patient care perspectives

Treatment Adherence Challenges in Type 2 Diabetes

by Marie E. McDonnell, MD

Overview

Strategies to improve treatment adherence in patients type 2 diabetes rely on identifying specific barriers for individual patients. Checking in with patients following treatment initiation helps to manage issues related to tolerability, cost, and treatment burden, all of which may hinder adherence.

Expert Commentary

Marie E. McDonnell, MD

Chief, Diabetes Section
Division of Endocrinology, Diabetes and Hypertension
Director, Diabetes Program
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA

“Along with side effects and costs, treatment burden is something that can reduce adherence. Insulin or other injectables are probably the best examples. Treatment burden relates to a patient’s home life and the totality of what is needed to implement a medical regimen.”

Marie E. McDonnell, MD

Medication persistence data show that up to 80% of patients are not taking their prescribed medications at 1-year follow-up. Although this can be due to a multitude of reasons, side effects and issues related to tolerability are among them. If we can “get ahead” of potential side effects so that patients are made aware of the possibility of their development before they occur, we are in a better position. Additionally, follow-up with a care team member can help with adherence, and it should ideally occur 1 to 2 weeks after the initiation of a new treatment. Tolerability issues can include things such as gastrointestinal side effects that can occur when starting metformin; nausea and/or vomiting after starting a glucagon-like peptide 1 receptor agonist; or genital yeast infections, which are quite common in the first few months of starting sodium-glucose cotransporter-2 inhibitors. 

Another cause of treatment nonadherence is cost, which may very well be a larger contributing factor than side effects from an overall population perspective. The degree to which cost is a contributing factor to nonadherence may depend on a patient’s state of residence, as medication costs through government programs differ from state to state. Some of the things that we can do as clinicians include providing ample information about savings programs and coupon-type offers.

Along with side effects and costs, treatment burden is something that can reduce adherence. Insulin or other injectables are probably the best examples. Treatment burden relates to a patient’s home life and the totality of what is needed to implement a medical regimen. For instance, although patients may be accepting of starting insulin at their clinic appointment, they often do not calculate, or were unprepared for, the burden associated with treatment. Patients may initially take these medications but then discontinue or not take them as frequently as prescribed because they underestimated how much they were going to dislike taking them. Further, if patients are taking their injectable medication in the evening, which is often the most stressful time of the day for many individuals, they might look at that injection and think, “I cannot do this right now.” Or the burden might relate to an unanticipated need for refrigerator storage in a house where the patient is living with roommates. Patients often do not foresee these roadblocks until they encounter them, and they may stop taking their medication to “keep the peace” in their lives. 

All of these challenges underscore the value of having a quick follow-up phone call by a care team member after treatment initiation, just to check in with the patient. It does not have to be a nurse or even a provider who calls, but someone to have that quick check-in with the patient to ask them how things are going. In addition, I think that we could address a lot of the adherence issues, perhaps even helping tailor medicines for people with obesity, using remote management programs that follow algorithms. If we could make that a standard practice and get it covered by insurance somehow, we would address many of the issues in modern diabetes management.

References

Hushie M. Exploring the barriers and facilitators of dietary self-care for type 2 diabetes: a qualitative study in Ghana. Health Promot Perspect. 2019;9(3):223-232. doi:10.15171/hpp.2019.31

Pereira MG, Pedras S, Ferreira G, Machado JC. Differences, predictors, and moderators of therapeutic adherence in patients recently diagnosed with type 2 diabetes. J Health Psychol. 2020;25(12):1871-1881. doi:10.1177/1359105318780505

Rathish D, Hemachandra R, Premadasa T, et al. Comparison of medication adherence between type 2 diabetes mellitus patients who pay for their medications and those who receive it free: a rural Asian experience. J Health Popul Nutr. 2019;38(1):4. doi:10.1186/s41043-019-0161-9

Sagalla N, Yancy WS Jr, Edelman D, et al. Factors associated with non-adherence to insulin and non-insulin medications in patients with poorly controlled diabetes. Chronic Illn. 2020;1742395320968627. doi:10.1177/1742395320968627

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