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Medication TakingA CommentaryFrom the The University of Oklahoma Health Sciences Center, College of Pharmacy, Oklahoma City, Oklahoma. Correspondence to Nancy Letassy, PharmD, CDE, The University of Oklahoma Health Sciences Center, College of Pharmacy, P.O. Box 26901, Oklahoma City, OK 73190. With the expanding armamentarium of diabetes medications over the past decade, multiple pathophysiologic processes can be modified, therapy can be tailored to a person, and alternatives can be provided when adverse effects occur. Advances in medication delivery technology have also increased the options available to a diverse diabetic population. These improvements have also occurred in drug classes used to treat common comorbid diseases in people with diabetes, thus increasing the likelihood of attaining good glycemic control while decreasing the risk of diabetic complications. Despite these tremendous therapeutic advances, diabetes control is still suboptimal, and complications occur. How can this be? While the answer is complex, understanding medication-taking behaviors (referred to here as medication adherence) and associated issues is essential for those who provide diabetes self-management education. Drs Odegard and Capoccia have provided a detailed, well-organized summary of the literature regarding medication-taking behavior in the diabetes population. Their review covers 36 articles published between 1990 and 2007 that focus on diabetes and measures of medication adherence. Most of the articles (n = 21) are retrospective reviews that evaluate historical data in patients using oral hypoglycemic agents (n = 20) and insulin (n = 1). The prospective studies (n = 7) verify adherence using medication electronic monitoring systems (5/7) or use patient questionnaires (2/7) to evaluate adherence and the impact of depression on adherence. From this literature, one can learn that simple regimens, monotherapy, once-daily dosing, and fixed-dose combination pills improve medication-taking adherence. Problems that adversely affect adherence are medication side effects, the severity of depression, and the patient's lack of belief in the immediate and future benefits of the diabetes drug. Implications for practice from this medication-taking systematic review include assessing patients' current medication-taking behaviors and determining if any of the aforementioned barriers exist. Care planning would then necessarily address strategies to reduce these barriers. This systematic review also emphasizes the significant influence of depression on medication taking, such that screening for depression or referrals for assessment should be used by the diabetes educators when it affects diabetes treatment. Educators also need to organize care delivery to ensure that patients understand, recognize, and take action if an adverse effect occurs. Finally, the number of intervention studies (n = 8) is very limited. These studies fail to demonstrate a significant impact of tailored education, counseling, weekly telephone contacts, or cue-dose training on patients' adherence with diabetes medications. The only interventions that did improve adherence were unit-dose medication packaging with refill reminders, and this suggests the need for additional intervention studies that seek to remove or address other barriers associated with medication adherence. Clearly, the evidence to guide educators' practice regarding interventions that improve medication adherence is insufficient. Obstacles the authors encountered in writing this review are the limited number of articles identifying factors affecting adherence and intervention studies to address these factors. Most of the investigations were done in middle-aged adults with type 2 diabetes who were taking oral agents. There is a paucity of data in patients with type 1 diabetes, insulin users, and studies that represent diabetes across all age groups. There were no studies evaluating the adherence of caregivers of young children to insulin regimens or medication-taking behavior in adolescents or elderly patients with type 2 diabetes. Research is needed to identity other barriers, attitudes, and beliefs that affect adherence. Subsequent, well-designed studies will be needed to evaluate interventions that address these factors. Areas for future research include determining how psychosocial factors, cultural beliefs, provider-to-patient communication, patients' attitudes toward their disease and providers, medication coverage through insurance plans, and the health care system structure affect adherence. While depression is documented to affect medication-taking behavior, the presence and demands of other comorbid diseases need to be investigated. In a recent review, Drs Piette and Kerr posed several research questions related to comorbid diseases.1 How do patients prioritize treatment and self-management when faced with multiple, complex diseases/conditions? How does that affect their medication-taking behavior? How do health systems create barriers to adherence? How can collaborative practice improve diabetes care and positively affect adherence? Given the complexity of care, it is likely that a combination of interventions will be needed to improve medication-taking behavior. In summary, adherence to medication regimens is important for attaining good glycemic control and reducing the impact of comorbid risks (kidney, cardiovascular). The current literature offers limited guidance on factors that improve adherence, such as simplifying complex regimens, and factors that adversely affect adherence, such as side effects, depression, and lack of confidence in treatment. Even more limited are the interventions that improve adherence. Many of the barriers and problems that patients face in the management of their diabetes have not been investigated or interventions sought that reduce these barriers. Well-constructed studies need to be conducted that are specific to particular diabetes populations and therefore more directly applicable: type 1 and type 2 diabetes, insulin and oral agents, and all age groups to establish a more inclusive picture of barriers to adherence. Then, based on these results, interventions need to be evaluated for their ability to improve adherence and begin to build the evidence that they positively affect diabetes outcome.
The Diabetes Educator, Vol. 33, No. 6,
1030-1031 (2007)
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