%) refused. Data collection is ongoing and data analysis is planned for 2022.

Conclusions

The PANDIA-IRIS study will provide crucial information about the impact of the medication adherence program on the adherence and clinical outcomes of patients with DKD. Monitoring medication adherence during the postintervention phase is innovative and will shed light on the duration of the intervention on medication adherence.

Trial Registration

Clinicaltrials.gov NCT04190251_PANDIA IRIS; https://clinicaltrials.gov/ct2/show/NCT04190251

International Registered Report Identifier (IRRID)

DERR1-10.2196/25966

'Teaching: individual' to improve adherence in hypertension and type 2 diabetes

Educational interventions with a multifaceted approach have proven effective to improve adherence to therapeutic regimens in people with chronic diseases. The present study aimed to evaluate the efficacy of a nursing intervention involving individual teaching compared with usual care to improve adherence with therapeutic regimens in people with hypertension and/or type-2 diabetes mellitus (T2DM). This was a parallel randomised two-arm clinical trial in 200 patients from a primary care programme. After 6 months of follow-up, there was a significant improvement in treatment adherence with a score of 0.87 (95% CI 0.30 to 1.44) on a 13 point scale, and an average reduction in systolic blood pressure (SBP) of 3.79 mmHg (95% CI: -6.85 to -0.73) in the intervention group, but not in glycated haemoglobin (HbA1c) levels (-0.16% 95% CI: -0.41 to 0.09). The individual teaching intervention was effective in improving therapeutic adherence and improving blood pressure values among the participants from the primary care programme.

Optimizing Therapeutic Outcomes With Oral Semaglutide: A Patient-Centered Approach

In September 2019, the U.S. Food and Drug Administration approved oral semaglutide as the first orally administered glucagon-like peptide 1 (GLP-1) receptor agonist for treating people with type 2 diabetes. Although injectable GLP-1 receptor agonists are well-established treatment options for people with type 2 diabetes, clinical experience with an oral formulation in this class is limited. This article provides practical guidance for diabetes care and education specialists on how to effectively counsel patients initiating therapy with oral semaglutide on appropriate administration of the treatment and its possible effects on glycemic control, body weight, and quality of life. Strategies for mitigating potential side effects typical of the GLP-1 receptor agonist class, namely nausea, vomiting, and diarrhea, are also provided. Involving patients in treatment decisions and educating them about available and prescribed medications are key strategies for encouraging treatment adherence and ensuring optimal therapeutic outcomes.

Determinants of Diabetic Nephropathy among Diabetic Patients in General Public Hospitals of Tigray, Ethiopia, 2018/19

BACKGROUND

Diabetic nephropathy is real damage resulting from having uncontrolled diabetes mellitus. Unmanaged diabetic nephropathy is one of the most leading causes of kidney failure. There is a scarcity of information on the determinants of diabetic nephropathy among diabetes mellitus patients in Ethiopia. Identification of the determinants can help devise a strategy to properly address the disease and its consequences. Therefore, this study was designed to assess the determinants of diabetic nephropathy among diabetes mellitus patients.

METHODS

Unmatched case-control study design with 168 cases and 672 controls with a mean age of 45.18 and 62.12, respectively, participated in the study. An interviewer-administered questionnaire was employed for data collection, and a systematic sampling technique was used to select the study participants. Data were entered into Epi data and exported to SPSS for data clarification and analysis. Binary logistic regression analysis was carried out to check the level of association between diabetic nephropathy and the independent variables.

RESULTS

Comorbidity (AOR: 4.96 at 95 CI: 1.77-13.87), hypertension (AOR: 6.33, 95% CI: 2.51-16.02), poor glycemic control (AOR: 3.27, 95% CI: 1.31, 8.21), age (AOR: 1.14, 95%: 1.09-1.19), duration with diabetes mellitus since diagnosis (AOR: 1.83, 95 CI: 1.62-2.06), and nonadherence to diabetic medication (AOR: 3.3, 95% CI: 1.34, 8.15), diet (AOR: 5.96, 95%: 1.92-18.54), and exercise (AOR: 5.60, 95% CI: 1.94-16.21) were the determinants of diabetic nephropathy.

CONCLUSION

Adherence to medication, diet, and exercise should be empowered to achieve glycemic control and to prevent diabetic nephropathy. More attention has to be also given for old aged diabetic patients, long duration since diagnosis of diabetes mellitus, hypertension, and other comorbidities.

A study on the impact of poor medication adherence on health status and medical expense for diabetes mellitus patients in Taiwan: A longitudinal panel data analysis

Medication adherence plays an important role in disease management, especially for diabetes. The aim of this study was to examine the impacts of demographic characteristics on medication nonadherence and the impacts of nonadherence on both health status and medical expenses for diabetic patients in Taiwan.A total of 1 million diabetes mellitus patients were randomly selected from the National Health Insurance Research Database between January 1, 2000 and December 31, 2004. All records with missing values and those for participants under 18 years of age were then deleted. Because many patients had multiple clinical visit records, all records within the same calendar year were summarized into 1 single record for each person. This pre-processing resulted in 14,602 total patients with a combined 73,010 records over the course of 5 years. Generalized estimating equation models were then constructed to investigate the effects of demographic characteristics on medication nonadherence and the effects of nonadherence on patient health status and medical expenses. The demographic characteristics examined for each patient include gender, age, residential area, and socioeconomic status.Our analysis of how demographic variables impacted nonadherence revealed that elderly patients exhibited better overall medication adherence, but that male patients exhibited poorer medication adherence than female patients. Next, our analysis of how nonadherence impacted health status revealed that patients who exhibited medication nonadherence had poorer health status than patients with proper medication adherence. Finally, our analysis of how nonadherence impacted medical expenses revealed that patients who exhibited medication nonadherence incurred more medical expenses than those who exhibited proper medication adherence.This study's empirical results corroborate the general relationships expressed in the current literature regarding medication nonadherence. However, this study's results were statistically more reliable and revealed the precise impact on health status in terms of the Charlson comorbidity index and increased annual medical expenses. This indicates the need to improve patient attitudes toward medication adherence, which can have substantial effects both medically and economically.

Adherence to metformin monotherapy in people with type 2 diabetes mellitus in New Zealand

AIM

To describe adherence to metformin monotherapy in New Zealanders with type 2 diabetes mellitus (T2DM) initiating pharmacological treatment for the first time.

METHODS

We created a cohort of all New Zealanders with T2DM commencing metformin monotherapy between 1 January 2006 and 30 September 2014 using national data collections and followed them until the end of 2015. We obtained data on person- and health-related characteristics at metformin initiation from these collections and calculated medication possession ratios from pharmacy dispensing data. Regression modelling was used to assess changes in adherence over time.

RESULTS

We identified 85,066 people with T2DM who initiated metformin monotherapy. Lower adherence to metformin monotherapy was associated with time since initiating metformin, younger age and being of Māori or Pacific ethnicity. Higher adherence was associated with receiving more non-diabetic medications, a history of CVD and recent cancer registration.

CONCLUSIONS

Our findings are consistent with international literature and highlight groups of people who experience poor adherence over time. Understanding the drivers of lower adherence in Māori and Pacific peoples is a particular priority given the high prevalence of T2DM in these populations.

Adherence to antihyperglycemic medications and glucagon-like peptide 1-receptor agonists in type 2 diabetes: clinical consequences and strategies for improvement

Adherence to antihyperglycemic medications is often suboptimal in patients with type 2 diabetes, and this can contribute to poor glycemic control, increased hospitalization, and the development of diabetic complications. Reported adherence rates to antihyperglycemics vary widely among studies, and this may be related to differences in methodology for measuring adherence, patient populations, and other factors. Poor adherence may occur regardless of the specific regimen used and whether therapy is oral or injectable, and can be especially common in chronic, asymptomatic conditions, such as type 2 diabetes. More convenient drug-administration regimens and advances in formulations and delivery devices are among strategies shown to improve adherence to antihyperglycemic therapy, especially for injectable therapy. This is exemplified by technological developments made in the drug class of glucagon-like peptide 1-receptor agonists, which are a focus of this narrative review. Dulaglutide, albiglutide, and prolonged-release exenatide have an extended duration of action and can be administered once weekly, whereas such agents as liraglutide require once-daily administration. The convenience of once-weekly versus once-daily administration is associated with better adherence in real-world studies involving this class of agent. Moreover, provision of a user-friendly delivery device has been shown to overcome initial resistance to injectable therapy among patients with type 2 diabetes. This suggests that recent innovations in drug formulation (eg, ready-to-use formulations) and delivery systems (eg, single-dose prefilled pens and hidden, ready-attached needles) may be instrumental in encouraging patient acceptance. For physicians who aim to improve their patients' adherence to antihyperglycemic medications, it is thus important to consider the patient's therapeutic experience (treatment frequency, drug formulation, delivery device). Better adherence, powered by recent technological advances in the delivery of glucagon-like peptide 1-receptor agonists, may thus lead to improved clinical outcomes in type 2 diabetes.

Impact of cancer diagnosis on persistence of oral antidiabetic drugs

AIMS

The purpose of this study was to determine the effects of cancer occurrence on persistence of oral antidiabetic drugs (OAD) in France.

METHODS

A retrospective cohort including incident OAD users between 2006 and 2011 was set up using a permanent sample of health insurance beneficiaries (Echantillon Généraliste de Bénéficiaires, EGB). A Cox model was used to assess the association between cancer occurrence and OAD persistence. Non-persistence was defined as a gap in OAD treatment coverage between the end of a given prescription and a new one greater than or equal to 90 days. Cancer occurrence was studied as a time-dependent variable.

RESULTS

The study included 13,943 OAD users. Median follow-up was 760 days. After adjustment for age, sex, first OAD used, type of prescriber and polypharmacy, non-persistence risk was higher after a diagnosis of cancer: (HR: 1.93 and IC 95% 1.69; 2.21). Subgroup analyses according to cancer localization found a higher risk of non-persistence for lung cancer (HR: 2.66 and IC 95% 1.68; 4.23) and colorectal cancer (HR: 2.02 and IC 95% 1.40; 2.91).

CONCLUSIONS

Our findings indicate there is an association between cancer diagnosis and OAD non-persistence. Additional studies of this type would be useful to evaluate the association between cancer diagnosis and persistence of treatment of other chronic diseases.

Continuity of care with physicians and risk of subsequent hospitalization and end-stage renal disease in newly diagnosed type 2 diabetes mellitus patients

Purpose

Effective management for type 2 diabetes mellitus (DM) can slow the progression of kidney outcomes and reduce hospital admissions. Better continuity of care (COC) was found to improve patients’ adherence and self-management. This study examined the associations between COC, hospitalization, and end-stage renal disease (ESRD) in DM patients.

Patients and methods

In the cohort study, data from 1996 to 2012 were retrieved from the Longitudinal Health Insurance Database, using inverse probability weighted analysis. A total of 26,063 patients with newly diagnosed type 2 DM who had been treated with antihyperglycemic agents were included. COC is to assess the extent to which a DM patient visited the same physician during the study period. This study categorized COC into 3 groups – low, intermediate, and high, – according to the distribution of scores in our sample.

Results

The number of ESRD patients in the high, intermediate, and low COC groups were 92 (22.33%), 130 (31.55%), and 190 (46.12%), respectively, and the mean follow-up periods for the 3 groups were 7.13, 7.12, and 7.27 years, respectively. After using inverse probability weighting, the intermediate and low COC groups were significantly associated with an increased risk of ESRD compared with the high COC group (adjusted hazard ratio (aHR) 1.36 [95% CI, 1.03–1.80] and aHR 1.76 [95% CI, 1.35–2.30], respectively). The intermediate and low COC groups were also significantly associated with the subsequent hospitalization compared with the high COC group (aHR 1.15 [95% CI, 0.99–1.33] and aHR 1.72 [95% CI, 1.50–1.97], respectively).

Conclusion

COC is related to ESRD onset and subsequent hospitalization among patients with DM. This study suggested that when DM patients keep visiting the same physician for managing their diseases, the progression of renal disease can be prevented.

Antihyperglycemic Medications: A Claims-Based Estimate of First-line Therapy Use Prior to Initialization of Second-line Medications

OBJECTIVE

The American Diabetes Association recommends metformin as first-line therapy for type 2 diabetes. However, nonadherence to antihyperglycemic medication is common, and a clinician could confuse nonadherence with pharmacologic failure, potentially leading to premature prescribing of second-line therapies. We measured metformin use prior to second-line therapy initialization.

RESEARCH DESIGN AND METHODS

This retrospective cross-sectional study used unidentifiable member claims data from individuals covered from 2010 to 2015 by Aetna, a U.S. health benefits company. Beneficiaries with two physician claims or one hospitalization with a type 2 diabetes diagnosis were included. Recommended use of metformin was measured by the proportion of days covered over 60 days. Through sensitivity analysis, we varied estimates of the percentage of beneficiaries who used low-cost generic prescription medication programs.

RESULTS

A total of 52,544 individuals with type 2 diabetes were eligible. Of 22,956 patients given second-line treatment, only 1,875 (8.2%) had evidence of recommended use of metformin in the prior 60 days, and 6,441 (28.0%) had no prior claims evidence of having taken metformin. At the top range of sensitivity, only 49.5% patients could have had recommended use. Patients were more likely to be given an additional second-line antihyperglycemic medication or insulin if they were given their initial second-line medication without evidence of recommended use of metformin (P < 0.001).

CONCLUSIONS

Despite published guidelines, second-line therapy often is initiated without evidence of recommended use of first-line therapy. Apparent treatment failures, which may in fact be attributable to nonadherence to guidelines, are common. Point-of-care and population-level processes are needed to monitor and improve guideline adherence.

Impact of initial medication non-adherence on use of healthcare services and sick leave: a longitudinal study in a large primary care cohort in Spain

BACKGROUND

Initial medication non-adherence is highly prevalent in primary care but no previous studies have evaluated its impact on the use of healthcare services and/or days on sick leave.

AIM

To estimate the impact of initial medication non-adherence on the use of healthcare services, days of sick leave, and costs overall and in specific medication groups.

DESIGN AND SETTING

A 3-year longitudinal register-based study of all primary care patients (a cohort of 1.7 million) who were prescribed a new medication in Catalonia (Spain) in 2012.

METHOD

Thirteen of the most prescribed and/or costly medication subgroups were considered. All medication and medication subgroups (chronic, analgesics, and penicillin) were analysed. The number of healthcare services used and days on sick leave were considered. Multilevel multivariate linear regression was used. Three levels were included: patient, GP, and primary care centre.

RESULTS

Initially adherent patients made more use of medicines and some healthcare services than non-adherent and partially adherent patients. They had lower productivity losses, producing a net economic return, especially when drugs for acute diseases (such as penicillins) were considered. Initial medication non-adherence resulted in a higher economic burden to the system in the short term.

CONCLUSION

Initial medication non-adherence seems to have a short-term impact on productivity losses and costs. The clinical consequences and long-term economic consequences of initial medication non-adherence need to be assessed. Interventions to promote initial medication adherence in primary care may reduce costs and improve health outcomes.

Initial medication non-adherence: prevalence and predictive factors in a cohort of 1.6 million primary care patients

AIMS

Adherence to medicines is vital in treating diseases. Initial medication non-adherence (IMNA) - defined as not obtaining a medication the first time it is prescribed - has been poorly explored. Previous studies show IMNA rates between 6 and 28% in primary care (PC). The aims of this study were to determine prevalence and predictive factors of IMNA in the most prescribed and expensive pharmacotherapeutic groups in the Catalan health system.

METHODS

This is a retrospective, register-based cohort study which linked the Catalan PC System (Spain) prescription and invoicing databases. Medication was considered non-initiated when it was not collected from the pharmacy by the end of the month following the one in which it was prescribed. IMNA prevalence was calculated using July 2013-June 2014 prescription data. Predictive factors related to patients, general practitioners and PC centres were identified through multilevel logistic regression analyses. Missing data were attributed using simple imputation.

RESULTS

Some 1.6 million patients with 2.9 million prescriptions were included in the study sample. Total IMNA prevalence was 17.6% of prescriptions. The highest IMNA rate was observed in anilides (22.6%) and the lowest in angiotensin-converting-enzyme (ACE) inhibitors (7.4%). Predictors of IMNA are younger age, American nationality, having a pain-related or mental disorder and being treated by a substitute/resident general practitioner in a resident-training centre.

CONCLUSIONS

The rate of IMNA is high when all medications are taken into account. Attempts to strengthen trust in resident general practitioners and improve motivation to initiate a needed medication in the general young and older immigrant population should be addressed in Catalan PC.

Simultaneous control of glycemic, blood pressure, and lipid significantly reduce the risk of renal progression in diabetes patients

BACKGROUND AND AIM

Hyperglycemic, hypertension, and lipid abnormalities are risk factors for diabetic kidney disease However, no study has discussed the association of the simultaneous control of glycemic, blood pressure, and lipids with renal function among diabetes patients. Thus, this study examined the interactive effects of the intensive control of all 3 conditions on the progression of renal function.

MATERIALS AND METHODS

The study population was derived from eight hospitals in Taiwan from October 2008 to April 2015. Demographic characteristics were collected using structured questionnaires. Clinical variables were obtained from medical chart review. The renal progression was defined as a decline in the eGFR by more than 25% according to the baseline eGFR.

RESULTS

Total of 1602 diabetes patients were included in the study analysis, the mean age was 63.03±10.98years, 55.56% were men. Compared to the simultaneous control of glycemic, blood pressure and lipid group, the poor control of all three diseases had the highest risk of renal progression, with an adjusted OR of 2.21 (95% CI, 1.26-3.86). Even if the patients with an intensive control of lipid, the result showed that the poor control of both glycemic and hypertension was associated with the increased risk of renal progression than the reference group.

CONCLUSION

This study demonstrated that the simultaneous poor control of glycemic, blood pressure, and lipid had the highest risk of renal progression. Thus, patients with type 2 diabetes should not only control glycemic but also manage their blood pressure and lipid.