The DIACOM study (effect of DosIng frequency of oral Antidiabetic agents on the COMpliance and biochemical control of type 2 diabetes)

Half a Century of Fragmented Research on Deviations from Advised Therapies: Is This a Good Time to Call for Multidisciplinary Medication Adherence Research Centres of Excellence?

Medication adherence is a key precondition of the effectiveness of evidence-based therapies. However, in real-life settings, non-adherence to medication is still very common. This leads to profound health and economic consequences at both individual and public health levels. The problem of non-adherence has been extensively studied in the last 50 years. Unfortunately, with more than 130,000 scientific papers published on that subject so far, we are still far from finding an ultimate solution. This is, at least partly, due to fragmented and poor-quality research that has been conducted in this field sometimes. To overcome this deadlock, there is a need to stimulate the adoption of best practices in medication adherence-related research in a systematic way. Therefore, herein we propose the establishment of dedicated medication adherence research Centres of Excellence (CoEs). These Centres could not only conduct research but could also create a profound societal impact, directly serving the needs of patients, healthcare providers, systems and economies. Additionally, they could play a role as local advocates for good practices and education. In this paper, we propose some practical steps that might be taken in order to establish such CoEs. We describe two success stories, i.e., Dutch and Polish Medication Adherence Research CoEs. The COST Action "European Network to Advance Best practices & technoLogy on medication adherencE" (ENABLE) aims to develop a detailed definition of the Medication Adherence Research CoE in the form of a list of minimal requirements regarding their objectives, structure and activities. We hope that it will help to create a critical mass and catalyse the setup of regional and national Medication Adherence Research CoEs in the near future. This, in turn, may not only increase the quality of the research but also raise the awareness of non-adherence and promote the adoption of the best medication adherence-enhancing interventions.

Comparison of the Effectiveness of Once-Daily Alogliptin/Metformin and Twice-Daily Anagliptin/Metformin Combination Tablet in a Randomized, Parallel-Group, Open-Label Trial in Japanese Patients with Type 2 Diabetes

INTRODUCTION

The combination tablets of dipeptidyl peptidase-4 (DPP-4) inhibitors and metformin are used for both once-daily and twice-daily agents in Japan. If there is no difference in effectiveness between the once-daily and twice-daily DPP-4 inhibitor/metformin combination tablets, the once-daily agent is advantageous in terms of frequency of administration. The aim of this study was to compare the effectiveness of once-daily alogliptin/metformin combination tablet (alogliptin 25 mg/metformin 500 mg) and twice-daily anagliptin/metformin combination tablet low dose (LD) (anagliptin 100 mg/metformin 250 mg).

METHODS

Forty-eight Japanese patients with type 2 diabetes whose metformin administration of 250 mg twice daily had remained unchanged for at least 8 weeks, except when using DPP-4 inhibitors, glucagon-like peptide-1 receptor agonists, or insulin, were randomized to either the once-daily alogliptin/metformin combination tablet group or the twice-daily anagliptin/metformin combination tablet LD group. The primary endpoint was the difference in glycosylated hemoglobin (HbA1c) levels from baseline to week 12 of administration, whereas the secondary endpoints were fasting blood glucose, body mass index (BMI), and adherence.

RESULTS

Forty-four patients completed the study, and intention-to-treat analyses were performed. The adjusted mean value (standard error) for the change in HbA1c from week 0 to 12, was - 0.75 (0.109)% for the once-daily alogliptin/metformin combination tablet group and - 0.65 (0.109)% for the twice-daily anagliptin/metformin combination tablet LD group, with an intergroup difference of - 0.10% (95% confidence interval, CI - 0.407, 0.215). The upper limit of the bilateral 95% CI was 0.215%, below the 0.40% pre-defined as the non-inferiority margin. Fasting blood glucose, BMI, and adherence were not significantly different between the groups.

CONCLUSIONS

The once-daily alogliptin/metformin combination tablet was non-inferior to the twice-daily anagliptin/metformin combination tablet LD in Japanese patients with type 2 diabetes.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trial Registry (UMIN-CTR) (registration number: UMIN000034951).

Enhancement in medication adherence amidst COVID-19 using active reminders

The aim of this study is to enhance medication adherence amidst COVID-19 with the help of active reminders. Effect of: patients' perception of side effect, importance of physicians' instructions, and their beliefs, on medication adherence were measured. Sample size was 583. The study was conducted in the state of Sikkim in India. Responses were analyzed and a structural equation model was framed to test the paths. It was found that reminders had a significant impact on patients' perception about importance given to physician instruction ( β = 0.433 ) and their beliefs ( β = 0.224 ). These mediators helped to increase the adherence rate of patients.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1140/epjs/s11734-022-00532-7.

An assessment of canine ectoparasiticide administration compliance in the USA

Background

This study evaluated the timing of dog owner ectoparasiticide purchases to estimate administration compliance and assess the consequent impact of dose purchase gaps on the proportion of time that dogs were protected over a 12-month period.

Methods

Ectoparasiticide purchase transactions over a 12-month period were evaluated for 626 US veterinary hospitals to determine dose purchase timing and identify consequent gaps between dose administration in dogs. Orally administered prescription ectoparasitic medications with active ingredients from the isoxazoline family (afoxolaner, fluralaner, lotilaner, or sarolaner) were included in the analysis. A period was calculated for each of the four isoxazoline-containing medications that represented the duration of protection provided by two doses of ectoparasiticide plus the average gap between these two doses. The maximum percentage of time possible for ectoparasiticide protection for this aggregate period was then calculated for each active ingredient.

Results

Ectoparasiticide transaction records of owners were analyzed for 506,637 dogs. These showed that 43% of dog owners purchased just one dose over the 12-month period considered. If a dog owner purchased more than one dose, then the timing of their transactions could create a time gap between the completion of ectoparasite protection from the first dose and onset of protection from the subsequent purchase and administration of the second dose. Such gaps were observed in purchases made by 31–65% of dog owners, depending on the selected active ingredient and number of doses. The average gap duration between dose purchases was calculated for all possible dose combinations over 12 months of ectoparasite protection. Time gaps between the first and second doses are as follows: for sarolaner, 20.3 weeks; for afoxolaner, 12.9 weeks; for fluralaner ,12.8 weeks; and for lotilaner, 8.9 weeks. The proportion of time when protection was provided during the aggregate period between administration of the first and second doses was as follows: for fluralaner, 65%; for lotilaner, 49%; for afoxolaner, 40%; and for sarolaner, 30%.

Conclusions

Dog owner ectoparasiticide purchase transactions showed that there were time gaps between doses leading to reduced ectoparasite protection. The longer re-administration interval for fluralaner, a consequence of its extended duration of activity, resulted in dog owners gaining the greatest proportion of ectoparasite protection time with this medication compared with shorter-acting monthly re-treatment medications.

Graphical Abstract

Analysis of gaps in feline ectoparasiticide purchases from veterinary clinics in the United States

Background

The study objective was to examine cat owner ectoparasiticide purchases in the United States and estimate the impact of purchase gaps on timely ectoparasite protection administration. These purchase gaps lead to periods of time when cats are unprotected from ectoparasites.

Methods

Ectoparasiticide purchase transactions for individual cats from 671 U.S. veterinary clinics from January 1, 2017 through June 30, 2019 were evaluated to determine time “gaps” between doses of ectoparasiticides purchased in a defined 12-month period. Ectoparasiticides examined were topically applied products that contained fluralaner, fipronil/(S)-methoprene/pyriproxyfen, imidacloprid/pyriproxyfen or selamectin as active ingredients. The duration of protection following administration of one dose was 8–12 weeks for the fluralaner-containing product and one month for the other products.

Results

Ectoparasiticide purchase records were obtained from 114,853 cat owners and analysis found that most owners bought ≤ 6 months of protection during the year, with 61–75% (depending on the product) purchasing just 1–3 months of protection. The size of the average purchase gap was determined for all dose combinations out to 12 months of protection (5–7 doses for fluralaner and 12 doses for the other three products dosed monthly. The largest gaps occurred between the first and second doses and the second and third doses. Average purchase gaps for the four different products between doses 1 and 2 ranged from 11.2 to 13.9 weeks and between doses 2 and 3 ranged from 7.7 to 12.2 weeks. The fraction of purchases separated by gaps and the average length of the gap tended to decrease with increasing number of doses purchased. Owners purchasing the 8 to 12-week duration product containing fluralaner provided ectoparasite protection (“doses plus gap period”) for a larger proportion of each 2-dose period compared with owners purchasing products administered monthly.

Conclusions

When cat owners purchase flea and tick medication, gaps between subsequent purchases reduces the proportion of time ectoparasite protection can be provided. The duration of the gap between doses has an impact on the effectiveness of flea/tick medication because it inserts a period without flea and tick protection between doses of flea and tick medication. The gaps between purchases were shorter and the period of ectoparasite protection was larger for owners purchasing a 12-week product than for owners purchasing a monthly product.

Determinants of medication adherence among Iranian patients with type 2 diabetes: An application of health action process approach

To identify determinants of medication adherence among patients with type 2 diabetes based on the health action process approach. This cross-sectional study was conducted among 734 patients with type 2 diabetes attending to south Tehran health centers during June to December 2018. Data were gathered using the Morisky Medication Adherence Scale (MMAS-8-Item) and the health action process approach questionnaire. We used Mann-Whitney, Pearson Chi-Squared, Fisher's Exact and Independent Samples Tests for comparison of adherence medication by demographic characteristics; and linear regression analysis to predict factors related to medication adherence based on HAPA. P-value less than 0.05 considered statistically significant. A total of 232 men and 502 women participated in the study, Mean age was 61.61 ± 9.74. Most participants (82.3%) reported low medication adherence (females: 68.4%). Medication adherence was significantly associated with gender (p = 0.03). Medication adherence was significantly predicted by intention (β = 0.172, p = 0.0001), task self-efficacy (β = 0.172, p = 0.01), copping planning (β = 0.6, p = 0.0001) and copping self-efficacy (β = -0.244, p = 0.001). The level of adherence to medications among type 2 diabetes patients was low. The behavior intention, task self-efficacy, copping planning and copping self-efficacy were significant determinants contributed to the medication adherence. HAPA inventory includes various factors, especially types of self-efficacy. Thus, utilization of this comprehensive model in interventional studies is suggested. These determinants should be considered in developing interventional programs to improve adherence.

Randomized Multicenter Evaluation of Quality of Life and Treatment Satisfaction in Type 2 Diabetes Patients Receiving Once-Weekly Trelagliptin Versus a Daily Dipeptidyl Peptidase-4 Inhibitor

INTRODUCTION

Dipeptidyl peptidase-4 (DPP-4) inhibitors are an established treatment in type 2 diabetes mellitus (T2DM). The objective of this study was to investigate differences in quality of life (QOL) and treatment satisfaction among treatment-naïve T2DM patients receiving once-weekly trelagliptin or a daily DPP-4 inhibitor.

METHODS

In this multicenter, randomized, open-label, parallel-group, phase IV study conducted in Japan, 218 patients were randomized to trelagliptin 100 mg once weekly or a once- or twice-daily DPP-4 inhibitor for 12 weeks (NCT03014479; JapicCTI-173482). QOL and treatment satisfaction were assessed using the Diabetes Therapy-Related QOL (DTR-QOL) Questionnaire and Diabetes Treatment Satisfaction Questionnaire (DTSQ), respectively. The primary endpoint was change from baseline in DTR-QOL total score at week 12. Secondary endpoints included further analysis of the DTR-QOL and DTSQ components. Other endpoints included glycemic control, treatment adherence, and safety.

RESULTS

The between-group difference in the change from baseline to week 12 in DTR-QOL total score was 2.418 (95% confidence interval - 1.546, 6.382; P = 0.2305). Analysis of the DTR-QOL and DTSQ results by subscales and stratification generally showed a numerical improvement with trelagliptin over daily DPP-4 inhibitors. QOL and treatment satisfaction improved with a reduction in frequency of concurrent and study drug dosing. Treatment adherence was > 97% for both groups. The effect of trelagliptin on glycemic control was similar to that seen with daily DPP-4 inhibitors. Trelagliptin and daily DPP-4 inhibitors were well-tolerated and demonstrated similar safety profiles.

CONCLUSIONS

Once-weekly trelagliptin 100 mg administered for 12 weeks resulted in a numerically, but not statistically, greater improvement in QOL and treatment satisfaction versus daily DPP-4 inhibitors. The decision to administer once-weekly or daily DPP-4 inhibitor treatment is likely to depend on patient preferences and the treatment policies of physicians.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03014479) and JAPIC (JapicCTI-173482).

FUNDING

Takeda Pharmaceutical Company Ltd.

Compliance, adherence, concordance, empowerment, and self-management: five words to manifest a relational maladjustment in diabetes

Background: The pathological reality of diabetes and the incidents in following the prescribed therapies have been considered and are still a serious and relevant problem in the health sector. Objective: This review aims at highlighting the importance of clinical psychological phenomena that underlie the notion of therapies. Methods: The review was conducted through search engines such as PubMed, Medline, Web of Science and Google Scholar. The articles related to compliance, adherence, concordance, empowerment and the self-management of diabetes were included, in order to highlight the possible similarities and differences that these terms bring with them in them management of diabetes. Results: Starting from 252 initial publications, 101 articles were selected that highlighted the practical implications that each term has compared to the others. Conclusion: The review can represent a bridge between the medical approach and clinical psychology, in which integration can suggest paths aiming at improving patients' existential conditions and adaptation.

The Standard of Care in Type 2 Diabetes: Re-evaluating the Treatment Paradigm

There is currently a worldwide epidemic of type 2 diabetes (T2D) that is predicted to increase substantially in the next few years. With 80% of the global T2D population living in low to middle-income countries, there are issues with cost and of access to appropriate medicines. The objective of this symposium was to provide an overview of the efficacy and safety of glucose-lowering drugs, focussing in particular on sulfonylureas (SUs) in patients with T2D using data taken from both randomised controlled trials (RCTs) and real-world studies, the application of strategies to ensure optimal patient adherence and clinical outcomes, and the optimal use of SUs in terms of dose adjustment and agent choice to ensure the best clinical outcome. The symposium began by exploring a profile of the typical patient seen in diabetes clinical practice and the appropriate management of such a patient in the real world, before moving on to an overview of the risks associated with T2D and how the currently available agents, including newer antidiabetic medications, mitigate or exacerbate those risks. The final presentation provided an overview of real-world studies, the gap between RCTs and the real world, and the use of available glucose-lowering agents in daily clinical practice. Clinical evidence was presented demonstrating that tight glucose control improved both microvascular and macrovascular outcomes, but that aggressive treatment in patients with a very high cardiovascular risk could lead to adverse outcomes. Real-world data suggest that older agents such as SUs and metformin are being used in a large proportion of patients with T2D with demonstrable effectiveness, indicating that they still have a place in modern T2D management. The symposium, while acknowledging the need for newer antidiabetic drugs in specific situations and patient groups, recommended the continuation of SUs and metformin as the primary oral antidiabetic agents in resource-constrained regions of the world.Funding:Servier.

The Effect of Linagliptin versus Metformin Treatment-Related Quality of Life in Patients with Type 2 Diabetes Mellitus

INTRODUCTION

There have been no studies directly comparing the effect of dipeptidyl peptidase-4 inhibitors with that of metformin on treatment-related quality of life (QOL) when used as first-line therapy in patients with type 2 diabetes mellitus (T2DM).

METHODS

This study is a prospective, randomized, open-label, multicenter, parallel-group, comparative study. Forty-four participants who failed to achieve target glycemic control with diet and exercise therapy were randomly allocated to receive linagliptin or metformin therapy. We compared treatment-related QOL among the two groups using the Oral Hypoglycemic Agent Questionnaire, version 2 (OHA-Q version 2) and the self-administered Diabetes Therapy-Related QOL (DTR-QOL) questionnaire.

RESULTS

After randomization, 21 patients in the linagliptin group and 22 patients in the metformin treatment group were included in the full analysis set. Biochemical parameters, incidence of adverse effects, and rate of adherence to medication were comparable between the two groups. Over the 24-week treatment period, no significant differences in overall OHA-Q scores between the groups were observed, although the subscale 1 (treatment convenience) score was significantly higher in the linagliptin group than in the metformin group. The overall DTR-QOL score did not differ between the two groups; however, the DTR-QOL scores significantly improved after 24 weeks of linagliptin treatment, but not after metformin treatment.

CONCLUSION

We did not find significantly better treatment-related QOL with linagliptin among Japanese patients with T2DM. In terms of treatment convenience, our data showed that linagliptin was superior to metformin.

FUNDING

This study was financially supported by Nippon Boehringer Ingelheim Co., Ltd. and Eli Lilly and Company. The journal's article processing fees were covered by a research fund from Juntendo University.

CLINICAL TRIAL REGISTRATION

UMIN000022953.

Effects of linagliptin versus voglibose on treatment-related quality of life in patients with type 2 diabetes: sub-analysis of the L-STEP study

Treatment-related quality of life (QOL) is an important aspect of diabetes management. However, no studies have compared the influence of dipeptidyl peptidase-4 inhibitors versus alpha-glucosidase inhibitors on treatment-related QOL. This prespecified sub-analysis of the Linagliptin Study of Effects on Postprandial blood glucose (L-STEP) compared the effects of linagliptin (5 mg once daily) and voglibose (0.2 mg/meal thrice daily) on treatment-related QOL in Japanese patients with type 2 diabetes (T2DM) inadequately controlled with diet and exercise therapy. Among 366 subjects in the original study, 182 in the linagliptin group and 173 in the voglibose group were included in this analysis. The outcome of this study was change in QOL as assessed by the Diabetes Therapy-Related Quality of Life 17 (DTR-QOL17) questionnaire from baseline to week 12. Compared with baseline data, total DTR-QOL17 scores were significantly higher after 12 weeks of linagliptin and voglibose treatment. The change in the total DTR-QOL17 score and the score of one domain, burden on social activities and daily activities, was significantly greater in the linagliptin group than in the voglibose group. In addition, only linagliptin treatment was identified as a factor associated with an increased total DTR-QOL17 score. Linagliptin is superior to voglibose in terms of improving treatment-related QOL in Japanese patients with T2DM.

Improved treatment satisfaction and medication adherence after readjusting oral medication regimens with the cooperation of health insurance pharmacy in type 2 diabetic patients in Japan

Background

Treatment satisfaction and medication adherence can be improved if physicians carefully monitor the situations, check the level of difficulties patients experience when taking medications at specific times, and readjust medication regimens based on this information. However, physicians in Japan encounter difficulties in taking enough time to collect this information in clinical practice. The aim of the current study was to investigate improvements in satisfaction and adherence with the cooperation of a health insurance pharmacy in clinical practice.

Methods

We retrospectively analyzed 29 type 2 diabetic outpatients who were receiving their prescriptions at a medical clinic and filling prescriptions at a nearby pharmacy. The pharmacy collected information regarding satisfaction, adherence, and preferred time of taking medications, and provided these data to the clinic. The oral medication regimens for these 29 patients were readjusted based on the information obtained.

Results

After readjustments, the dosing frequency was decreased from 3.4 ± 1.2 to 1.8 ± 0.5 times/day, and the number of pills was reduced from 5.7 ± 2.0 to 4.5 ± 1.7 (both p < 0.001). Increases in treatment satisfaction from 33 ± 12 to 44 ± 10 points (n = 29, p < 0.001) were observed when assessed using a questionnaire (60-point maximum). Medication adherence based on pill counts increased from 75% ± 22% to 91% ± 14% (n = 24, p < 0.001) (5 patients were excluded due to missing data).

Conclusions

Treatment satisfaction and medication adherence were improved after readjustments of oral medication regimens with the cooperation of a health insurance pharmacy in clinical practice in Japan.

Medications Adherence and Associated Factors among Patients with Type 2 Diabetes Mellitus in the Gaza Strip, Palestine

AIM

The aim of this study was to evaluate the adherence to anti-diabetic medications among patients with type 2 diabetes mellitus (DM) seeking medical care in the Gaza Strip, Palestine.

METHODS

A cross-sectional study was conducted among 369 primary care patients with type 2 DM from October to December 2016. Adherence to medications was measured using the Morisky Medication Adherence Scale (MMAS-4). Socio-demographic and clinical variables, provider-patient relationship, health literacy, and health belief were examined for each patient. Univariate, binary logistic regression and multiple linear regression were applied to determine the independent factors influencing adherence to anti-diabetic medications using SPSS version 22.

RESULTS

Of all the respondents, 214 (58%), 146 (39.5%), and nine (2.5%) had high (MMAS score = 0), medium (MMAS score = 1 + 2), and low (MMAS score ≥ 3) adherence to anti-diabetic medications, respectively. Factors that were independently associated with adherence to anti-diabetic medications were as follows: female gender [odds ratio (OR): 1.657, 95% confidence interval (CI): 1.065-2.578] and perception of disease's severity (OR: 1.510, 95% CI: 0.410-5.560). Elderly (t = 1.345) and longer duration of DM (t = 0.899) were also predictors of adherence but showed no statistical significance (p > 0.05).

CONCLUSION

The level of complete adherence to anti-diabetic medications was sub-optimal. New strategies that aim to improve patients' adherence to their therapies are necessary taking into consideration the influencing factors and the importance of having diabetes educators in the primary care centers.

Effects of linagliptin monotherapy compared with voglibose on postprandial blood glucose responses in Japanese patients with type 2 diabetes: Linagliptin Study of Effects on Postprandial blood glucose (L-STEP)

AIMS

To compare the efficacy on glycemic parameters between a 12-week administration of once-daily linagliptin and thrice-daily voglibose in Japanese patients with type 2 diabetes.

METHODS

In a multi-center, randomized, parallel-group study, 382 patients with diabetes were randomized to the linagliptin group (n=192) or the voglibose group (n=190). A meal tolerance test was performed at weeks 0 and 12. Primary outcomes were the change from baseline to week 12 in serum glucose levels at 2h during the meal tolerance test, HbA1c levels, and serum fasting glucose levels, which were compared between the 2 groups.

RESULTS

Whereas changes in serum glucose levels at 2h during the meal tolerance test did not differ between the groups, the mean change in HbA1c levels from baseline to week 12 in the linagliptin group (-0.5±0.5% [-5.1±5.4mmol/mol]) was significantly larger than in the voglibose group (-0.2±0.5% [-2.7±5.4mmol/mol]). In addition, there was significant difference in changes in serum fasting glucose levels (-0.51±0.95mmol/L in the linagliptin group vs. -0.18±0.92mmol/L in the voglibose group, P<0.001). The incidences of hypoglycemia, serious adverse events (AEs), and discontinuations due to AEs were low and similar in both groups. However, gastrointestinal AEs were significantly lower in the linagliptin group (1.05% vs. 5.85%; P=0.01).

CONCLUSIONS

These data suggested that linagliptin monotherapy had a stronger glucose-lowering effect than voglibose monotherapy with respect to HbA1c and serum fasting glucose levels, but not serum glucose levels 2h after the start of the meal tolerance test.

Text-message reminders plus incentives increase adherence to antidiabetic medication in adults with type 2 diabetes

Some adults with Type 2 diabetes mellitus have difficulty adhering to their oral medication regimens. The current study used a multiple baseline design with 3 adults with Type 2 diabetes. Medication taking was monitored remotely in real time via an electronic pill bottle. During the intervention, monetary incentives were delivered contingent on evidence of adherence to taking medication at specified times. Text-message reminders were also sent if medication was not taken. Adherence increased for all participants. Future studies should separate the relative contributions of text-message and incentive components of the intervention.

Is gliclazide a sulfonylurea with difference? A review in 2016

Sulfonylureas (SUs) remain the most commonly prescribed drug after metformin in the treatment of type 2 diabetes (T2DM), despite the availability of several newer agents. The primary reason of SUs being most popular is their quick glycemic response, time-tested experience and least cost. Although SUs are one amongst the several other second line agents after metformin in all major guidelines, the new Dutch type 2 guidelines specifically advise gliclazide as the preferred second line drug instead of SUs as a class. The World Health Organization (WHO) has also included gliclazide in their Model List of Essential Medicines 2013 motivated by its safety data in elderly patients. Specifically advising gliclazide may have been based on emerging evidence suggesting cardiovascular neutrality of gliclazide over other SUs. This prompted us to do a literature review of gliclazide efficacy and safety data compared to other SUs as well as oral anti-diabetic drugs.

Understanding adherence to medications in type 2 diabetes care and clinical trials to overcome barriers: a narrative review

AIM

To identify factors affecting adherence to medications in type 2 diabetes (T2D) care and clinical trials.

BACKGROUND

Adherence to medication is associated with better patient outcomes, lower healthcare costs, and improved quality and robustness of trial data. In T2D, non-adherence to regimens may compromise glycemic, blood pressure and lipid control, which can, in turn, increase morbidity and mortality rates.

DESIGN

A literature search was performed to identify studies reporting adherence to medications and highlighting specific adherence challenges/approaches in T2D. The search was limited to clinical trials, comparative studies or meta-analyses, reported in English with a freely available abstract.

DATA SOURCE

MEDLINE (31 December 2008 to 31 December 2013).

REVIEW METHODS

Studies not reporting adherence to medications or highlighting adherence challenges/approaches in T2D, presenting only self-reported adherence or including fewer than 100 patients were excluded. Eligible reports are discussed narratively.

RESULTS

Factors identified as having a detrimental impact on adherence were smoking, depression and polypharmacy. Conversely, increased convenience (e.g. pen compared with vial and syringe; medication supplied by mail order vs. retail pharmacy) was associated with better patient adherence, as were interventions that increased patient motivation (e.g. individualized, nurse-led consultation) and education.

CONCLUSIONS

Medication adherence is influenced by complex and multifactorial issues, which can include smoking, depression, polypharmacy, convenience of obtaining and administering the medication, patient motivation and education. We recommend simplifying treatment regimens, where possible, improving provider-patient communication, and providing support and education to increase medication adherence, with a view to improving patient outcomes and clinical trial data quality.

Systematic review and meta-analysis of the efficacy and hypoglycemic safety of gliclazide versus other insulinotropic agents

AIMS

Sulfonylureas are well positioned in treating type 2 diabetes, after lifestyle modification and metformin. The sulfonylurea gliclazide was given preference over glibenclamide in older people with type 2 diabetes in the World Health Organization model list of essential medicines. Consequently, a systematic review and meta-analysis of randomized controlled trials of the efficacy and safety of gliclazide versus other oral insulinotropic agents (sulfonylureas, dipeptidyl peptidase-4 inhibitors, and glinides) was performed.

METHODS

Two reviewers searched MEDLINE for studies of ≥12 weeks duration in adults with type 2 diabetes. The key search word was "gliclazide", filtered with "randomized controlled trial", "human" and "19+ years". Differences were explored in mean change in glycated hemoglobin (HbA(1c)) from baseline (primary outcome) and risk of hypoglycemia (secondary outcome) between gliclazide and other oral insulinotropic agents; and other sulfonylureas.

RESULTS

Nine out of 181 references reported primary outcomes, of which 7 reported secondary outcomes. Gliclazide lowered HbA1c more than other oral insulinotropic agents, with a weighted mean difference of -0.11% (95%, CI -0.19 to -0.03%, P=0.008, I(2)=60%), though not more than other sulfonylureas (-0.12%; 95%, CI -0.25 to 0.01%, P=0.07, I(2)=77%). Risk of hypoglycemia with gliclazide was not different to other insulinotropic agents (RR 0.85; 95%, CI 0.66 to 1.09, P=0.20, I(2)=61%) but significantly lower than other sulfonylureas (RR 0.47; 95%, CI 0.27 to 0.79, P=0.004, I(2)=0%).

CONCLUSION

Compared with other oral insulinotropic agents, gliclazide significantly reduced HbA1c with no difference regarding hypoglycemia risk. Compared with other sulfonylureas, HbA1c reduction with gliclazide was not significantly different, but hypoglycemia risk was significantly lower.

PDE 5 inhibition with udenafil improves left ventricular systolic/diastolic functions and exercise capacity in patients with chronic heart failure with reduced ejection fraction; A 12-week, randomized, double-blind, placebo-controlled trial

BACKGROUND

Impaired nitric oxide-mediated pulmonary vascular tone is commonly found in heart failure with reduced ejection fraction (HFrEF), and is associated with derangement of left ventricular (LV) hemodynamics and decreased exercise capacity, which may be reversed by PDE5 inhibitor. This study investigated the effects of a new, long-acting PDE5 inhibitor on LV hemodynamics and exercise capacity in HFrEF.

METHODS

Patients with chronic HFrEF on optimal medical therapy for >30 days before enrollment were randomly assigned to placebo or udenafil at a dose of 50mg 2x/day for the first 4 weeks followed by 100mg 2x/day for the next 8 weeks. All patients underwent cardiopulmonary exercise echocardiography before and after the 12-week treatment.

RESULTS

Improvement of subjective functional capacity was more frequently reported in the udenafil group (P = 0.002). Also, a higher increase in peak VO2 (Δpeak VO2, 21.6% (6.9 ~ 106.4%) vs 1.9% (-15.7 ~ 21.0%) in the placebo group, P = 0.04) and a larger decrease in ventilatory efficiency were observed in the udenafil group (Δ-6.4 ± 9.7 vs Δ1.9 ± 12.1 in the placebo group, P = 0.03). Regarding LV systolic function, the extent of increment in LV ejection fraction was significantly greater in the udenafil group (6.6 ± 6.4% vs 2.3 ± 4.8% in the placebo group, P = 0.02). In the udenafil group, an echocardiographic surrogate of LV filling pressure was more prominently decreased (P = 0.006) along with a significant reverse remodeling of left atrial volume index (57 ± 25mL at baseline to 44 ± 23 at 12th week, P = 0.04) and a progressive fall in B-type natriuretic peptide level (589 ± 679pg/mL at baseline to 220 ± 225pg/mL at 12th week, P < 0.001), indicating LV diastolic function improvement. Udenafil was well tolerated without excess of adverse events compared to placebo.

CONCLUSIONS

Udenafil improves LV systolic/diastolic functions and exercise capacity in conjunction with established conventional pharmacotherapy, without significant adverse events in HFrEF.

Once-weekly trelagliptin versus daily alogliptin in Japanese patients with type 2 diabetes: a randomised, double-blind, phase 3, non-inferiority study

BACKGROUND

Trelagliptin is a novel once-weekly oral DPP-4 inhibitor. We assessed the efficacy and safety of trelagliptin versus the daily oral DPP-4 inhibitor alogliptin in Japanese patients with type 2 diabetes.

METHODS

We did a randomised, double-blind, active-controlled, parallel-group, phase 3, non-inferiority study at 26 sites in Japan. We included individuals with type 2 diabetes inadequately controlled by diet and exercise. We randomly assigned patients (2:2:1) to receive trelagliptin (100 mg) once per week, alogliptin (25 mg) once per day, or placebo for 24 weeks. Randomisation was done electronically and independently from the study with permuted blocks of ten patients. Patients and clinicians were masked to group assignment. Patients in the trelagliptin group were given trelagliptin once a week and oral alogliptin placebo every day, whereas patients in the alogliptin group were given oral trelagliptin placebo once a week and oral alogliptin every day (double-dummy design). Patients in the placebo group were given an oral alogliptin placebo once a day and an oral trelagliptin placebo once a week. Our primary outcome was between-groups difference in change in HbA1c concentration from baseline to the end of treatment. The non-inferiority margin was 0·4%. Our analysis included all patients who were randomised and received at least one dose of study drug. The study is registered with ClinicalTrials.gov, number NCT01632007.

FINDINGS

Between May 26, 2012, and Nov 20, 2012, we enrolled 357 patients. 243 patients were included in the analysis (101 for trelagliptin, 92 for alogliptin, and 50 for placebo). In the primary analysis, the least squares mean change in HbA1c concentration was -0·33% in the trelagliptin group (SE 0·059) and -0·45% in the alogliptin group (0·061) based on the ANCOVA model. The least squares mean difference (trelagliptin minus alogliptin) of change from baseline in HbA1c concentration was 0·11% (95% CI -0·054 to 0·281). Trelagliptin was non-inferior to alogliptin. Both active groups had significantly reduced mean HbA1c concentrations at end of treatment compared with placebo (p<0·0001). The frequency of adverse events was similar between groups. No hypoglycaemia was reported with trelagliptin and the drug was well tolerated.

INTERPRETATION

The once-weekly DPP-4 inhibitor trelagliptin showed similar efficacy and safety to alogliptin once daily in Japanese patients with type 2 diabetes. Trelagliptin could be a useful new antidiabetes drug that needs to be given once a week.

FUNDING

Takeda Pharmaceutical Company.

Association between number of doses per day, number of medications and patient's non-compliance, and frequency of readmissions in a multi-ethnic Asian population

Objective

To investigate whether number of doses per day and number of medications are significantly associated with the number of readmissions and to study the association of readmission frequency with other medical and socio-demographic variables.

Methods

Retrospective cross-sectional study involving 432 patients who were readmitted within 15 days of previous hospital discharge between January 1, 2013 and March 31, 2013. Relevant medical records were collected from the national electronic databases of every public tertiary hospital in Singapore. Significant variables (p < 0.05) were identified using forward selection and modeled using generalized linear mixed models.

Results

A total of 649 unplanned readmissions were reviewed. At a multivariable level, number of readmission was significantly associated with the number of medications (p = 0.002) and number of doses per day (p = 0.003) after adjusting for race, liver disease, schizophrenia and non-compliance.

Conclusion

Complex medication regimen (i.e. multiple medications and multiple doses per day) is a statistically significant predictor of number of readmissions. Simplifying therapeutic regimens with alternatives such as longer-acting or fixed-dose combination drugs may facilitate better patient adherence and reduce costly readmissions.

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Patient's non-compliance can increase risk of unplanned readmissions.

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The number of doses per day is a positive predictor of unplanned readmissions.

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Higher number of medications is associated with more frequent readmissions.

Safety and efficacy of gliclazide as treatment for type 2 diabetes: a systematic review and meta-analysis of randomized trials

Objective and Design

Gliclazide has been associated with a low risk of hypoglycemic episodes and beneficial long-term cardiovascular safety in observational cohorts. The aim of this study was to assess in a systematic review and meta-analysis of randomized controlled trials the safety and efficacy of gliclazide compared to other oral glucose-lowering agents (PROSPERO2013:CRD42013004156)

Data Sources

Medline, EMBASE, Clinicaltrials.gov, Trialregister.nl, Clinicaltrialsregister.eu and the Cochrane database.

Selection

Included were randomized studies of at least 12 weeks duration with the following outcomes: HbA1c change, incidence of severe hypoglycemia, weight change, cardiovascular events and/or mortality when comparing gliclazide with other oral blood glucose lowering drugs. Bias was assessed with the Cochrane risk of bias tool. The inverse variance random effects model was used.

Results

Nineteen trials were included; 3,083 patients treated with gliclazide and 3,155 patients treated with other oral blood glucose lowering drugs. There was a considerable amount of heterogeneity between and bias in studies. Compared to other glucose lowering agents except metformin, gliclazide was slightly more effective (−0.13% (95%CI: −0.25, −0.02, I² 55%)). One out of 2,387 gliclazide users experienced a severe hypoglycemic event, whilst also using insulin. There were 25 confirmed non-severe hypoglycemic events (2.2%) in 1,152 gliclazide users and 22 events (1.8%) in 1,163 patients in the comparator group (risk ratio 1.09 (95% CI: 0.20, 5.78, I² 77%)). Few studies reported differences in weight and none were designed to evaluate cardiovascular outcomes.

Conclusions

The methodological quality of randomized trials comparing gliclazide to other oral glucose lowering agents was poor and effect estimates on weight were limited by publication bias. The number of severe hypoglycemic episodes was extremely low, and gliclazide appears at least equally effective compared to other glucose lowering agents. None of the trials were designed for evaluating cardiovascular outcomes, which warrants attention in future randomized trials.

Identification and assessment of adherence-enhancing interventions in studies assessing medication adherence through electronically compiled drug dosing histories: a systematic literature review and meta-analysis

Background

Non-adherence to medications is prevalent across all medical conditions that include ambulatory pharmacotherapy and is thus a major barrier to achieving the benefits of otherwise effective medicines.

Objective

The objective of this systematic review was to identify and to compare the efficacy of strategies and components thereof that improve implementation of the prescribed drug dosing regimen and maintain long-term persistence, based on quantitative evaluation of effect sizes across the aggregated trials.

Data sources

MEDLINE, EMBASE, CINAHL, the Cochrane Library, and PsycINFO were systematically searched for randomized controlled trials that tested the efficacy of adherence-enhancing strategies with self-administered medications. The searches were limited to papers in the English language and were included from database inception to 31 December 2011.

Study selection

Our review included randomized controlled trials in which adherence was assessed by electronically compiled drug dosing histories. Five thousand four hundred studies were screened. Eligibility assessment was performed independently by two reviewers. A structured data collection sheet was developed to extract data from each study.

Study appraisal and synthesis methods

The adherence-enhancing components were classified in eight categories. Quality of the papers was assessed using the criteria of the Cochrane Handbook for Systematic Reviews of Interventions guidelines to assess potential bias. A combined adherence outcome was derived from the different adherence variables available in the studies by extracting from each paper the available adherence summary variables in a pre-defined order (correct dosing, taking adherence, timing adherence, percentage of adherent patients). To study the association between the adherence-enhancing components and their effect on adherence, a linear meta-regression model, based on mean adherence point estimates, and a meta-analysis were conducted.

Results

Seventy-nine clinical trials published between 1995 and December 2011 were included in the review. Patients randomized to an intervention group had an average combined adherence outcome of 74.3 %, which was 14.1 % higher than in patients randomized to the control group (60.2 %). The linear meta-regression analysis with stepwise variable selection estimated an 8.8 % increase in adherence when the intervention included feedback to the patients of their recent dosing history (EM-feedback) (p < 0.01) and a 5.0 % increase in adherence when the intervention included a cognitive-educational component (p = 0.02). In addition, the effect of interventions on adherence decreased by 1.1 % each month. Sensitivity analysis by selecting only high-quality papers confirmed the robustness of the model. The random effects model in the meta-analysis, conducted on 48 studies, confirmed the above findings and showed that the improvement in adherence was 19.8 % (95 % CI 10.7–28.9 %) among patients receiving EM-feedback, almost double the improvement in adherence for studies that did not include this type of feedback [10.3 % (95 % CI 7.5–13.1 %)] (p < 0.01). The improvement in adherence was 16.1 % (95 % CI 10.7–21.6 %) in studies that tested cognitive-educational components versus 10.1 % (95 % CI 6.6–13.6 %) in studies that did not include this type of intervention (p = 0.04). Among 57 studies measuring clinical outcomes, only 8 reported a significant improvement in clinical outcome.

Limitations

Despite a common measurement, the meta-analysis was limited by the heterogeneity of the pooled data and the different measures of medication adherence. The funnel plot showed a possible publication bias in studies with high variability of the intervention effect.

Conclusions

Notwithstanding the statistical heterogeneity among the studies identified, and potential publication bias, the evidence from our meta-analysis suggests that EM-feedback and cognitive-educational interventions are potentially effective approaches to enhance patient adherence to medications. The limitations of this research highlight the urgent need to define guidelines and study characteristics for research protocols that can guide researchers in designing studies to assess the effects of adherence-enhancing interventions.

Electronic supplementary material

The online version of this article (doi:10.1007/s40265-013-0041-3) contains supplementary material, which is available to authorized users.

Impact of reducing dosing frequency on adherence to oral therapies: a literature review and meta-analysis

OBJECTIVES

To assess the impact of reduced frequency of oral therapies from multiple-dosing schedules to a once-daily (OD) dosing schedule on adherence, compliance, persistence, and associated economic impact.

METHODS

A meta-analysis was performed based on relevant articles identified from a comprehensive literature review using MEDLINE® and Embase®. The review included studies assessing adherence with OD, twice-daily (BID), thrice-daily (TID), and four-times daily (QID) dosing schedules and costs associated with optimal/suboptimal adherence among patients with acute and chronic diseases. Effect estimates across studies were pooled and analyzed using the DerSimonian and Laird random-effect model.

RESULTS

Forty-three studies met inclusion criteria, and meta-analyzable data were available from 13 studies. The overall results indicated that OD schedules were associated with higher adherence rates (odds ratio [OR] 3.07, 95% confidence interval [CI] 1.80-5.23; P < 0.001 for OD versus > OD dosing) and compliance rates (OR 3.50, 95% CI 1.73-7.08; P < 0.001 for OD versus > OD dosing); persistence rates showed the same direction but were not statistically significant (OR 1.43, 95% CI 0.62-3.29; P = 0.405 for OD versus BID dosing). Results for each of the conditions were consistent with those observed overall with respect to showing the benefits of less frequent dosing. From a health economic perspective, higher adherence rates with OD relative to multiple dosing in a number of conditions were consistently associated with corresponding lower costs of health care resources utilization.

CONCLUSION

Current meta-analyses suggested that across acute and chronic disease states, reducing dosage frequency from multiple dosing to OD dosing may improve adherence to therapies among patients. Improving adherence may result in subsequent decreases in health care costs.

Efficacy and safety of glimepiride as initial treatment in Chinese patients with Type 2 diabetes mellitus

OBJECTIVE

To investigate the efficacy and safety of glimepiride as initial mono-therapy in type 2 diabetes patients in China.

METHODS

This is a multi-center, open-label, single arm study. A total of 391 subjects were enrolled to receive glimepiride treatment for 16 weeks, the initiation dose was 1 mg/d, with titration to 2 mg/d and 4 mg/d according to the fasting blood glucose (FBG) level measured at each visit. The change in HbA1c, fasting plasma glucose (FPG), 2 h postprandial blood glucose (2hPPG), HOMA-IR, weight, waist circumference and the incidence of hypoglycemia were evaluated. An exploratory analysis was conducted to identify the potential population prone to achieve target glycemic control.

RESULTS

HbA1c was reduced significantly from 8.6 ± 1.6% to 6.9 ± 0.9% (p < 0.001); 60.9% of the subjects achieved HbA1c <7% at study endpoint. The reduction in FPG and 2hPPG were 2.3 mmol/L and 4.4 mmol/L (p < 0.001) respectively. Insulin resistance was improved significantly with HOMA-IR decreasing from 2.5 ± 2.3 to 2.2 ± 1.9 (p = 0.009). The incidence of confirmed hypoglycemia (BG ≤ 3.9 mmol/L) was 3.1%.

CONCLUSIONS

Glimepiride treatment as initial mono-therapy could effectively improve blood glucose control in type 2 diabetic patients, with a favorable safety profile. Lack of control group was the major limitation of this study. ClinicalTrial.gov identifier: NCT00908921.

Impact of dose frequency on compliance and health outcomes: a literature review (1966-2006)

In order for treatments to be effective, patients must be compliant with their medication regimens. Currently, patient compliance is seen as one of the most challenging issues in treating patients with chronic diseases. Studies in which dose frequency has been changed have been reviewed across several different diseases to examine the impact of a change in dose frequency on compliance and health outcomes, as well as efficacy and tolerability. In general, reducing dose frequency may improve medication compliance and effectiveness, and reduce adverse events, while possibly reducing healthcare costs. Suggestions for future research have been presented, including a need to measure compliance with injectable formulations and a standardized definition of compliance.

Patient adherence to medication requirements for therapy of type 2 diabetes

Type 2 diabetes is a complex, progressive endocrine and metabolical disease that typically requires substantial lifestyle changes and multiple medications to lower blood glucose, reduce cardiovascular risk and address comorbidities. Despite an extensive range of available and effective treatments, < 50% of patients achieve a glycaemical target of HbA(1c) < 7.0% and about two-thirds die of premature cardiovascular disease. Adherence to prescribed therapies is an important factor in the management of type 2 diabetes that is often overlooked. Inadequate adherence to oral antidiabetes agents, defined as collecting < 80% of prescribed medication, is variously estimated to apply to between 36% and 93% of patients. All studies affirm that a significant proportion of type 2 diabetes patients exhibit poor adherence that will contribute to less than desired control. Identified factors that impede adherence include complex dosing regimens, clinical inertia, safety concerns, socioeconomic issues, ethnicity, patient education and beliefs, social support and polypharmacy. This review explores these factors and potential strategies to improve adherence in patients with type 2 diabetes.

New perspectives in type 2 diabetes, cardiovascular risk, and treatment goals

Diabetes mellitus is a complex and increasingly common metabolic disease that is characterized by hyperglycemia and associated with microvascular and macrovascular complications. Approximately 90% of patients with diabetes have type 2 diabetes. Obesity and type 2 diabetes are intricately linked, with weight gain being a major contributor to the increasing incidence of type 2 diabetes. Both conditions are independent risk factors for cardiovascular disease, which is the cause of death for the majority (65%) of patients with diabetes. Data from recent large-scale outcomes trials continue to clarify the role of glucose-lowering therapy for patients with type 2 diabetes and increased risk of cardiovascular disease. This serves to further underscore the importance of an individualized treatment approach that takes duration of disease, presence of complications and comorbidities, and the potential adverse risks of therapy into consideration. Although the currently available antidiabetes medications are effective in lowering glucose, some of these agents, including insulin, sulfonylureas, and thiazolidinediones, are often limited by weight gain and/or hypoglycemia. Expert panel guidelines recommend a comprehensive approach that targets the traditional risk factors (glucose, weight, blood pressure, lipids) as the ideal treatment strategy to prevent complications of type 2 diabetes. Incretin-based therapies, including the glucagon-like peptide-1 receptor agonists, target the fundamental defects of type 2 diabetes, reduce glycosylated hemoglobin and body weight, and have potentially beneficial effects on blood pressure, lipids, and other surrogate markers, leading to reduced cardiovascular risk. Physicians should be encouraged to adopt a therapeutic approach with individualized patient goals. By reinforcing the role of patients with type 2 diabetes in treatment decisions, better compliance and achievement of treatment goals can be achieved.

Adherence in patients transferred from immediate release metformin to a sustained release formulation: a population-based study

AIM

Metformin is the most commonly prescribed oral agent used in the treatment of type 2 diabetes. It is effective at reducing glycosylated Haemoglobin (HbA1c) and decreasing microvascular and macrovascular disease. However, up to 25% of patients develop gastrointestinal side effects leading to cessation in 5-10% of users. Metformin XL (glucophage SR) is a once a day preparation that delays absorption, leading to decreased peak metformin concentrations. We hypothesised that the XL preparation of metformin would be better tolerated than the standard immediate release (IR) preparation leading to improved adherence to therapy.

METHODS

In a retrospective observational study, we studied adherence and glycaemic control in patients prescribed metformin IR and XL preparations in Tayside, UK.

RESULTS

Metformin XL was used by 137 patients during the study period. Overall adherence was greater in the XL group (80%) compared with the 10,772 patients in the IR group (72%, p = 0.0026). In the 40 patients who changed from metformin IR to metformin XL who had sufficient data to determine adherence, the adherence increased from 62% in the IR group to 81% in the XL group (p < 0.0001). This was associated with an HbA1c reduction from 9.1 to 8.4% (p = 0.0739, n = 29).

CONCLUSIONS

Metformin XL use is associated with increased adherence compared with the IR preparation, although the mechanism for this cannot be determined from this study. In patients intolerant of metformin IR the XL preparation should be considered.

Systematic review: impact of non-adherence to 5-aminosalicylic acid products on the frequency and cost of ulcerative colitis flares

BACKGROUND

Ulcerative colitis (UC) can be maintained in remission with 5-aminosalicylic acid (5-ASA) medications, but frequent non-adherence by patients who are feeling well has been associated with more frequent flares of colitis.

AIM

To perform a systematic review of the published literature and unpublished randomized clinical trials (RCTs) regarding the impact of non-adherence with 5-ASA medications on the incidence of UC flares and costs of care.

METHODS

A search of MEDLINE, EMBASE and the Cochrane databases was performed. Prospective studies of UC maintenance with 5-ASAs in adults were selected if they included data on adherence and disease flares. Studies using insurance claims data to estimate the impact of non-adherence on cost of care were included. Data from unpublished RCTs were obtained from the FDA with a request under the Freedom of Information Act.

RESULTS

The relative risk for flare in non-adherent vs. adherent patients ranged from 3.65 to infinity. Data were obtained from six unpublished 5-ASA RCTs, but none measured the impact of adherence on disease activity. The comorbidity-adjusted annual costs of care in adherent patients were 12.5% less than in non-adherent patients, despite increased medication expenditures.

CONCLUSIONS

A substantial proportion of UC flares and medical costs of UC are attributable to 5-ASA non-adherence. As non-adherence to 5-ASA medications is common, cost-effective strategies to improve adherence are needed. The impact of adherence on disease activity should be measured in RCTs of all inflammatory bowel disease treatments.

Haemoglobin A1c goal attainment in relation to dose in patients with diabetes mellitus taking metformin: a nested, case-control study

BACKGROUND AND OBJECTIVE

Conclusions from clinical trials suggest possible therapeutic advantages for once-daily agents over twice-daily agents in the treatment of type 2 diabetes mellitus. This study set out to investigate the relationship between metformin dosing frequency and glycosylated haemoglobin (HbA1c)-goal attainment in daily practice.

METHODS

This was a nested case-control study. Data were obtained from the PHARMO Record Linkage System, which includes linked drug-dispensing and clinical-laboratory records for approximately three million individuals in defined areas of the Netherlands. The study cohort included new users of oral antihyperglycaemic drugs between 1999 and 2005 with a baseline HbA1c> or =7% and at least one further HbA1c measurement within 18 months after the index date. Cases attained HbA1c goal (<7%) within 18 months; controls did not attain this HbA1c goal. Compliant cases and controls taking metformin monotherapy were included in the analyses. Dosing frequency was dichotomized into once daily and twice daily or more frequently. In the multivariate analysis we considered oral antihyperglycaemic dose, baseline HbA1c, first prescriber and number of HbA1c measurements.

RESULTS

The study cohort included 3107 new oral antihyperglycaemic drug users. The analyses included 753 cases and 477 controls taking metformin. Dosing twice daily or more was associated with a 71% higher probability of attaining goal (odds ratio 1.71 [95% CI 1.31, 2.24]) compared with once-daily dosing, after adjustment for baseline HbA1c, first prescriber, sex and age. We could not distinguish between the effect of dose and dosing frequency as these were closely related. Statistical testing in the analyses stratified by dose was prohibited by small numbers.

CONCLUSION

About 40% of compliant metformin users did not achieve their HbA1c goal within 18 months because of dosing problems. However, the strong correlation between total daily dose and dosing frequency did not permit identification of which of these dosing issues was the most important contributor to not achieving HbA1c goal.

A systematic review of interventions to improve medication taking in elderly patients prescribed multiple medications

A range of behavioural, educational and provider-focused strategies have been tested, individually or in combination, for improving medication adherence. The results of various interventions in different patient groups, including the elderly, have been subjected to systematic reviews and meta-analyses, but because most studies have focused on improving adherence to one drug or drug group, they may have limited applicability to the general elderly population who more commonly use multiple medications for multiple co-morbidities.A systematic review of controlled studies aimed at improving adherence in community-living elderly patients prescribed at least three, or a mean/median of four or more, long-term medications was undertaken. Only studies which included a minimum of 60 patients in each group, followed patients for >or=4 weeks after intervention, and measured adherence to all medications at baseline and at the conclusion of the study were considered for inclusion in the review. Eight studies met the inclusion criteria. All eight studies used verbal and/or written medication information in combination with behavioural strategies with or without provider-focused strategies. Pharmaceutical care was the theoretical framework of the interventions used in the majority of the studies. Only four studies demonstrated a significant improvement in adherence as a result of the interventions. The relative change in adherence in the intervention groups was highly variable, ranging from -13% to +55.5% (mean +11.4%). Regular scheduled patient follow-up along with a multi-compartment dose administration aid was an effective strategy for maintaining adherence in one study, while group education combined with individualized medication cards was successful in another study. Medication review by pharmacists with a focus on regimen simplification was found to be effective in two studies.Overall, as a result of inconsistent methodology and findings across the eight studies, we were unable to draw firm conclusions in favour of any particular intervention. Innovative strategies for enhancing medication adherence in the elderly and reliable measures of adherence are needed. Until further evidence from single-intervention strategies becomes available, combinations of educational and behavioural strategies should be used to improve medication adherence in the elderly.

Preferred drug lists: potential impact on healthcare economics

Objectives

To analyze the implementation of Medicaid preferred drug lists (PDLs) in a number of states and determine its impact on quality of care and cost relative to other segments of healthcare.

Methods

We reviewed research and case studies found by searching library databases, primarily MEDLINE and EBSCOHost, and searching pertinent journals. Keywords initially included “drug lists,” “prior authorization,” “prior approval,” and “Medicaid.” We added terms such as “influence use of other healthcare services,” “quality of care,” and “overall economic impact.” We mainly used primary sources.

Results

Based on our literature review, we determined that there are a number of issues regarding Medicaid PDLs that need to be addressed. Some issues include: (a) the potential for PDLs to influence the utilization of other healthcare services, (b) criteria used by Medicaid for determining acceptance of drugs onto a PDL, (c)the effect of PDL implementation on compliance to new regimens, (d) the potential effects of restricting medication availability on quality of care, (e) administrative costs associated with PDLs, and (f) satisfaction rates among patients and medical providers. This review highlighted expected short-term cost savings with limited degree of compromised quality of PDL implementation, but raised the concern about the potential long-term decline in quality of care and overall economic impact.

Conclusions

The number of concerns raised indicates that further studies are warranted regarding both short-term cost benefits as well as potential long-term effects of Medicaid PDL implementation. Objective analysis of these effects is necessary to ensure cost-effectiveness and quality of care.

Efficacy of once-daily olopatadine 0.2% ophthalmic solution compared to twice-daily olopatadine 0.1% ophthalmic solution for the treatment of ocular itching induced by conjunctival allergen challenge

Olopatadine 0.1% (Patanol) and olopatadine 0.2% (Pataday) ophthalmic solutions are topical ocular anti-allergic agents with antihistaminic and mast cell stabilizing properties. The efficacy of two doses of olopatadine 0.1% was compared to one dose of olopatadine 0.2% in the prevention of ocular itching associated with allergic conjunctivitis over 24 hours. This double-masked conjunctival allergen challenge (CAC) study found no significant difference in the mean itching scores between two drops of olopatadine 0.1% and one drop of olopatadine 0.2%. Both showed significant activity at the 24-hour time point and were statistically superior to placebo. No adverse events occurred while on drug therapy.

Medication taking and diabetes: a systematic review of the literature

PURPOSE

The purpose of this systematic review is to evaluate the evidence of the challenges and barriers to medication taking (adherence) and to summarize the interventions that improve medication taking in type 1 and type 2 diabetes mellitus.

METHODS

PubMed, the Cochrane Collaborative, and the Health and Psychosocial Instruments databases were used to obtain articles identified by using the MeSH headings of diabetes, medication, oral hypoglycemic agents, oral antihyperglycemic agents, oral antidiabetic agents, insulin, adherence, medication taking, compliance, fears, treatment, and electronic monitoring. Only articles published in English between 1990 and May 7, 2007, and including individuals of all ages with type 1 or type 2 diabetes mellitus were included. Retrospective and prospective studies reporting adherence to medications using self-report, pill counts, medication possession ratios, and electronic monitoring devices were included. Database analyses of prescription records from various organizations or countries were included only if adherence to pharmacologic therapy was stated. Surveys and questionnaires assessing medication taking were also included. The data from the selected literature was abstracted independently. The various studies were grouped together based on the type of study conducted. Studies were not included if a specific measure of adherence to medication was not used or stated. The studies are presented in 3 tables according to design.

CONCLUSIONS

Several barriers to medication taking have been suggested for those with diabetes mellitus, although well-controlled trials to confirm and resolve these barriers are limited. Diabetes educators should be aware of the common barriers to medication taking (regimen complexity of more than 1 diabetes mellitus drug or more than 1 dose daily, depression, and remembering doses and refills) and provide screening and support to their patients to resolve barriers if they exist. Further studies are needed to test specific interventions to improve medication taking in diabetes.

The impact of medication regimen factors on adherence to chronic treatment: a review of literature

This article reviews recent literature in chronic illness or long-term health management including asthma, contraception, diabetes, HIV disease, and hypertension/cardiovascular disease, mental disorders, pain, and other diseases to determine the relationship between regimen factors and adherence to medications. The authors conducted an electronic literature search to detect articles published between 1998 and 2007. Articles were included if they pertained to a chronic illness or to contraception, included a clear definition of how adherence was measured, and included regimen factors as primary or secondary explanatory variables. Methodology of the studies varied greatly, as did methods of measuring adherence and regimen factors. Surprisingly few of these articles concerned (1) chronic treatment, (2) regimen factors such as dosing, pill burden, and regimen complexity, and (3) adherence measured in a clear manner. Most studies failed to use state-of-the-art methods of measuring adherence. Despite these flaws, a suggestive pattern of the importance of regimen factors, specifically dose frequency and regimen complexity, emerged from this review.

Combination treatment in the management of type 2 diabetes: focus on vildagliptin and metformin as a single tablet

Vildagliptin is a potent and selective inhibitor of dipeptidyl peptidase-IV (DPP-4), orally active, that improves glycemic control in patients with type 2 diabetes (T2DM) primarily by enhancing pancreatic (alpha and beta) islet function. Thus vildagliptin has been shown both to improve insulin secretion and to suppress the inappropriate glucagon secretion seen in patients with T2DM. Vildagliptin reduces HbA(1c) when given as monotherapy, without weight gain and with minimal hypoglycemia, or in combination with the most commonly prescribed classes of oral hypoglycemic drugs: metformin, a sulfonylurea, a thiazolidinedione, or insulin. Metformin, with a different mode of action not addressing beta-cell dysfunction, has been used for about 50 years and still represents the universal first line therapy of all guidelines. However, given the multiple pathophysiological abnormalities in T2DM and the progressive nature of the disease, intensification of therapy with combinations is typically required over time. Recent guidelines imply that patients will require pharmacologic combinations much earlier to attain and sustain the increasingly stringent glycemic targets, with careful drug selection to avoid unwanted adverse events, especially hypoglycemia. The combination of metformin and vildagliptin offers advantages when compared to currently used combinations with additive efficacy and complimentary mechanisms of action, since it does not increase the risk of hypoglycemia and does not promote weight gain. Therefore, by specifically combining these agents in a single tablet, there is considerable potential to achieve better blood glucose control and to improve compliance to therapy.

Compliance, clinical outcome, and quality of life of patients with stable angina pectoris receiving once-daily betaxolol versus twice daily metoprolol: a randomized controlled trial

Background

A randomized, controlled trial was conducted in an outpatient setting to examine the effect of beta-blocker dosing frequency on patient compliance, clinical outcome, and health-related quality of life in patients with stable angina pectoris.

Methods

One hundred and twelve beta-blockers-naive outpatients with stable angina pectoris were randomized to receive betaxolol, 20 mg once daily or metoprolol tartrate, 50 mg twice daily for 8 weeks. The principal outcome measure was overall compliance measured electronically, whereas secondary outcome measures were drug effectiveness and health-related quality of life.

Results

The overall compliance was 86.5 ± 21.3% in the betaxolol group versus 76.1 ± 26.3% in the metoprolol group (p < 0.01), and the correct number of doses was taken on 84.4 ± 21.6% and 64.0 ± 31.7% of treatment days, respectively (p < 0.0001). The percentage of missed doses was 14.5 ± 21.5% in the once-daily group and 24.8 ± 26.4% in the twice-daily group (p < 0.01). The percentage of doses taken in the correct time window (58.6% vs 42.0%, p = 0.01), correct interdose intervals (77.4% v 53.1%, p < 0.0001), and therapeutic coverage (85.6% vs 73.7%, p < 0.001) were significantly higher in the once-daily group. Both studied drugs had similar antianginal effectiveness. Health-related quality of life improved in both groups, but this increase was more pronounced in the betaxolol arm in some dimensions.

Conclusions

The study demonstrates that patient compliance with once-daily betaxolol is significantly better than with twice daily metoprolol. Similarly, this treatment provides better quality of life. These results demonstrate possible therapeutic advantages of once-daily over twice-daily beta-blockers in the treatment of stable angina pectoris.

Overcoming the hurdles to achieving glycemic control

Several factors influence diabetes control, and many of these can adversely affect endeavors to obtain optimal glycemic management. For many patients with type 2 diabetes mellitus, the passage of time often results in a loss of responsiveness to medication and a greater difficulty in achieving desired target levels. Although these observations in part reflect a natural progression of diabetes, irrespective of treatment given, it is possible to identify modifiable hurdles that can be addressed with better outcome results. Lifestyle measures, particularly diet and exercise, remain paramount, whereas other secondary confounding factors such as systemic or endocrine disease or other conflicting medication need specific therapeutic attention. Most patients with type 2 diabetes mellitus will require oral hypoglycemic medication and this should be prescribed in the simplest, most effective, and safest way. Ensuring that patients fully understand treatment objectives is important resulting in better compliance with advised treatment. Such compliance can be significantly improved by keeping treatment regimens simple. With its novel once-daily formulation, gliclazide modified release has been shown to improve adherence to medication and result in better glycemic outcome as determined by improved HbA(1c) levels. Its benefits in terms of reduced risk of hypoglycemia have been demonstrated in the GlUcose control In type 2 diabetes: Diamicron modified release versus glimEpiride study.

An evaluation of patient preferences for osteoporosis medication attributes: results from the PREFER-US study

OBJECTIVE

To evaluate preferences for eight medication attributes that women may consider when evaluating prescription osteoporosis medications.

RESEARCH DESIGN AND METHODS

The eligible sample consisted of women aged 50 years or older who responded to the 2003 or 2004 Internet-based National Health and Wellness Survey as being diagnosed with osteoporosis, considering themselves at risk, or having a family history of osteoporosis. In this Internet survey (the PREFER survey), respondents were asked to: (1) force-rank order the eight attributes from one to eight according to their preferences and (2) separately rate the importance of each attribute on a Likert-type scale from 1 (extremely unimportant) to 7 (extremely important).

RESULTS

We collected 999 responses across 3 days from a sample of 3368 women and stopped compiling responses after achieving sample size targets. Drug effectiveness (e.g., ability to reduce the risk of fractures) was force ranked as the No. 1 preferred osteoporosis medication attribute by 37% of the sample. Side effects were force ranked as the No. 1 preferred medication attribute by 36% of the sample. Dosing frequency, dosing procedure, and formulation (i.e., how the drug is taken) were each force ranked as No. 1 by 2% or less of the sample. Drug effectiveness had the highest percentage of 'extremely important' responses (59%) followed by drug interactions (53%). Drug effectiveness was the highest-rated attribute (mean [S.D.] = 6.1 [1.6], median = 7), while dosing frequency was the lowest-rated attribute (mean [S.D.] = 4.7 [1.8], median = 5).

CONCLUSIONS

In our sample of women with a diagnosis of osteoporosis or at risk for osteoporosis, drug effectiveness was the most highly ranked and rated of eight osteoporosis medication attributes. Side effects and drug interactions were also highly ranked and rated. Healthcare providers should consider incorporating patient preferences for key medication attributes into their therapeutic decision-making processes.