Medication adherence and glycemic control among newly diagnosed diabetes patients

BACKGROUND

Poor medication adherence can have negative consequences for the patients, the provider, the physician, and the sustainability of the healthcare system. To our knowledge, the association between medication adherence and glycemic control among newly diagnosed diabetes patients has not been studied. This study aims to bridge the gap.

METHOD

This is a retrospective cohort study of 2463 patients managed in the National Healthcare Group in Singapore with newly diagnosed diabetes. Patients were followed up for the first two years from their first medication dispensed for measuring medication adherence, proportion of days covered (PDC); and for another three years for investigating outcomes of glycemic control, emergency department visit, and hospitalization. Multivariable regressions were performed to study the association between medication adherence and the outcomes as well as the risk factors of poor adherence.

RESULTS

The prevalence of medication adherence (PDC≥80%) was 65.0% (95% CI 63.1% to 66.9%) among newly diagnosed diabetes patients in Singapore. Male, Indian, or patients without hypertension or dyslipidemia were associated with poorer medication adherence. The HbA1c level of poor adherent patients (PDC <40%) increased by 0.4 (95% CI 0.2 to 0.5) over the two years, and they were also more likely to have hospitalization (OR 2.6,95% CI 1.7 to 3.8) or emergency department visit (OR 2.4,95% CI 1.7 to 3.4) compared with the fully adherent patients (PDC=100%).

CONCLUSIONS

The medication adherence in the early stage of diabetes is important for maximizing the effectiveness of pharmaceutical therapy. Health policies or interventions targeting the improvement of medication adherence among newly diagnosed diabetes patients are in need.

Risk factors for genital infections in people initiating SGLT2 inhibitors and their impact on discontinuation

INTRODUCTION

To identify risk factors, absolute risk, and impact on treatment discontinuation of genital infections with sodium-glucose co-transporter-2 inhibitors (SGLT2i).

RESEARCH DESIGN AND METHODS

We assessed the relationship between baseline characteristics and genital infection in 21 004 people with type 2 diabetes initiating SGLT2i and 55 471 controls initiating dipeptidyl peptidase-4 inhibitors (DPP4i) in a UK primary care database. We assessed absolute risk of infection in those with key risk factors and the association between early genital infection and treatment discontinuation.

RESULTS

Genital infection was substantially more common in those treated with SGLT2i (8.1% within 1 year) than DPP4i (1.8%). Key predictors of infection with SGLT2i were female sex (HR 3.64; 95% CI 3.23 to 4.11) and history of genital infection; <1 year before initiation (HR 4.38; 3.73 to 5.13), 1-5 years (HR 3.04; 2.64 to 3.51), and >5 years (HR 1.79; 1.55 to 2.07). Baseline HbA1c was not associated with infection risk for SGLT2i, in contrast to DPP4i where risk increased with higher HbA1c. One-year absolute risk of genital infection with SGLT2i was highest for those with a history of prior infection (females 23.7%, males 12.1%), compared with those without (females 10.8%, males 2.7%). Early genital infection was associated with a similar discontinuation risk for SGLT2i (HR 1.48; 1.21-1.80) and DPP4i (HR 1.58; 1.21-2.07).

CONCLUSIONS

Female sex and history of prior infection are simple features that can identify subgroups at greatly increased risk of genital infections with SGLT2i therapy. These data can be used to risk-stratify patients. High HbA1c is not a risk factor for genital infections with SGLT2i.

Effect of medication adherence on clinical outcomes in type 2 diabetes: analysis of the SIMPLE study

Objective

Medication adherence is impacted by regimen complexity. The SIMPLE (Simple basal Insulin titration, Metformin Plus Liraglutide for type 2 diabetes with very Elevated HbA1c) study compared GLP1RA plus basal insulin (GLP1RA+BI) to basal-bolus insulin (BBI) regimen in participants with very uncontrolled type 2 diabetes mellitus (T2DM). This analysis aimed to evaluate medication adherence to GLP1RA+BI compared with BBI, the effect of adherence on clinical and patient-reported outcomes, and baseline predictors of adherence.

Research design and methods

This was an analysis of the SIMPLE study based on prespecified outcome. The study took place in pragmatic, real-world setting. A total of 120 adults with T2DM and HgbA1c≥10% were randomized to detemir plus liraglutide, or detemir plus aspart before each meal; 6-month follow-up. The main outcomes evaluated were: adherence, HgbA1c, weight, quality of life, and hypoglycemia. Adherence rate was calculated for each study medication at each follow-up visit; participants were classified as ≥80% or <80% adherent.

Result

A higher percentage of participants in the GLP1RA+BI compared with the BBI group had ≥80% adherence to detemir (59.3% vs 35.7%, p=0.02) as well as liraglutide versus aspart (57.4% vs 30.4%, p=0.007). Higher age was predictive of ≥80% adherence (OR per 5-year increment=1.48, 95% CI 1.09 to 2.0, p=0.01). Higher adherence led to greater improvement in HbA1c and weight in both groups. Treatment with GLP1RA+BI compared with BBI led to greater improvement in HbA1c, weight, and quality of life and lower risk of hypoglycemia even after adjusting for the difference in adherence between groups.

Conclusions

Adherence was higher with the simplified regimen of GLP1RA+BI compared with BBI. Greater adherence to the simpler regimen amplified the treatment effect on HbA1c, weight, quality of life, and risk of hypoglycemia, yet statistically significant greater benefits were noted even when adjusted for adherence.

Trial registration number

NCT01966978.

Clinical and economic outcomes among injection-naïve patients with type 2 diabetes initiating dulaglutide compared with basal insulin in a US real-world setting: the DISPEL Study

AIMS

To report 1-year clinical and economic outcomes from the retrospective DISPEL (Dulaglutide vs Basal InSulin in Injection Naïve Patients with Type 2 Diabetes: Effectiveness in ReaL World) Study.

MATERIALS AND METHODS

This observational claims study included patients with type 2 diabetes (T2D) and ≥1 claim for dulaglutide or basal insulin between November 2014 and April 2017 (index date=earliest fill date). Propensity score matching was used to address treatment selection bias. Change from baseline in hemoglobin A1c (HbA1c) was compared between the matched cohorts using analysis of covariance; diabetes-related costs were analyzed using generalized linear models.

RESULTS

Matched cohorts (903 pairs total; 523 pairs with complete cost data) were balanced in baseline characteristics with mean HbA1c 8.6%, mean age 54 years. At 1 year postindex, dulaglutide patients had significantly greater reduction in HbA1c than basal insulin (-1.12% vs -0.51%, p<0.01), lower medical costs ($3753 vs $7604, p<0.01), higher pharmacy costs ($9809 vs $6175, p<0.01), and similar total costs ($13 562 vs $13 779, p=0.76). Medical and total costs per 1% HbA1c reduction were lower for dulaglutide than basal insulin (medical: $3128 vs $12 673, p<0.01; total: $11 302 vs $22 965, p<0.01), while pharmacy costs per 1% HbA1c reduction were lower without reaching statistical significance ($8174 vs $10 292, p=0.15).

CONCLUSIONS

In this real-world study, patients with T2D initiating dulaglutide demonstrated greater HbA1c reduction compared with those initiating basal insulin. Although total diabetes-related costs were similar, the total diabetes-related costs per HbA1c reduction were lower for dulaglutide, highlighting the importance of evaluating effectiveness along with the economic impact of medications.

Exploring Validated Self-Reported Instruments to Assess Adherence to Medications Used: A Review Comparing Existing Instruments

OBJECTIVE

To provide an overview of instruments that measure adherence to medications to facilitate selection of an instrument and to provide a summary of some published adherence assessment tools tailored to be used by the healthcare team, especially the pharmacists.

DATA SOURCES

Studies were identified via PubMed, Medline, Embase, and Google Scholar using the search terms medication adherence, compliance, persistence, combined with the terms questionnaire, scale, survey, self-report, and instrument.

STUDY SELECTION

Articles written in English, describing questionnaire instruments that were psychometrically evaluated (reporting a good coefficient of internal consistency, reliability assessed through Cronbach's alpha, and had been validated against a subjective or objective measure), and containing 30 or fewer items were included.

DATA SYNTHESIS

Twelve instruments were identified and included in this review. Instruments were reviewed by evaluating specific characteristics (number of items, sample size, reliability, sensitivity, specificity, questionnaire completion time, criterion validity, and component analysis).

CONCLUSION

Various instruments are used to assess patient adherence to medications; however, no single one performs well on all criteria. Every instrument has different advantages and unique properties. A particular instrument can be chosen after considering certain factors, such as the specific requirements, population, the needed time to complete the questionnaire, the sensitivity, and the specificity of the questionnaire. Moreover, there is a recognized need to provide primary care medication adherence services customized to patient's needs. A link for teamwork between healthcare providers such as pharmacists and patients is needed. This link can be a validated instrument to assess patient's adherence to medication.

Schizophrenia: Impact of psychopathology, faith healers and psycho-education on adherence to medications

BACKGROUND

Many patients suffering from psychosis are nonadherent to their medications. Nonadherence can range from treatment refusal to irregular use or partial change in daily medication doses.

AIM

To investigate whether symptom dimensions, post-discharge care plans and being involved with faith healer affect the adherence to treatment in patients with schizophrenia.

METHOD

A total of 121 patients with schizophrenia were examined 6 weeks post-discharge from the inpatient unit and assessed for full, partial or nonadherence to medication.

RESULTS

There was a significant association between family involvement and partial adherence and between community team involvement post-discharge and full adherence to medications. Psycho-education was a predictor for adherence to medications, persecutory delusions and lack of insight predicted partial adherence, while being involved with faith healers predicted nonadherence.

CONCLUSION

Adherence to medications and socio-demographic variables are independent. This study demonstrated that nonadherence or partial adherence to medications is associated with lack of insight and persecutory delusions. Psycho-education could improve the adherence to medication compliances.

Adherence to lipid-lowering therapy and risk for cardiovascular disease and death in type 1 diabetes mellitus: a population-based study from the Swedish National Diabetes Register

Dyslipidemia is an important modifiable risk factor and lipid-lowering treatment (LLT) is essential to reduce the risk of cardiovascular disease (CVD). Studies in type 2 diabetes indicate that low adherence to statin therapy is a barrier to reach full protective potential, and less is known in type 1 diabetes (T1D). The aim was to assess risk of CVD by adherence and nonpersistence to LLT in T1D.  METHOD: A population-based study with a retrospective longitudinal design was conducted between 2006 and 2010, with follow-up until December 2013. In total, 6192 adult individuals with T1D, initiating LLT between 2006 and 2010, were included. Information on LLT, socioeconomic characteristics, comorbidities and cardiovascular events were collected. After 18 months, refill adherence was estimated by calculating medication possession ratio (MPR). Nonpersistence was defined as being without medicines on hand for at least 180 days. Individuals were thereafter followed until CVD, death or end of follow-up in December 2013. Cox regression analyses were performed to assess adherence level and nonpersistence of LLT as predictor of CVD. Analyses were adjusted for cardiovascular risk factors and socioeconomic status.   RESULTS: Mean MPR was 72%, 52% of the participants had an MPR above 80% and 27% discontinued LLT. There were 637 nonfatal and 58 fatal CVD events, mean follow-up 3.6 and 3.9 years, respectively. MPR above 80% was associated with reduced risk for nonfatal CVD compared with lower MPR, HR 0.78 (95% CI 0.65 to 0.93)). For fatal CVD, results indicated a negative effect of high adherence but the association did not reach statistical significance, HR 1.96 (0.96 to 4.01). Individuals discontinuing LLT had higher risk of nonfatal CVD, HR 1.43 (95% CI 1.18 to 1.73).  CONCLUSIONS/INTERPRETATION: In T1D, the risk for nonfatal CVD was lower among individuals with high adherence and higher among those discontinuing LLT within 18 months. It is important to evaluate and emphasize adherence to prescribed LLT at clinical visits to achieve treatment goals and reduce the risk of CVD.

Predictors of medium-term mortality in patients hospitalised with coronary artery disease in a resource-limited South-East Asian setting

Objective

To measure medium-term outcomes and determine the predictors of mortality in patients with coronary artery disease (CAD) both during and after hospitalisation in a resource-limited South-East Asian setting.

Methods

From February 2013 to December 2014, we conducted a prospective observational cohort study of 477 patients admitted to Makassar Cardiac Center, Indonesia, with acute coronary syndrome and stable CAD. We actively obtained data on clinical outcomes and after-discharge management until April 2017. Multivariable Cox proportional hazard analysis was performed to examine predictors for our primary outcome, all-cause mortality.

Results

From hospital admission, patients were followed over a median of 18 (IQR 6-36) months; in total 154 (32.3%) patients died. More patients with acute myocardial infarction died in the hospital compared with patients with unstable and stable angina (p=0.002). Over the total follow-up, there was a difference in mortality between non-ST-segment elevation myocardial infarction (n=41, 48.2%), ST-segment elevation myocardial infarction (n=65, 30.8%), unstable angina (n=18, 26.5%) and stable coronary artery disease (n=30, 26.5%) groups (p=0.007). The independent predictors of all-cause mortality were hyperglycaemia on admission (HR 1.55 (95% CI 1.12 to 2.14), p=0.008), heart failure/Killip class ≥2 (HR 2.50 (95% CI 1.76 to 3.56), p<0.001), estimated glomerular filtration rate <60 mL/min (HR 1.77 (95% CI 1.26 to 2.50), p=0.001), no revascularisation (percutaneous coronary intervention/coronary artery bypass grafting) (HR 2.38 (95% CI 1.31 to 4.33), p=0.005) and poor adherence to after-discharge medications (HR 10.28 (95% CI 5.52 to 19.16), p<0.001). Poor medication adherence predicted postdischarge mortality and did so irrespective of underlying CAD diagnosis (p interaction=0.88).

Conclusions

Patients with CAD in a poor South-East Asian setting experience high in-hospital and medium-term mortality. The initial severity of the disease, lack of access to guidelines-recommended therapy and poor adherence to after-discharge medications are the main drivers for excess mortality. Improved access to early and late hospital care and patient education should be prioritised for better survival.

Psychosocial factors correlate with adherence to medications among cardiovascular outpatient clinics in Jordan

BACKGROUND

Adherence to medications is a significant element of self-care behaviors for patients with cardiovascular diseases (CVDs). Non-adherence to cardiovascular medications is the major risk for poor outcomes following any cardiac event. However, there is a lack of studies that addressed medication adherence among patients with CVDs attending outpatient clinics in Arabic countries, including Jordan. Thus, this study purposed to assess the psychosocial factors (e.g. depression, anxiety, stress, social support and self-esteem) and their correlation with adherence to medications among patients with CVDs attending outpatient clinics in Jordan.

METHODS

A total of 395 Jordanian patients attending CVDs outpatient clinics at government, military and private healthcare facilities were recruited.

RESULTS

Our study findings showed that 31.4% of the patients reported complete adherence to their medications. The proportion of psychological reactions reported by the participants was 72.1% for depressive symptoms, 62.6% for anxiety and 50.1% for stress; 79.7% had moderate and normal social support, and 44% had low self-esteem. Depression, anxiety and stress had a significant negative correlation with adherence to medications; however, self-esteem had a significant positive relationship with adherence to medications. In addition, depression, anxiety and stress were the main predictors of adherence to medications.

CONCLUSION

Our findings might aid in paving the road for designing and developing strategies and interventions to increase adherence to medications and minimize these psychosocial problems among CVD patients in outpatient clinics.

Older Peoples' Adherence and Awareness of Changes in Drug Therapy after Discharge from Hospital

Non-adherence is important to address because it might affect the effectiveness of therapy and lead to adverse effects. The objectives of this interview study were to investigate old peoples’ general adherence to drugs and their awareness of and adherence to changes in drug therapy after their hospital stay. Following ethical approval, 42 patients admitted to the medical ward were invited to participate in this study. Of these, 36 persons, with a mean age of 82.5 years, who were discharged to their home, were interviewed by telephone using the Medical Adherence Report Scale (MARS) to assess their general adherence to prescribed drugs. Questions regarding awareness and adherence to drug changes during their hospital stay were asked. Different factors related to adherence and non-adherence were investigated using the Pearson chi-square test and the independent sample t-test. The average MARS score was 23.9 ± 1.4, with 31 persons (86%) assessed as adherent to their drug therapy and 5 persons (14%) as non-adherent. Of the 36 people, 30 had at least one change in their drug therapy during their hospital stay, and 23 (77%) of these people were aware of all changes and 23 (77%) were adherent to all of the changes. No significant differences between adherence and age, gender, living situation, or number of drugs were found. This small study found that some older people who were discharged from hospital were generally non-adherent, and some were not aware of or adherent to changes made in the drug therapy during their hospital stay. This is an important problem to address with further interventions.

Virtual monitoring for stable chronic hepatitis B patients does not reduce adherence to medications: A randomised controlled study

INTRODUCTION

Chronic hepatitis B (CHB) remains common in endemic regions, causing significant healthcare burden. Patients with CHB may need to be adherent to nucleoside analogue (NA) for a long period of time to prevent complications. This study aims to investigate the safety, efficacy and patient experience of a virtual monitoring clinic (VMC) in monitoring stable patients taking NA for CHB.

METHODS

Patients on NA and regular follow-up were randomised to either VMC alternating with doctors' clinic visit or to a control group in which they continued standard follow-up by doctors. Therapy adherence was measured by medication possession ratio (MPR) for NA therapy, incidence of virological breakthrough and hepatocellular carcinoma (HCC) development at two years of follow-up. Patient acceptance was measured on a Likert scale of 1-10.

RESULTS

A total 192 patients completed follow-up: 94 and 98 patients in the VMC and control groups, respectively. Mean age was 60.6 ± 10.8 years, with 95.3% Chinese ethnicity and 64.1% males. Age, gender, race, educational, employment and financial status were similar in both groups. Upon study completion, the majority of patients - 76 (80.9%) in VMC group and 74 (75.5%) in control group - had MPR ≥0.8; 88.8% were satisfied and rated VMC better than a traditional follow-up clinic with doctors only. More than 85% of patients rated ≥8/10 on the Likert scale for VMC, and preferred VMC over traditional clinic visits. Clinical outcomes observed were HCC development in one (1.1%) in the VMC group and four (4.1%) in the control group (p = 0.369). Two (2.1%) and one (1.0%) virological breakthroughs were observed in the VMC and control groups, respectively (p = 0.615). No incidence of HCC or abnormal blood tests were missed in the VMC arm.

DISCUSSION

VMC is a viable and safe clinical model for monitoring stable CHB patients on NA therapy without compromising patients' adherence to medications and is preferred by patients.

Clinical implication of the patient's disease awareness and adherence to medications in patients undergoing atrial fibrillation ablation

Background

The effects of the patient's disease awareness on the management of postablation of atrial fibrillation (AF) are unknown.

Methods

One hundred thirty-three AF patients undergoing an initial ablation were given a disease awareness questionnaire with a score of 16 points (8 points about AF in general and 8 points about oral anticoagulants) for the Jessa Atrial Fibrillation Knowledge Questionnaire (JAKQ) before and 1-year-after ablation. We divided them into the poor disease awareness group and good disease awareness group according to the median value (75%) of the total JAKQ score about AF in general, and compared the baseline patient characteristics and the 1-year changes in the JAKQ score, medication adherence, blood pressure, laboratory data, echocardiographic parameters, and AF/atrial tachycardia (AT) recurrence rate between the two groups.

Results

Forty-two (31.6%) patients were classified as having poor disease awareness (<75% of the total JAKQ score), which was closely associated with poor medication adherence, hypertension, diabetes, dyslipidemia, and greater left atrial volume (LAV). These trends in the poor disease awareness group remained unchanged 1 year after the ablation. During the 25.3-month follow-up, the AF/AT recurrence rate was significantly higher in the poor disease awareness than the good disease awareness group (23.8% vs. 7.7%; p = .003 by the log-rank test).

Conclusions

Poor disease awareness was linked to poor medication adherence, lifestyle-related diseases, and greater LAV before and even 1 year after the ablation, making it a potential surrogate marker for AF/AT recurrence. These findings highlight the clinical significance of disease awareness in AF management.

Medication non-adherence in acute coronary syndrome patients in Duhok, Iraqi Kurdistan

Background

Adherence to long-term secondary preventive therapies is vital for improving outcomes in patients recovering from acute coronary syndrome (ACS). This study aims to quantify the extent of non-adherence to these therapies in Iraq and identify the main factors contributing to this issue, addressing a research gap in the Eastern Mediterranean region.

Methods

This cross-sectional study was conducted from June 2023 to March 2024 in Cardiology Ward of Azadi Teaching Hospital and the Duhok Heart Center, Duhok, Kurdistan Region of Iraq, enrolling 400 patients diagnosed with (ACS). The Adherence in Chronic Diseases Scale (ACDS) was utilized to categorize patients into high, intermediate, or low adherence groups. The study questionnaire comprised three sections including clinicodemographic data, adherence assessment based on the ACDS, and patient-reported reasons for non-adherence.

Results

The study revealed that the mean age of the participants was 65.78 ± 11.8 years. Within the sample, 24% reported low adherence, 39% reported medium adherence, and only 37% exhibited high adherence. Significant associations were observed between low adherence and older age (P = 0.026), lower education levels (P = 0.0051), and the presence of endocrine disorders (P = 0.029). Conversely, higher adherence was found among patients taking 3-5 different medication classes (P = 0.0003) and those who underwent coronary interventions (P = 0.014). The primary reason for non-adherence was forgetfulness (89.5%).

Conclusion

The study concludes that a substantial portion of ACS patients in Iraq show low adherence to secondary preventive therapies. To increase adherence among patients with ACS, strategies should be developed to improve medication adherence and promote healthy behaviors simultaneously, Forgetfulness and lack of follow-up are the primary reasons for non-adherence.