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Although the American Diabetes Association's Scientific Sessions in Orlando, Fla., provided a heady 5-day forum for the discussion of pharmacologic therapy developments, in just 30 minutes one man pointed out a very fundamental issue related to each of them.
"The treatments available today offer the potential to dramatically influence the human and economic impact of the disease," said Richard Rubin, PhD, associate professor of medicine and pediatrics at the Johns Hopkins University School of Medicine. "But medications only work if people take them."
Physicians can intervene to improve medication compliance in their diabetic patients with simple adjustments to their practice—better monitoring and better communication, Rubin said. The major factors affecting poor drug adherence are regimen complexity, side effects, cost, and the attitudes and beliefs of both patients and clinicians.
Research shows low health literacy is common, especially in populations with high rates of diabetes, Rubin said.
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"Physicians rarely assess patients' comprehension of their medication instructions," he said, adding that it is "astounding" how often doctors think they are being clear and simple when explaining new concepts while patients walk away with little understanding.
Although the data on medication adherence for patients with type 2 diabetes is sparse, compliance appears to be far from optimal, Rubin said. He cited a literature review of 20 studies by Joyce Cramer of Yale University School of Medicine, published in May in the journal Diabetes Care, that concluded a large proportion of diabetes patients have difficulty managing their medication regimens.
Many patients with diabetes took less than the prescribed amount of medication, including both oral hypoglycemic agents (OHAs) and insulin, Cramer reported. Her retrospective analysis showed adherence to OHA therapy ranged from 36% to 93% in patients over the course of 2 years. Insulin adherence among type 2 diabetes patients was 62% to 64%. Young patients filled prescriptions for one-third of their prescribed insulin doses.
Another study in the May issue of Diabetes Care found out-of-pocket costs also affect poor compliance. Lead author John D. Piette, of the Center for Practice Management and Outcomes Research at the VA Ann Arbor (Mich.) Health Care System, reported that in a national survey of 875 adults with diabetes treated with hypoglycemic medication, 11% reported taking less medication because of cost. Few respondents, including those reporting cost problems, said their health care providers had given them assistance to address medication cost pressures.
Piette concluded that physicians should identify patients with cost problems and try to modify their medication regimens. He also recommended that clinicians help diabetes patients understand the importance of each prescribed medication, provide information on low-cost alternatives, and link patients with drug-coverage programs.
Rubin noted that the Diabetes Attitudes, Wishes and Needs (DAWN) survey, an ongoing study sponsored by diabetes-care company Novo Nordisk A/S, has shown that "psychological insulin resistance," in which 57% of diabetes patients are very worried about taking insulin and just 23% think insulin will help them control their diabetes, also affects physicians.
The DAWN survey found 59% of primary care practitioners and almost half (47%) of diabetes specialists delay using insulin until absolutely essential. Similarly, 43% of primary care practitioners and 41% of diabetes specialists delay prescribing OHA treatment.
"Many physicians, particularly primary care physicians, are resistant to being too aggressive with medication for type 2 diabetes," Rubin said.
As for solutions, Rubin said Piette's research has shown that biweekly, automated calls with nurse follow-up have resulted in fewer problems with medication adherence, lower A1C levels, and fewer diabetes symptoms. Cramer's research concludes that electronic monitoring systems also were useful in improving adherence for individual patients.
Rubin added that doctors could encourage patients to express their concerns about side effects, the complexity of treatment, or any feelings of being overwhelmed or depressed.
"We can make a difference in the likelihood that patients will
adhere," Rubin said. 
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