Medication adherence and newly diagnosed diabetes

Introduction

Medication adherence is a critical aspect of medical treatment. In chronic conditions such as diabetes medication adherence plays a vital role in the management of disease and the gradual normalization of hyperglycaemic levels in the body.

In spite of playing a major role the adherence to pharmacotherapy, there is an overall reduced implementation of prescription adherence as shown by WHO. The report stated the average non adherence rate among the patients with chronic illnesses is barely 50%. Medication non adherence has a greater impact of negative consequences in almost all the parties in medical niche i.e. the patients, the provider, the physician, and the sustainability of the healthcare system as well as the pharmaceutical industry. Annually an estimated $100 billion in preventable costs occur in USA alone. The year 2013witnessed estimated direct and indirect costs of non-adherence to pile up to the colossal amount of $337 billion in USA alone – nine times higher than the amount of expenditure spent on the total healthcare within the same year. All of these factors poster the problem of medication non adherence as a common and costly problem.

Indian perspective

It is already known that India was infamously declared the diabetes capital of the world and its consequences are not only seen in the health but also in the economic sphere. When chroniuc diseases such as diabetes, hypertension and other lifestyle diseases are increased at epidemic levels, it  macroscopically increases costs of treatment. The long-term glycemic control is an essential required component for the prevention of microvascular and macrovascular complications development in diabetes patients as these complications would further increase the already overloaded economic burden. It was evident that reduced glycemic control is directly proportional to increased health resource use and medical care costs. Oral hypoglycaemic medicines and insulin injections are usually recommended for normalisation of sugar levels within the blood. Nevertheless the bane of medication non adherence is rampant which therefore discounts the perfection of pharmacotherapy.

The hurdles and the leaps

There are various barriers to medication adherence which are similar to most of the other complex health behaviours, such as obesity, weight loss, etc that comprises of multiple contributing factors. Identification of underlying patient behaviours must be given the utmost attention as that in turn escalates the enhancement of diagnostic accuracy of the problem

The 6 representative medication non adherence phenotypes, discovered till date which highlight the divergence of the underlying hurdles and behaviours that are identified at the patient level are:

  1. The inability of the patient in the comprehension of the relevance of medication adherence in the maintenance of health and well-being;
  2. The rudimentary pharmacoeconomic analysis executed by the patient within his/her inclusively limited understandings stating the medications taking benefits do not outweigh the costs of the same
  3. The issuing of prescription to the patient which contains greater complexity of medication management exceeding the patient’s information processing capacity.
  4. The patient’s attentiveness is inadequate
  5. The native beliefs and social stigma presented by the patient are either inaccurate, irrational, or pose conflicting beliefs about medications contrary to the normative.
  6. The inability of the patient’s perception to find therapeutic efficacy to the therapeutic regimen.

However the etiological advantage must be established accurately prior treating a medical condition i.e. an infallible diagnosis must be circumstantiated. Screening the population of interest could be one of the finest approaches to identify the status of these discreet patient behaviours such as medication non adherence.  

That being presented, it was to be understood that majority of the clinicians neither were formally trained about screening for, and diagnosing, medication non adherence, nor about the aftermath treatment for medication non adherence once detected. This eventually resulted in the development of varying heuristic processes contemplating with the diagnosis and documentation of medication non adherence within the few dedicated clinicians – a rare breed. The most common diagnostic measurement for finding the medication non adherence is a simple interrogation of the patients en masse if they encounter any hindrance which might negatively impact the prescribed medication regimen. Even after performing such interrogations, there will never be a guaranteed and authentic response from the patients who try to conceal their fallible behaviours, fearing a straight black lash from the healthcare community. When no further questions are asked, potentially addressable medication issues are left unattended.

Each medication nonadherence phenotype needs an array divergent diagnostic tools and treatments in the same way that subtypes of a medical condition.

The tale of the newly diagnosed

The chronic and progressive nature of diabetes can be tamed and harnessed early on if the medical intervention was provided precociously. Studies evidenced the early medical intervention’s potential to enhance glycemic control.

Hong and Kang found that the risk of hospitalization in the third year edges as high as 26% among the non adherent patients taking oral medication for the first two years who were newly diagnosed with type 2 diabetes.

Lee-Kai Lin, et al retrospectively studied the patterns of medication non adherence in newly diagnosed patients. The hypoglycaemic drugs such as alpha-glycosidase inhibitors, biguanides, dipeptidyl peptidase 4 inhibitors, meglitinides, sulfonylureas, thiazolidinedione as well as insulins, were reviewed. The measurement for medication adherence used for this study is Proportion of Days Covered (PDC) which can be calculated for each study subject.

The study revealed few insights which weren’t observed before. The study revealed that medication non-adherence (PDC <80%) was about 35% among the newly diagnosed diabetes patients.

  • The ethnic differences play a vital role in medication adherence as it was found that the medication non-adherence is seen greater within the Indian diaspora when compared with Chinese, Malay, and others in Singapore.
  • The strong racial and ethnic disparities impacting medication adherence has been could be due to both non-modifiable factors like financial burden of medications, competing demands, cultural and social barriers, family support; and modifiable factors such as health literacy, language barriers, clinical support services, the patient–provider relationship.
  • The average patient age was found to be inversely proportional to medication adherence
  • It could be reasoned that the evidence of reduced adherence in the geriatric patient group could be comprehended due to the declination in cognitive functioning, while the higher prescription adherence in the youngest group can be attributed to the competing life demands.
  • It was seen that the patients with multiple chronic conditions were either more cautious about maintaining their health conditions or their realization of being accustomed to polypharmacy made them more likely to adhere to the medical treatment.
  • The above reasoning can be evidenced in the study where the patients suffering with either long term hypertension or dyslipidemia were found to be more likely medication adherent.
  • Another peculiarity was noticed in the inversely proportional relationship was seen between baseline HbA1c level and medication adherence.
  • In other words, highest and lowest baseline Hba1c level patients were associated with reduced medication adherence when compared with other groups.
  • The rationale could be the conclusion of higher adherence association was greater in patients with objectively poorer health conditions lower in seriousness
  • In conditions of higher seriousness, worse adherence association was observed with objectively poorer health.
  • While it remains a known fact that medication adherence is sufficient to trigger the consequences of better glycemic control with fewer ED visits and hospitalizations, nevertheless it was observed that medication adherence also supplements patients with behavioural modification, glucose self-monitoring, attendance with medical care, and other components of diabetes self-management.

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