Medication Non-Adherence in Diabetic Treatment

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Author: Adekola Taylor
August, 2015

Introduction

Medication non-adherence is an intricate and many-sided health care problem. According to WHO, adherence can be defined as the extent to which patients’ attitudes agree with recommendations for prescribed treatments by a health care professional (Jaarsma, Nikolova-Simons & van der Wal, 2012). During various stages of patients’ treatment, they may be non-adherent. Medication adherence has been recognized as a serious challenge both to the healthcare providers and the patients since it involves adherence to various self-care behaviors. Patients may resolve not to begin their treatment at all or decide not to fill their prescription. They may take their medication at the wrong time or take less or more than the prescribed medication. The reasons for medication non-adherence are diverse and may be intentional or unintentional (Hugtenburg et al., 2013).

Medication non-adherence is associated with complications in diabetes, increased risk of morbidity and mortality, and frequent readmissions. The causes of medication non-adherence may be linked to the method of treatment, health care provider, and the patient (Linn et al., 2012). For instance, a patient may consider a treatment unnecessary, the risk of medication non-adherence may increase due to complex treatment, and inadequate communication between the healthcare provider and the patient may also increase the risk of medication non-adherence (Vrijens et al., 2012).

Medication Non-adherence in Diabetic Treatment


When compared adherence rates in patients with chronic conditions and acute conditions, they are primarily higher among patients with acute medical conditions (Sharma et al., 2014). Various studies on this comparison show that medication adherence in chronic diseases is averagely 50%. The treatment of diabetes is very challenging and difficult to manage successfully. It needs repeated self-monitoring of blood glucose, exercise, dietary modifications, and administration of medications as specified. Therefore, the problems of regimen non-adherence are common among patients with diabetes, thus leading to difficulty in control the glycemic level (Joan, Erisa & Agatha, 2008).

Among type 2 diabetic patients, poor medication adherence appears to be a major barrier to positive clinical outcome. Patients are likely to deviate from the dosage regimen due to omission of doses. Also, fear of difficulty attached to daily consumption of too many medications has been considered to be a potent hindrance to medication adherence, in particular, among diabetes patients and, in general, among patients with chronic diseases. Reduction in the number of daily doses in diabetic treatment has proven to be effective in enhancing adherence (Sharma et al., 2014). The growing prevalence rates of diabetes are a major concern for health-insurance providers and governments because most type 2 diabetes patients suffer from multiple co-morbid health conditions.

Several medications, such as cholesterol-lowering, glucose-lowering, and blood-pressure-lowering drugs are given to manage diabetes patients. Inadvertently, the use of multiple medications has been practically linked to problems of medication adherence (Blackburn, Swidrovich & Lemstra, 2013). Especially, among type 2 diabetes mellitus where there is high prevalence rate of non-adherence resulting to increased mortality and morbidity (Asche, LaFleur & Conner, 2011). In four hospitals in the United States, when all non-adherence associated with hospitalizations were classified, diabetes was found to be the second top cause of mental health conditions (Blackburn, Swidrovich & Lemstra, 2013).

Diabetes Drug Categories and Medication Regimen

When considering the treatment options for a diabetes patient using the appropriate pharmacological therapy, one significant factor to be considered is whether the patient is insulin resistant, insulin deficient, or both (American Diabetes Association, 2014). The treatment options for diabetes can be grouped into secretagogues, insulin sensitizers, incretins, alpha glucosidase, insulin and insulin analogs, SGLT-2 inhibitors and pramilintide.

Insulin sensitizer

Biguanides (Metformin) are insulin sensitizers used in the treatment of diabetes mellitus. Its mechanism of action is based on suppression of hepatic glucose output. Also, it improves insulin sensitivity of fat and muscle. Its target is on fasting glycemia, and however, some reductions in postprandial glucose concentrations can be observed in particular after the midday meal. They are typically taken twice daily, thrice daily or once daily in extended release. The maximum dose per day is 2,550 mg, and the starting oral dose is 500 mg daily.

Secretagogues

Sulfonylureas belong to secretagogues, and examples are Chlorpropamide (Diabinese), Tolazamide (Tolinase), Glimepiride (Amaryl), Tolbutamide (Orinase). Glibenclamide (Glyburide) and Glipizide (Glucotrol). They lower postprandial and fasting glucose levels. Hypoglycemia and weight gain are their main adverse effects. In patients with kidney or liver dysfunction caution should be taken. The usual oral dose is twice or once daily (American Diabetes Association, 2009).

Alpha-glucosidase inhibitors

Acarbose (Precose) and Miglitol (Glyset) are in a group of alpha-glucosidase inhibitors. Their mechanism of action is rooted in competitive blocking of the enzyme alpha-glucosidase in the brush borders of the small intestine to delay carbohydrate absorption. They target the postprandial hyperglycemia without resulting to hypoglycemia. Alpha-glucosidase inhibitors are to be avoided in patients with severe renal or hepatic impairment. The major side effects are GI complaints, such as abdominal cramps, bloating, diarrhea, and flatulence. Dosing must be taken before carbohydrate-containing meals (American Diabetes Association, 2014).

Insulin

Insulin has been indicated to be the most efficacious method of reducing hyperglycemia. In its dosing for therapeutic effect does not have any upper limit, so it is used to bring hemoglobin A1c to almost normal levels. Insulin and insulin analogs can decrease triglycerides levels and increase HDL. Insulin current available products include: rapid-acting insulin (e.g. Aspart, Lispro), short-acting (e.g. regular), intermediate, Basal (e.g. Neutral protamine Hagedorn (NPH), long-acting (e.g. Insulin glargine, Insulin detemir), and premixed (e.g. 75% Insulin lispro protamine/25% insulin lispro (Humalog mix 75/25) (American Diabetes Association, 2014).

Pramlintide

Pramlintide is synthetically derived from amylin, and a hormone secreted by beta-cells which are responsible for the suppression of glucagon secretion, slowing down of gastric emptying, and suppression of appetite via central pathway. It targets postprandial blood glucose levels. In US, it is authorized only as an adjunctive therapy with insulin in the treatment of both type 1 and type 2 diabetes mellitus. The starting dose for type 1 diabetes mellitus is 15 µg subcutaneously before each meal and for type 2 diabetes mellitus is 60 µg before meals. Pramlintide can be used in patients taking, metformin, insulin, or sulfonylureas (American Diabetes Association, 2009).

Three Consequences of Non-adherence to Diabetic Treatment

There are many consequences of non-adherence to diabetic treatment. The three most significant ones are increased mortality rate, increased morbidity and co-morbidity rate, and increased societal costs due to increased in hospitalizations.

Three factors associated with Medication Non-adherence in Diabetic Treatment


In order to enhance medication adherence, it is imperative to comprehend the reasons behind medication non-adherence. Many studies have detailed a number of factors associated with diabetes regimen adherence challenges. Three of the factors associated with diabetes regimen non-adherence are social factors, psychological factors, and health care provider and medical system factors.

Social factors

It should be noted that relationships in families play an epoch-making role in the management of diabetes. It has been shown that good communication patterns, high levels of organization and cohesion, and low levels of conflict are related to better regimen adherence (Delamater, 2006). In other words, high levels of social support, especially diabetes-related support from members of family, friends and spouses, are linked to better regimen adherence. Social support is also believed to cushion the undesirable effect of stress in the management of diabetes.

Psychological factors

Regimen adherence and psychological factors are also related in the treatment of diabetes. Health beliefs, such as effectiveness of therapy, perceived seriousness, and vulnerability to complications, which are appropriate, can be used to predict better adherence. When the treatment regimen is effective and appealing to patients, they tend to adhere well to the treatment regimen. Also, when it is believed that the merits exceed the costs, when they believe that they can succeed using the regimen or when they live in an environment that supports regimen-related behaviors, patients seem to adhere well to treatment regimen.

It is evident that greater levels of maladaptive coping and stress have been linked to many of the adherence difficulties. Psychological challenges, such as depression, eating disorders, and anxiety, have been associated with poorer diabetes management in both adult and youth diabetic patients. The DAWN study reported that poor psychological well-being was associated with a significant number of diabetes patients and it had been reported by many health care providers that these psychological problems adversely hindered medication adherence (Peyrot et al., 2005).

Health care provider and medical system factors

Adherence to medications, SMBG, diet, and weight loss have been shown to be promoted by social support provided by nurse case managers. The study also showed that having frequent contact via the telephone with patients enhance medication adherence and attained improvements in blood pressure levels, glycemic and lipid control (Delamater, 2006). Besides, support from health care team members, what is also important to medication adherence is the quality of the patient-doctor relationship. Invariably, patients in good and cordial relationship with their health care providers have better chances of adhering to their diabetic treatment.

Furthermore, patients that are not in good or cordial relationship with their doctors have lower chances of adhering to their diabetic treatment. Patients with a negative view, distrust and discomfort towards their health care providers with poor communication have been shown to have lower rates to SMBG and oral medications (Ciechanowski et al., 2001). Institutional factors that can enhance medication adherence include phone calls and reminder postcards about impending appointments.

Three nursing strategies to promote medication adherence

There are many strategies nurses can use to promote medication adhere. Three out of these strategies are effective behavioral strategies, increase patients’ knowledge, and convincing patients (Jaarsma, Nikolova-Simons & van der Wal, 2012).

Increase patients’ knowledge

Undoubtedly, increase in patients’ knowledge is vital to promoting medication adherence. The patients have to be taught by the nurses all they required to know about the use of their medications. This approach focuses on factual knowledge and instructing the patient to put to practice what they are being taught so as to get the optimal benefits from their medications. The method is worded as: offer knowledge, present facts, tell the patient, illustrate, discuss and explain. The nurses are to address the patients based on the factual knowledge and lay emphasis on the significance of the application of the knowledge in everyday life of the patients. The benefits of adherence to medications would be stressed to the patients so that they can know what they stand to gain if taken their medications as prescribed.

Convincing patients

The nurses are needed to convince the patients to adhere to their medications as prescribed, in addition to the provision of knowledge. Convincing patients to adhere to their treatment regimen goes beyond telling or informing the patients about likely consequences, but it means to win over the patients. This can also serve as a potent tool for patients' motivation to drive them to perform a specific behavior. The patients' autonomy has to be respected while convincing or motivating them to perform certain tasks. The nurses would give a patient the opportunity to explain which aspect that is making him not to adhere to his medications. The issues have to be ironed out amicably to help the patient.

Effective behavioral strategy

It should be understood that behavioral changes are part of interpersonal process. However, patients are answerable to their self-care behaviors and their own decisions. It should be noted that the patient outcomes can be affected by the behaviors of the health care providers. For nurses to promote adherence to medication, their approaches have to be patient-centered and should cultivate a supportive relationship, provide counsel, and communicate effectively when patients are in the mood to learn about from their recommendations (Hugtenburg et al., 2013).

The behavioral changes can be effected through establishment of rapport and conveyance of sincere interest in the patients. Effective behavioral strategy involves setting terms of talk about some certain health care goals. Nurses should assess the significance their patients place on the confidence they repose to specific health behaviors to evaluate their motivation or readiness. Patient confidence is built by exploring the significance of medication-related behaviors during clinical encounters. Exchanging of information is very critical to effective behavioral change process that would yield positive outcomes. The patients have to be intimated of the rationale behind the recommended treatments to promote positive behavior and medication adherence.

Conclusion


Medication non-adherence is a multidimensional and complicated health care problem. Many studies report that only few of the strategies being implored in promoting medication adherence are effective. However, the combination of these strategies is proven to be efficacious in decreasing the rate of medication non-adherence. Enhancing medication adherence in diabetes management is very imperative but also challenging. The patients, health care providers and patients’ relatives and friends have important roles to play in achieving high rates of medication adherence among diabetic patients.

It is evident that an increase in patients' knowledge, convincing patients and effective behavioral strategy are vital to promoting medication adherence. Nurses, being a health care professional which plays extensive roles in caring for patients, have to be well acquainted with the strategies to enhance medication adherence. Finally, increasing the actual knowledge of patients by providing facts and explaining the goals and effected outcomes is the first-line nursing strategy, but it has to go with motivating the patients to attain medication adherence.

References

American Diabetes Association (2009). Standards of medical care in diabetes—2009. Diabetes Care, 2(suppl 1):S13–S61.

American Diabetes Association (2014). Standards of medical care in diabetes—2014. Diabetes Care, 37[suppl 1]:S14–S80. Retrieved from http:// care.diabetesjo urnals.org/content /37/Supplement_1/S14.full.pdf+html.

Asche C., LaFleur J., Conner C. (2011). A review of diabetes treatment adherence and the association with clinical and economic outcomes. Clin Ther, 33(1):74–109.

Blackburn David F, Swidrovich Jaris, Lemstra Mark (2013). Non-adherence in type 2 diabetes: practical considerations for interpreting the literature. Patient Preference and Adherence, (7): 183–189

Ciechanowski P.S., Katon W.J., Russo J.E., Walker E.A. (2001). The patient-provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry, (158):29–35

Delamater Alan M. (2006). Improving patient adherence. Clinical Diabetes, 24(2):71-77

Hugtenburg Jacqueline G., Timmers Lonneke, Elders Petra J.M., Vervloet Marcia, Dijk Liset van. (2013). Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions. Patient Preference and Adherence, (7): 675–682

Jaarsma Tiny, Nikolova-Simons Mariana and van der Wal Martje H. L. (2012) Nurses strategies to address self-care aspects related to medication adherence and symptom recognition in heart failure patients: An in-depth look, 2012, Heart & Lung, 41(6):583-593.

Joan N., Erisa O., Agatha P. (2008). Non-adherence to diabetes treatment at Mulago Hospital in Uganda: Prevalence & associated factors. African Health Sciences, 8(2): 67-73.

Linn A.J., van Weert J.C., Smit E.G., Schouten B.C., Van Bodegraven A., Van Dijk L. (2012). Words that make pills easier to swallow: a communication typology to address practical and perceptual barriers to medication intake behavior. Patient Prefer Adherence, (6):871 –885.

Peyrot M., Rubin R.R., Lauritzen T., Snoek F.J., Matthews D.R., Skovlund S.E. (2005). Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study. Diabet Med, (22):1379–1385.

Sharma Taruna, Kalra Juhi, Dhasmana D.C.,Basera Harish (2014). Poor adherence to treatment: A major challenge in diabetes. JIACM, 15(1): 26-9

Vrijens B., De Geest S., Hughes D.A., et al. (2012) A new taxonomy for describ¬ing and defining adherence to medications. Br J Clin Pharmacol, 73(5):691–705.

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