Adherence to diabetes treatment: Crucial, but challenging

Issue: November 2013

ByEdward C. Chao, DO

I recently saw a 56-year-old gentleman with type 2 diabetes, who sheepishly admitted to running out of his diabetes medications. When I’d asked whether he’d brought his logbook and glucometer, he even more sheepishly replied, “Doc, I’m sorry, but I don’t know where my meter is. I haven’t checked in like 3, maybe 6, months.” Does this scenario sound familiar to you?

Although this is not your most typical example, it’s also not uncommon. We can have the latest medications at our disposal, the most advanced glucometers that require hardly any blood, but what good are they if patients take their medications about 50% of the time, don’t perform their self-monitoring blood glucose, don’t exercise or choose healthier diets consistently, or forget to bring in their logbook? As C. Everett Koop, MD, once said, “Drugs don’t work in patients who don’t take them.”

Classically, adherence to medication regimens and lifestyle changes to treat chronic conditions has consistently been hovering around a dishearteningly low 50%. A cross-sectional study using patients with type 2 diabetes in the Third National Health and Nutrition Examination Survey found that 65% of those on oral medications, 24% of those taking insulin, and 80% of those treated by diet and exercise alone either never performed SMBG or did so less than once per month.

Edward C. Chao

In a questionnaire, patients’ most common reasons for a lack of adherence to medications were: forgetfulness (30%), other priorities (16%), decision to omit doses (11%), lack of information (9%) and emotional factors (7%). More than one-quarter (27%) of the respondents did not specify a reason for poor adherence to a regimen.

We all are very familiar with the potential barriers to improved self-management of diabetes and tools such as motivational interviewing, so I won’t cover these here. But what new, additional resources can help patients?

An example is a study by Marcia Vervloet, MSc, and colleagues that examined the real-time medication monitoring (RTMM) system, the first to pair real-time monitoring of medication use, along with sending text messages (SMS) to those patients when they do not take their medication. The team randomly assigned patients aged 18 to 65 years with type 2 diabetes, with a medication refill adherence rate of less than 80%, into one of three groups: 1) those who receive an SMS if they do not open their medication bottle within a specified time period, chosen by the patient initially; 2) those who receive the same bottles that permit real-time tracking, but who are not sent SMS; and 3) a control group receiving standard care. The trial showed a significant difference in medication adherence in those sent SMS reminders: 50% vs. 39% within 1 hour, and 81% vs. 70% within 4 hours. Although this is an indirect measurement, the results suggest another means to help patients.

Simply asking, “I know it must be difficult to take all your medications regularly. How often do you miss taking them?” can be an effective way to start on the path toward improved adherence. Multiple approaches, involving education, enlisting help from family members, and improving communication between patient and clinician, all have been demonstrated to help.

Cramer J. Identifying and improving compliance patterns. In: Cramer JA, Spilker B, eds. Patient Compliance in Medical Practice and Clinical Trials. New York: Raven Press;1991:387-392.

Harris MI. Diabetes Care. 2001;24:979-982.

Haynes RB, et al. Compliance in Health Care. Baltimore, Md.: Johns Hopkins University Press; 1979.

Vervloet M. Int J Med Inform. 2012;81:594-604.

Edward C. Chao, DO, is associate professor of clinical medicine at University of California, San Diego, and staff physician at VA Medical Center, San Diego. He reports no relevant financial disclosures.