Impact of compliance with oral antihyperglycemic agents on health outcomes in type 2 diabetes mellitus: a focus on frequency of administration

Treatment adherence and the contemporary approach to treating type 2 diabetes mellitus

The rising burden of type 2 diabetes mellitus (T2D) poses a significant healthcare challenge on a global scale. The economic impact is also substantial and continually increasing. In Serbia, even though the prevalence is officially around 12 percent, nearly 40 percent of the adult population is estimated to be living with undiagnosed diabetes and more than half the population is obese or overweight. This review comprehensively addresses the present approach to treating T2D, emphasizing the critical role of treatment adherence. We review the various components of T2D treatment, underlining the significance of lifestyle modifications. The pros and cons of medications used in treatment are discussed and factors influencing adherence are analysed. A healthy lifestyle remains the foundation of the treatment, and if not sufficient, early pharmacotherapy is initiated. Medications have been developed to lower blood sugar levels with cardiorenal protection, however, due to their still high cost, metformin remains the drug of first choice for most patients. Adherence to the treatment regimen is often poor. Factors associated with this are diverse and often multiple in a particular patient. Poor adherence is associated with poor glycaemic control, increased risk of disease complications, higher cardiovascular risk, increased mortality, hospitalizations, and healthcare costs. In addition to reducing the complexity of drug therapy and better informing the patient, improved education and motivation could lead to greater adherence. Enhanced communication between the patient and the physician and reduced treatment costs could also have a positive impact. The review concludes that addressing factors affecting adherence can significantly improve T2D outcomes and reduce costs. Further research is needed to identify region-specific risk factors for poor adherence.

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.

Applicability of the Spoken Knowledge in Low Literacy Patients with Diabetes in Brazilian elderly

Objective

To translate, adapt and evaluate the properties of a Brazilian Portuguese version of the Spoken Knowledge in Low Literacy Patients with Diabetes, which is a questionnaire that evaluate diabetes knowledge.

Methods

A cross-sectional study with type 2 diabetes patients aged ≥60 years, seen at a public healthcare organization in the city of Sao Paulo (SP). After the development of the Portuguese version, we evaluated the psychometrics properties and the association with sociodemographic and clinical variables. The regression models were adjusted for sociodemographic data, functional health literacy, duration of disease, use of insulin, and glycemic control.

Results

We evaluated 129 type 2 diabetic patients, with mean age of 75.9 (±6.2) years, mean scholling of 5.2 (±4.4) years, mean glycosylated hemoglobin of 7.2% (±1.4), and mean score on Spoken Knowledge in Low Literacy Patients with Diabetes of 42.1% (±25.8). In the regression model, the variables independently associated to Spoken Knowledge in Low Literacy Patients with Diabetes were schooling (B=0.193; p=0.003), use of insulin (B=1.326; p=0.004), duration of diabetes (B=0.053; p=0.022) and health literacy (B=0.108; p=0.021). The determination coefficient was 0.273. The Cronbach a was 0.75, demonstrating appropriate internal consistency.

Conclusion

This translated version of the Spoken Knowledge in Low Literacy Patients with Diabetes showed to be adequate to evaluate diabetes knowledge in elderly patients with low schooling levels. It presented normal distribution, adequate internal consistency, with no ceiling or floor effect. The tool is easy to be used, can be quickly applied and does not depend on reading skills.

Objetivo

Traduzir, adaptar e avaliar as propriedades de uma versão, em português do Brasil, do Spoken Knowledge in Low Literacy Patients with Diabetes, um questionário que avalia conhecimento em diabetes.

Métodos

Estudo transversal, em diabéticos tipo 2, com idade ≥60 anos de uma instituição pública de saúde, em São Paulo (SP). Após o desenvolvimento da versão na língua portuguesa, foram avaliadas suas propriedades psicométricas e associação com variáveis sociodemográficas e clínicas. Os modelos de regressão foram ajustados para dados sociodemográficos, alfabetismo funcional em saúde, tempo de doença, uso de insulina e controle glicêmico.

Resultados

Foram avaliados 129 diabéticos, com média de idade de 75,9 (±6,2) anos, escolaridade média de 5,2 (±4,4) anos, hemoglobina glicada média de 7,2% (±1,4) e valor médio do Spoken Knowledge in Low Literacy Patients with Diabetes de 42,1% (±25,8). No modelo de regressão, as variáveis associadas de forma independente ao Spoken Knowledge in Low Literacy Patients with Diabetes foram escolaridade (B=0,193; p=0,003), uso de insulina (B=1,326; p=0,004), tempo de doença (B=0,053; p=0,022) e alfabetismo em saúde (B=0,108; p=0,021). O coeficiente de determinação foi de 0,273. O a de Cronbach apresentou valor de 0,75, revelando consistência interna adequada.

Conclusão

Esta versão traduzida do Spoken Knowledge in Low LiteraFcy Patients with Diabetes mostrou-se adequada para avaliar conhecimentos em diabetes em idosos de baixa escolaridade, apresentando distribuição normal, consistência interna adequada, sem a presença de efeito teto ou chão. O instrumento teve boa aplicabilidade, já que pôde ser administrado de maneira rápida e não depende da capacidade de leitura.

Synchronized and controlled release of metformin hydrochloride/glipizide from elementary osmotic delivery

The combination of metformin hydrochloride (MTF) and glipizide (GLZ) is second-line medication for diabetes mellitus type 2 (DMT2). In the present study, elementary osmotic pump ( EOP) tablet is designed to deliver the combination of MTF and GLZ in a sustained and synchronized manner. By analyzing different variables of the formulation, sodium hydrogen carbonate is introduced as pH modifier to improve the release of GLZ, while ethyl cellulose acts as release retardant to reduce the burst release phase of MTF. A two-factor, three-level face-centered central composite design (FCCD) is applied to investigate the impact of different factors on drug release profile. Compared with conventional tablets, the EOP tablet demonstrates a controlled release behavior with relative bioavailability of 99.2% for MTF and 99.3% for GLZ. Data also shows EOP tablet is able to release MTF and GLZ in a synchronized and sustained manner both in vitro and in vivo.

Pill Burden in Patients With Type 2 Diabetes in Germany: Subanalysis From the Prospective, Noninterventional PROVIL Study

IN BRIEF Type 2 diabetes and its associated comorbidities often require polypharmacotherapy, which may result in poor adherence to treatment. This study evaluated, using subjective patient and physician questionnaire surveys, the impact of pill burden and its associated consequences on patients treated with vildagliptin as add-on to metformin, a fixed-dose combination of vildagliptin/metformin, or another dual oral antidiabetic therapy. Patients' responses were also analyzed by age (<65 or ≥65 years). The surveys revealed that a high pill count in antidiabetic therapy constitutes a large burden for patients with type 2 diabetes. Treating physicians are aware of the problems that result from a high pill burden, and a majority of them prefer prescribing fixed-dose combinations that have better efficacy and tolerability to reduce pill burden.

Economic impact of combining metformin with dipeptidyl peptidase-4 inhibitors in diabetic patients with renal impairment in spanish patients

BACKGROUND

To evaluate resource use and health costs due to the combination of metformin and dipeptidyl peptidase-4 (DPP-4) inhibitors in patients with diabetes and renal impairment in routine clinical practice.

METHODS

An observational, retrospective study was performed. Patients aged ≥30 years treated with metformin who initiated a second oral antidiabetic treatment in 2009 to 2010 were included. Two groups of patients were analysed: metformin+DPP-4 inhibitors and other oral antidiabetics. The main measures were: compliance, persistence, metabolic control (glycosylated hemoglobin< 7%) and complications (hypoglycemia, cardiovascular events) and total costs. Patients were followed up for 2 years.

RESULTS

We included 395 patients, mean age 70.2 years, 56.5% male: 135 patients received metformin+DPP-4 inhibitors and 260 patients received metformin+other oral antidiabetics. Patients receiving DPP-4 inhibitors showed better compliance (66.0% vs. 60.1%), persistence (57.6% vs. 50.0%), and metabolic control (63.9% vs. 57.3%), respectively, compared with those receiving other oral antidiabetics (P<0.05), and also had a lower rate of hypoglycemia (20.0% vs. 47.7%) and lower total costs (€ 2,486 vs. € 3,002), P=0.001.

CONCLUSION

Despite the limitations of the study, patients with renal impairment treated with DPP-4 inhibitors had better metabolic control, lower rates (association) of hypoglycaemia, and lower health costs for the Spanish national health system.

Use of metformin and vildagliptin for treatment of type 2 diabetes in the elderly

BACKGROUND

The aim of this study was to describe the clinical (treatment adherence, metabolic control, hypoglycemia, and macrovascular complications) and economic (resource use and costs) consequences of using a combination of metformin + vildagliptin to treat type 2 diabetes in elderly patients seen in daily clinical practice.

METHODS

We conducted a multicenter, retrospective, observational study that included patients aged ≥65 years treated with metformin who started a second oral antidiabetic therapy during the years 2008-2009. There were two groups of patients: a study group receiving metformin + vildagliptin and a reference group receiving metformin + other oral antidiabetics (sulfonylureas or glitazones). The main measures were comorbidity, compliance/persistence, metabolic control (glycosylated hemoglobin <7%), complications (hypoglycemic, macrovascular), and total costs. The patients were followed for 2 years.

RESULTS

We recruited 987 patients (49.1% male) of mean age 74.2 years. There were 270 (27.4%) patients in the metformin + vildagliptin group and 717 (72.6%) in the reference group. Vildagliptin-treated patients had significantly (P<0.05) improved compliance (68.3% versus 62.5%, respectively), persistence (61.5% versus 55.1%), and metabolic control (63.3% versus 57.6%). They also had lower rates of hypoglycemia (17.4% versus 42.8%) and cardiovascular events (4.4% versus 8.6%) and lower total costs (€2,544 versus €2,699, P<0.05).

CONCLUSION

Patients treated with metformin and vildagliptin showed better adherence and metabolic control and lower rates of hypoglycemia, resulting in lower health care costs for the national health system.

Adherence to therapies in patients with type 2 diabetes

Adherence to therapy is defined as the extent to which a person's behavior in taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider. Patients presenting with type 2 diabetes mellitus are initially encouraged to maintain a healthy diet and exercise regimen, followed by early medication that generally includes one or more oral hypoglycemic agents and later may include an injectable treatment. To prevent the complications associated with type 2 diabetes, therapy frequently also includes medications for control of blood pressure, dyslipidemia and other disorders, since patients often have more than three or four chronic conditions. Despite the benefits of therapy, studies have indicated that recommended glycemic goals are achieved by less than 50% of patients, which may be associated with decreased adherence to therapies. As a result, hyperglycemia and long-term complications increase morbidity and premature mortality, and lead to increased costs to health services. Reasons for nonadherence are multifactorial and difficult to identify. They include age, information, perception and duration of disease, complexity of dosing regimen, polytherapy, psychological factors, safety, tolerability and cost. Various measures to increase patient satisfaction and increase adherence in type 2 diabetes have been investigated. These include reducing the complexity of therapy by fixed-dose combination pills and less frequent dosing regimens, using medications that are associated with fewer adverse events (hypoglycemia or weight gain), educational initiatives with improved patient-healthcare provider communication, reminder systems and social support to help reduce costs. In the current narrative review, factors that influence adherence to different therapies for type 2 diabetes are discussed, along with outcomes of poor adherence, the economic impact of nonadherence, and strategies aimed at improving adherence.

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.

Cumprimento da terapia com antidiabéticos orais em usuários da atenção primária

O objetivo deste estudo foi avaliar o cumprimento medicamentoso de usuários de antidiabéticos orais. A pesquisa envolveu 437 diabéticos, de ambos os sexos, com idade entre 18-92 anos de 12 unidades básicas de saúde de Fortaleza-Ceará entre março e junho de 2009. Para avaliar a adesão aos antidiabéticos orais aplicou-se, nos domicílios, o Teste de Batalla, o Teste de Medida de Adesão ao Tratamento, além da contagem de comprimidos. Constatou-se, que 74,6%, 86,3% e 71,2%, foram considerados não cumpridores, segundo os testes aplicados, respectivamente. Entre os sujeitos não cumpridores do tratamento com antidiabéticos, 95% já faltaram as consultas do programa terapêutico para diabetes (p=0,000) e 76% estão com a glicemia acima dos valores recomendados (p=0,013). Talvez o cerne do problema esteja na relação profissional/cliente e na educação em saúde. Portanto, o resgate dos fundamentos da promoção da saúde necessitam permear as ações dos profissionais envolvidos na atenção ao diabético.

Drug attitude and adherence to anti-glaucoma medication

PURPOSE

The purpose of this study is to assess patient attitudes towards anti-glaucoma medication and their association with adherence, visual quality of life, and personality traits.

MATERIALS AND METHODS

One hundred and forty-seven glaucoma patients were enrolled this study. The participants were divided into 'pharmacophobic' and 'pharmacophilic' groups according to their scores on the Modified Glaucoma Drug Attitude Inventory (MG-DAI). To establish a correlation with patient drug attitude, each group had their subjective drug adherence, visual quality of life, and personality traits examined. For personality traits, the Myers-Briggs Type Indicator (MBTI) was used to sub-classify each group.

RESULTS

Among the patients analyzed, 91 (72.80%) patients showed a 'pharmacophobic' attitude and 34 (27.20%) patients showed a 'pharmacophilic' attitude. The pharmacophobic group tended to have worse adherence than the pharmacophilic group. Personality dichotomies from the MBTI also showed different patterns for each group.

CONCLUSION

In glaucoma patients, pharmacological adherence was influenced by their attitude towards drugs; an association might exist between drug attitude and underlying personality traits.

Fixed-dose single tablet antidiabetic combinations

Combinations of two or more oral agents with different mechanisms of action are often used for the management of hyperglycaemia in type 2 diabetes. While these combinations have customarily been taken as separate tablets, several fixed-dose single tablet combinations are now available. These are based on bioequivalence with the separate tablets, giving similar efficacy to the separate tablets and necessitating the same cautions and contraindications that apply to each active component. Fixed-dose combinations can offer convenience, reduce the pill burden and simplify administration regimens for the patient. They increase patient adherence compared with equivalent combinations of separate tablets, and this is associated with some improvements in glycaemic control. Presently available antidiabetic fixed-dose combinations include metformin combined with a sulphonylurea, thiazolidinedione, dipeptidylpeptidase-4 inhibitor or meglitinide as well as thiazolidinedione-sulphonylurea combinations, each at a range of dosage strengths to facilitate titration. Anticipated future expansion of multiple drug regimens for diabetes management is likely to increase the use of fixed-dose single tablet combinations.

Medication Adherence in Chronic Disease: Issues in Posttransplant Immunosuppression

Poor medication adherence is a widespread problem that undermines the potential benefits of medical treatment. Typical adherence rates among chronic disease patients are approximately 50%, and these low adherence rates have a substantial economic impact, estimated at $100 to $300 billion annually. Nonadherence to immunosuppressants among transplant recipients is surprisingly frequent, and the consequences are serious. Among adult renal transplant patients, the median rate of nonadherence is approximately 22% and is associated with acute rejection episodes and approximately 36% of all graft losses. In the United States, nonadherence results in an estimated 903 episodes of acute rejection and 1319 renal transplants failures annually, costing approximately $15 million and $100 million, respectively. Drug regimen complexity is known to impact adherence. Research demonstrates an inverse relationship between dosing frequency and medication adherence in various chronic diseases, with once-daily dosing resulting in the highest adherence rates. Reducing the dosing frequency may positively impact both clinical and patient-reported outcomes, as well as health care costs. However, the increased costs of less frequently administered drugs must be outweighed by the net savings achieved through improved adherence rates and better health outcomes. If trends among patients with chronic diseases apply, once-daily dosing regimens may improve adherence rates by approximately 6% to 14% among renal transplant patients and could substantially reduce the number of acute rejection episodes and graft failures, although the exact economic impact is difficult to estimate. Further research into adherence issues in transplant patients and the potential clinical and economic benefits of once-daily dosing of immunosuppressants is warranted.

Therapeutic compliance: a prospective analysis of various factors involved in the adherence rate in type 2 diabetes

It's established that adherence rates to treatment are bad in chronic illnesses. The number of medicines prescribed and the rates of daily dosages have been shown to be of major influence for therapeutic compliance in AIDS or hypertension. Nevertheless, data on adherence to prescribed medications amongst diabetics are scarce. The aim of our study was to evaluate parameters influencing therapeutic compliance in type 2 diabetes. Adherence to treatment was evaluated by a questionnaire filled out during patient's hospitalisation in the diabetology department of a French general hospital of 450 beds. Factors influencing compliance were quantified taking into account demographic characteristics of our population, the treatments used, biological and medical data. 94 patients hospitalised for uncontrolled diabetes, aged 41-89 years, were studied. Non-adherence rate was high, 33 of them showed poor adherence to their drug treatment. Non-compliers were younger than compliant patients (56.5+/-12.1 vs. 65.5+/-12.5 years old; P<0.0001) and with a lower social position. Clinically, they were characterised by a shorter duration of diabetes and a lower number of clinical complications as macroangiopathy (6.9 vs. 33.3%; P=0.006). The number of daily doses or medicines didn't affect adherence rate. Improved control in therapeutic compliance may lead to better diabetic patients education. The implication is that instead of increasing the dose, changing the medication, or adding a second drug when glucose and HbA(1c)levels are high, clinicians should consider counselling patients on how to improve therapeutic compliance.