Post on 12-Jan-2016
description
Patient adherence in type 2 diabetes: What’s the issue and how
to address itAnthony Barnett
University of Birmingham and Heart of England NHS Foundation Trust, UK
Prescribed regimen for 12 months
Fully compliant for 12 months
Fully persistent for 12 months
Partially compliant
Non-persistent (stopped therapy before
12 months)
Non-compliant and non-persistent
Non-acceptance (does not start therapy)
Definition of compliance and persistenceCompliance: extent to which a patient acts in accordance with the prescribed interval and dose of dosing regimenPersistence: accumulation of time from initiation to discontinuation of therapyAdherence: encompasses both
US population 2002. J Int Med Res. 2002;30:71.US population 2002. J Int Med Res. 2002;30:71.
So what really happens when you fill a prescription? PERSISTENCE
0
20
40
60
80
100
120
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96 100 104
Metformin monotherapySulphonylurea monotherapyM+SU polytherapy
Study period
Study groupa nPersistence
(in days)b
SDPersistence
rate (%)c
1 year Metformin (M) 4,033 183.8 142.7 51.06(360 days) Sulphonylurea
(SU)11,234 183.1 141.8 50.86
M+SU 661 111.1 117.4 30.862 YEARS Metformin 915 296.7 285.1 41.21
(720 days) Sulphonylurea 2983 274.3 276.5 38.10M+SU 158 121.9 186.9 16.93
Pers
iste
nt
pati
ents
(%
)
Weeks of therapy
So what really happens when you fill a prescription? COMPLIANCE
US population 2002. J Int Med Res. 2002;30:71.US population 2002. J Int Med Res. 2002;30:71.
65.06 64.64
44.42
63.07 60.54
35.76
0
20
40
60
80
100
Pati
ents
rem
ain
ing
com
plia
nt
to t
hera
py
(%)
1 Year (360 days) 2 Years (720 days)
Metformin Sulphonylurea Metformin + Sulphonylurea
Study period
Study groupa n
Compliance
(in days)b
SDPersistence
rate (%)c
1 year Metformin (M) 4033 234.2 110.8 65.06(360 days) Sulphonylure
a (SU)11,234 232.7 113.6 64.64
M+SU 661 159.9 115.3 44.422 YEARS Metformin 915 454.1 232.2 63.07
(720 days) Sulphonylurea
2983 435.9 232.6 60.54
M+SU 158 257.5 228.2 35.76
Diabetes Audit and Research in Tayside Study (DARTS)• Study population
– All people with Type 2 Diabetes living in Tayside, Scotland (~420,000)
– First prescription for oral anti-diabetes drug from 1 January 1993 onward
– Follow-up to 31 December 1995 with at least 12 months of prescriptions
Donnan PT et al. Diabet Med. 2002;19:279-284.Donnan PT et al. Diabet Med. 2002;19:279-284.
Total time drug prescribed
Total time of follow-up
Total time drug prescribed
Total time of follow-up
= Adherence index= Adherence index
Adherence index by type of therapy
Monotherapy Sulphonylurea 31Metformin 34
Polytherapy Sulphonylurea 19Metformin 13
Donnan PT et al. Diabet Med. 2002;19:279-284.Donnan PT et al. Diabet Med. 2002;19:279-284.
Retrospective, cohort study of community pharmacy records
(N=2,325)
Once the patient has ACCEPTED treatment, is everything fine?
Van Wijk et al. J Hypertens. 2005;23:2101-2107.Van Wijk et al. J Hypertens. 2005;23:2101-2107.
0 1 2 3 4 5 6 7 8 9 10
Years after first prescription
Con
tin
uou
s h
yp
ert
en
siv
e u
sers
(%
)
MenWomen
00
1010
2020
3030
4040
5050
6060
7070
8080
9090
100100
Sokol et al. Med Care. 2005;43:521-530.Sokol et al. Med Care. 2005;43:521-530.
Level of compliance (%)
All-c
au
se h
osp
italisati
on
ri
sk (
%)
44
3936
3027
0
10
20
30
40
1-19 20-39 40-59 60-79 80-100
Does it matter?Lessons from hypertension: improved outcome
Odds ratio = 1.45.*P = 0.026 (controlling for age, gender, and co-morbidities).
Does it matter?Lessons from hypertension: improved BP control
Bramley et al. J Manag Care Pharm. 2006;12:239-245.Bramley et al. J Manag Care Pharm. 2006;12:239-245.
10
40
30
20
Medium(50%–79%)
Low(< 50%)
Compliance (measured using MPR)
Pati
en
ts w
ith
BP
con
trol*
(%
)
0
**
42%42%
33%33%
32%32%
High(≥ 80%)
High(≥ 80%)
BUT for type 2 diabetes it can be difficult
• Progressive disease• Multi-system disease with co-morbidities—
polypharmacy!• Complex guidelines• Unmet needs of pharmacotherapies
Progressively declining beta cell function in T2D‘waiting for failure’
Adapted from: Heine RJ et al. BMJ. 2006;333:1200-1204.Adapted from: Heine RJ et al. BMJ. 2006;333:1200-1204.
100
00
HbA1c
ß-cell function
Lifestyle Monotherapy Dualtherapy
Insulin ±oral drugs for lowering
blood glucose
Time (years)
ß-c
ell f
un
cti
on
(%
) Hb
A1
c (%
)
8
>15
5
6
7
9
0
10
The treatment complexity in type 2 diabetes drives non-adherence to management strategiesMedication for Complex Diabetes
A 42-year-old woman’s regimen for treating complex diabetes includes…
• At least 15 types of oral medication• 2 over-the-counter products• 7 to 10 injections• 4 blood tests
…per day, costing over $1,800 a month retail
Source: Dr. John Buse, The New York TimesSource: Dr. John Buse, The New York Times
Mild to moderate hyperglycaemia (HbA1C <9.0%)
Overweight(BMI ≥ 25 kg/m2)
Non-overweight(BMI < 25 kg/m2)
Biguanide alone or incombination with 1 of:
•insulin sensitizer•insulin secretagogue
•insulin•alpha-glucosidase inhibitor
1 or 2 anti-hyperglycaemicagents from different classes
•biguanide•insulin sensitizer•insulin secretagogue•insulin•alpha-glucosidase
inhibitor
Add a drug from a different classor use insulin alone or in combination with:•biguanide•insulin
secretagogue•insulin sensitizer•alpha-glucosidase
inhibitor
Marked hyperglycaemia (HbA1C ≥9.0%)
2 anti-hyperglycaemic agentsfrom different classes
•biguanide•insulin sensitizer•insulin
secretagogue•insulin•alpha-glucosidase
inhibitor
Basal and/orpre-prandial insulin
Add an oralanti-hyperglycaemic agent
from a differentclass or insulin
Intensify insulinregimen or add
•biguanide•insulin
secretagogue•insulin sensitiser•alpha-glucosidase
inhibitor
If not at target
Timely adjustments to and/or additions of oral anti-hyperglycaemic agents and/or insulin should be made to attain target HbA1C within 6 to 12 months
Timely adjustments to and/or additions of oral anti-hyperglycaemic agents and/or insulin should be made to attain target HbA1C within 6 to 12 months
L
I
F
E
S
T
Y
L
E
Current treatment paradigms for type 2 diabetes are not “user-friendly”
If not at target If not at target If not at target
*Physicians were asked to indicate key areas. †Patients were asked to choose top three most important areas.*Physicians were asked to indicate key areas. †Patients were asked to choose top three most important areas.
0
5
10
15
20
25
30
35
40
0 5 10 15 20 25 30
Patients’ Need for Improvement†
Percent
Weight loss
HbA1c
Hypoglycaemia
Ease of Use
Reasons for choice†
Percent
0
5
10
15
20
25
30
35
40
0 10 20 30 40 50 60 70 80 90 100
Physicians’ Need for Improvement*Percent
Reasons for choice*Percent
HbA1cPreserves beta cell function
Weight loss
Cost
GI side effect profile
Unmet patient & physician needs in the treatment of type 2 diabetes in Europe
1. Xingbao C. Chinese Health Economics. 2003. Ling T. China Diabetic Journal. 2003. 2. Harris SB et al. Diabetes Res Clin Pract. 2005;70:90-97. 3. Lopez Stewart G et al. Rev Panam Salud Publica. 2007;22:12-20. 4. Saydah SH et al. JAMA. 2004;291:335-342. 5. Liebl A et al. Diabetologia. 2002;45:S23-S28.
1. Xingbao C. Chinese Health Economics. 2003. Ling T. China Diabetic Journal. 2003. 2. Harris SB et al. Diabetes Res Clin Pract. 2005;70:90-97. 3. Lopez Stewart G et al. Rev Panam Salud Publica. 2007;22:12-20. 4. Saydah SH et al. JAMA. 2004;291:335-342. 5. Liebl A et al. Diabetologia. 2002;45:S23-S28.
US(NHANES)4
HbA1c < 7%
37%
63%
Europe(CODE-2)5
HbA1c < 6.5%
31%
69%Canada(DICE)2
HbA1c < 7%
51%49%
China(CODIC-2)1
HbA1c < 7.5%
68%32%
Latin America(DEAL)3
HbA1c
<7%
43%57%
RESULT: Patients often fail to achieve glycaemic targets
Achieving glycaemic targetAchieving glycaemic target
Failed to achieve glycaemic targetFailed to achieve glycaemic target
Grant RW et al. Diabetes Care. 2003;26:1408-1412.Grant RW et al. Diabetes Care. 2003;26:1408-1412.
Side effectsDifficulty in rememberingdoses
Cost
Others*
Only 23% of patients who had side effects reported the problems to their primary care physician
Most common factors related to non-adherence in patients with type 2 diabetes
*Number of prescribed medications, patient characteristics
N=128 patients with Type 2 Diabetes.
Adherence to oral anti-diabetes agents
Literature search to determine extent of omitted oral anti-diabetes agentsLiterature search to determine extent of omitted oral anti-diabetes agents
Cramer J. Diabetes Care. 2004;27:1218-1224.Cramer J. Diabetes Care. 2004;27:1218-1224.
79.1
65.6
38.1
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tage o
f pati
ents
re
main
ing
com
plia
nt
to
thera
py
Once-daily regimens
Twice-daily regimens
Three times daily
regimens
UKPDS 34. Lancet. 1998:352:854-865. n=at baseline; Kahn et al (ADOPT).
N Engl J Med. 2006;355(23):2427-2443.
UKPDS 34. Lancet. 1998:352:854-865. n=at baseline; Kahn et al (ADOPT).
N Engl J Med. 2006;355(23):2427-2443.
Most current therapies promote weight gain
Years from randomization
Change in w
eig
ht
(kg)
0
1
5
8
7
6
4
3
2
UKPDS: up to 8 kg in 12 years
Glibenclamide (n=277)
Insulin (n=409)
Metformin (n=342)
0 3 6 9 12
Conventional treatment (n=411); diet initially then sulphonylureas, insulin, and/or metformin if FPG > 15 mmol/L
ADOPT: up to 4.8 kg in 5 years
Weig
ht
(kg)
Annualized slope (95% CI)Rosiglitazone, 0.7 (0.6 to 0.8)Metformin, -0.3 (-0.4 to -0.2)Glibenclamide, -0.2 (-0.3 to 0.0)
Years0 1 2 3 4 5
96
92
88
0
100 Treatment difference (95% CI)Rosiglitazone vs metformin 6.9 (6.3 tp 7.4); P<0.001Rosiglitazone vs glibenclamide, 2.5 (2.0 to 3.1); P<0.001
Glibenclamide (n=1,441)
Rosiglitazone (n=1,456)
Metformin (n=1,454)
HypoglycaemiaThe major limiting factor to achieving intensive
glycaemic control for people with type 2 Diabetes
Briscoe VJ et al. Clin Diab. 2006;24:115-121.Briscoe VJ et al. Clin Diab. 2006;24:115-121.
Clinical consequences of hypoglycaemia
• Hospital admissions:– Prospective study1 of well-controlled elderly T2D patients
—25% of hospital admissions for diabetes for severe hypoglycaemia
• Increased mortality:– 9% in a study2 of severe SU-associated hypoglycaemia
• Road accidents caused by hypoglycaemia events3:– 45 serious events per month
1. Diab Nutr Metab. 2004;17:23-26. 2. Horm Metab Res Suppl. 1985;15:105-111. 3. BMJ. 2006;332:812.1. Diab Nutr Metab. 2004;17:23-26. 2. Horm Metab Res Suppl. 1985;15:105-111. 3. BMJ. 2006;332:812.
Multicentre study funded by Dept for Transport
Determine the frequency of hypoglycaemia in type 2 Diabetes treated with SUs and insulin for differing duration
Compare frequencies with type 1 Diabetes
Prospective study over 9-12 months of patients with good glycaemic control
Documented severe and mild hypoglycaemia prospectively, supplemented with CGM x 2
UK Hypoglycaemia Study Group. Diabetologia. 2007;50:1140-1147.UK Hypoglycaemia Study Group. Diabetologia. 2007;50:1140-1147.
Hypoglycaemia in type 2 diabetes:sulphonylureas vs insulin• In patients treated for < 2 years, no difference in
the proportion of patients experiencing:– severe hypoglycaemia (7% vs 7%)– mild symptomatic (39% vs 51%)– interstitial glucose < 2.2 mmol/L (22% vs 20%)
UK Hypoglycaemia Study Group. Diabetologia. 2007;50:1140-1147.UK Hypoglycaemia Study Group. Diabetologia. 2007;50:1140-1147.
Hypoglycaemia in type 2 diabetes
• Hypoglycaemia symptoms common in type 2 diabetes, occurring in up to 38% of patients1
• Hypoglycaemia is associated with : – Reduced “quality of life”– Reduced treatment satisfaction– Reduced therapy adherence– More common at HbA1c <7%
1. Diab Obes and Metab. 2008;Suppl 1:25-32.1. Diab Obes and Metab. 2008;Suppl 1:25-32.
1. Asian-Pacific Type 2 Diabetes Policy Group. 4th Edition. 2005:1-58. 2. Henderson JN et al. Diabet Med. 2003;20:1016-1021. 3. Matyka K et al. Diabetes Care. 1997;20(2):135-141. 4. Miller CD et al. Arch Intern Med. 2001;161:1653-1659. 5. Wright et al. J Diabet Complicat. 2006;20:395-401. 6. Chico A et al. Diabetes Care. 2003;26(4):1153-1157. 7. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Can J Diabet. 2008;32(suppl 1):S62-S64. 8. California Healthcare Foundation. J Am Ger Soc. 2003;51(Suppl 5):S265-S280. 9. Amiel SA et al. Diabet Med. 2008;25(3):245-254. 10. Salti L. Diabetes Care. 2004.
1. Asian-Pacific Type 2 Diabetes Policy Group. 4th Edition. 2005:1-58. 2. Henderson JN et al. Diabet Med. 2003;20:1016-1021. 3. Matyka K et al. Diabetes Care. 1997;20(2):135-141. 4. Miller CD et al. Arch Intern Med. 2001;161:1653-1659. 5. Wright et al. J Diabet Complicat. 2006;20:395-401. 6. Chico A et al. Diabetes Care. 2003;26(4):1153-1157. 7. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Can J Diabet. 2008;32(suppl 1):S62-S64. 8. California Healthcare Foundation. J Am Ger Soc. 2003;51(Suppl 5):S265-S280. 9. Amiel SA et al. Diabet Med. 2008;25(3):245-254. 10. Salti L. Diabetes Care. 2004.
Type 2 diabetes: greatest risk of hypoglycaemia• Use of insulin and sulphonylureas1
• Older people2,3
• Long-duration diabetes2
• Irregular eating habits4 • Exercise4
• Periods of fasting4 (eg, Ramadan)• Have lower HbA1c5
• Prior hypoglycaemia6-8
• Hypoglycaemia unawareness9
• Excessive alcohol use10
Elderly Men Without Diabetes
Matyka K et al. Diabetes Care. 1997;20(2):135-14.Matyka K et al. Diabetes Care. 1997;20(2):135-14.
Hypoglycaemic clamp study of healthy men– symptom recognition is lower in older men
Time, min
Ch
an
ge in
Tota
l Sym
pto
m
Score
Pla
sm
a G
lucose,
mg
/dL
200–4036
54
72
90
108
0 40 80 120 1600
14
12
10
8
6
4
2
Glucose infusion
maintained at
5 mmol/L
Glucose infusion reduced
stepwise from 5 to 2.4 mmol/L
Glucose infusion
restored to
5 mmol/L
Young Men Without Diabetes
Wright et al. J Diabet Complicat. 2006;20:395-401.Wright et al. J Diabet Complicat. 2006;20:395-401.
Rates of hypoglycaemia increase as HbA1c levels decrease in patients with type 2 diabetes on OADs
0
10
20
30
40A
nn
ual ra
te,
%
0 4 5 6 7 8 9 10 11
Most recent HbA1c, %
Awareness of hypoglycaemia
• Recognition of warning symptoms fundamental for self-treatment and preventing progression to severe hypoglycaemia1
• Even mild hypoglycaemia induces defects in counter-regulatory responses and impaired awareness2
• Impaired awareness predisposes to 6-fold increase in the frequency of severe hypoglycaemia3
• Only 15% of type 2 diabetes patients who experienced a hypoglycaemic event reported the incident to their doctor1,4
1. McAulay V et al. Diabet Med. 2001;18:690-705. 2. Amiel SA et al. Diabetic Med. 2008;25:245-254. 3. Gold AE et al. Diabetes Carem. 1994;17:697-703. 4. Leiter LA et al. Can J Diabetes. 2005;29(3):186-192.
1. McAulay V et al. Diabet Med. 2001;18:690-705. 2. Amiel SA et al. Diabetic Med. 2008;25:245-254. 3. Gold AE et al. Diabetes Carem. 1994;17:697-703. 4. Leiter LA et al. Can J Diabetes. 2005;29(3):186-192.
Brain damage
Sweating, tremor
4
3
2
1
Blood glucose (mmol/L)
Start of brain dysfunction
Confusion/loss of concentration
Adrenaline release
Coma/seizure
Normal physiological response to hypoglycaemia
4
3
2
1
Confusion/loss of concentration
Sweating, tremor
Start of brain dysfunction
Coma/seizure
Impaired physiological response and unawareness
Adrenaline release
Blood glucose (mmol/L)
Brain damage
Potential mechanisms of hypoglycaemia-induced mortality• Cardiac arrhythmias due to abnormal cardiac
repolarization in high-risk patients (IHD, cardiac autonomic neuropathy)
• Increased thrombotic tendency/decreased thrombolysis
• Cardiovascular changes induced by catecholamines– Increased heart rate– Silent myocardial ischaemia– Angina and myocardial infarction
Effect of experimental hypoglycaemia on QT interval
5.0 mM
QTc = 456 ms
HR = 66 bpm
A
2.5 mM
QTc = 610 ms
HR = 61 bpm
B
What can we do?
• Progressive disease: need for therapies that influence natural history of the disease
• Polypharmacy: education, multi-disciplinary support, FDCs
• Simplify guidelines• Better tolerated drugs: low risk of hypoglycaemia/
weight neutral or weight loss
The ‘ideal’ drug for type 2 diabetes
• Safe • Efficacious• Durable control• Well tolerated• Low risk of hypoglycaemia• Weight neutral or weight loss
Incretin based therapies come close to this but long-term safety and outcome
data are awaited
Incretin based therapies come close to this but long-term safety and outcome
data are awaited
Fixed-dose combination therapy meta-analysis of cardiovascular drugs and adherence
Amer J Med. 2007;120:713-719.Amer J Med. 2007;120:713-719.
.1.1 11 1010Risk ratioRisk ratio Publication Bias
(Egger’s) P=0.43Publication Bias
(Egger’s) P=0.43Favours Fixed Dose
CombinationsFavours Fixed Dose
CombinationsFavours Free Drug
CombinationsFavours Free Drug
CombinationsHeterogeneity chi2=14.49 (P=0.07)Heterogeneity chi2=14.49 (P=0.07)
Overall
0.74 (0.69, 0.80)
0.74 (0.67, 0.81)
0.89 (0.51, 1.57)
0.81 (0.77, 0.86)
0.47 (0.22, 1.01)
0.50 (0.35, 0.71)
0.88 (0.55, 1.42)
0.78 (0.55, 1.11)
0.71 (0.62, 0.80)
0.74 (0.65, 0.84)
Risk ratio(95% Cl)
100.0Overall
22.1Taylor AA et al, 2003
1.8Taylor AA et al, 2003
29.0NDC Dataset, 2003
1.0Melikian C et al, 2002
4.2Melikian C et al, 2002
2.5Geiter LJ et al, 1987
4.3Eron JJ et al, 2000
17.6Dezii CM et al, 2000
17.5Dezii CM et al, 2000
% WeightStudy
Compliance = days supplied/total days.Modified from Melikian C et al. Clin Ther. 2002;24:460-467.Modified from Melikian C et al. Clin Ther. 2002;24:460-467.
Compliance decreases when switching to non-FDC therapy
Monotherapy(n=33,567)
Switched toFDC
(Glyburide/Metformin)
Switched toNon-FDC
(Glyburide+ Metformin)
Com
plian
ce r
ate
(%
)
8277
54
0
20
40
60
80
100
(n = 105)
(n = 1,815)
(n = 33,567)
Fixed-dose combination therapy and diabetes:compliance with >6,000 US patients over 6 months
Clin Ther. 2002;24:3.Clin Ther. 2002;24:3.
Ad
here
nce r
ate
(%
)
Comparison of adjusted adherence rates in patients receiving metformin and glyburide combination therapy and those receiving fixed-dose glyburide/metformin combination therapy. *P = 0.001.
77
54
0
10
20
30
40
50
60
70
80
90
Metformin and Glyburide Glyburide/Metformin
**
FDA on fixed-dose combination therapy (2005) – advantages• Advantages of fixed-dose combination drug
therapy:– Better adherence to a therapeutic regimen– Patient convenience– Economy (cost savings)– Generation of information regarding drug compatability
and drug interactions
Federal Register. 1971;36(33):3126-3127. Am J Cardiol. 2005;96:28K-33K.Federal Register. 1971;36(33):3126-3127. Am J Cardiol. 2005;96:28K-33K.
Fixed-dose combination therapy – conclusions• In many conditions, including diabetes,
combination therapy is inevitable• Poor adherence is common and significantly affects
outcome• FDC reduce non-adherence by ~25%• FDC may improve long-term outcomes and makes
life easier for the adherent
Improving adherence
• We have or will have:– Better tolerated drugs with low risk of hypoglycaemia and
weight gain, even weight loss!– Fixed-dose combinations for some– Possibility of once-weekly injectables coming through
The missing link:good rapport between patient, family, and healthcare professionals, including multi-
professional support
Diagnosis of Type 2 Diabetes = loss of patient’s accustomed state of health
Patient’s willpower and ability to improve outcomes depend on degree of acceptance of the serious nature of their condition
Relationship between patient and healthcareprofessionals critical in this process
Lacroix A et al. Schweiz Rundsch Med Prax. 1993;82:1370-1372.Lacroix A et al. Schweiz Rundsch Med Prax. 1993;82:1370-1372.
Helping patients to accept their condition andadhere to a management plan
“I don’t really monitor my blood glucose levels. It doesn’t seem that important.
The physician never asks me my numbers or measurements, so why am I doing it?”
“My healthcare professional has helped me understand my blood glucose results and the importance of regular testing.
I feel more in control of my diabetes.”
The need for good patient-healthcare professional rapport is essential to driving treatment adherence
Motivating patients to achieve and maintain glycaemic control will drive treatment adherence
Heisler M et al. Diabetes Care. 2005;28:816-822.Heisler M et al. Diabetes Care. 2005;28:816-822.
“This is great news.Continue with the good
work and keep your blood sugar under control – you’ll feel better
for it!”
“I’ve reached my glucose target by eating properly,exercising more, and taking my medicine.”
Establish a partnership between the patient and the healthcare professional
Discuss importance of implementing
change
Build confidence that change is
possible
Establish rapport
Agree on mutual agenda
Work together to:
Reduceresistance to change
Exchangeinformation
Challenges in improving patient understanding
35% recalled receiving advice about their medication
15% knew the mechanism of action of their therapy
10% taking sulphonylureas knew that they could cause hypoglycaemia
20% taking metformin knew it could cause GI side effects
Patient knowledge of oral anti-diabetes agents
Browne DL et al. Diabet Med. 2000;17:528-531.Browne DL et al. Diabet Med. 2000;17:528-531.
Expectations regarding side effects should be appropriately managed
Outcome Weight (lbs) % Reduction
Initial consultationN = 60 Obese Women
218 0
Dream 135 38
Happy 150 31
Acceptable 163 25
Disappointed 180 17
Foster et al. J Consult Clin Psychol. 1997;65:79.Foster et al. J Consult Clin Psychol. 1997;65:79.
Treatment adherence can only be achieved by ensuring appropriate treatment goals
Unrealistic weight loss goals in obese patients seeking treatment
A multi-disciplinary team has a significant impact on glycaemic control and hospital admissions
HbA1c
-1.4
-1.2
-1.0
-0.8
-0.6
-0.4
-0.2
0
Multi-disciplinary team
Control
Ch
an
ge in
Hb
A1
c f
rom
baselin
e (
%)
Sadur CN et al. Diabetes Care. 1999;22:2011-2017.Sadur CN et al. Diabetes Care. 1999;22:2011-2017.
Multi-disciplinary team
Control
30
25
20
15
10
5
0
Hosp
italiza
tion
s/1
,00
0 p
ers
on
-mon
ths
Hospitalizations
Variable Period of time after attending education courses
0 months 12 months
FPG (mmol/L) 10.2 8.7*
HbA1c (%) 8.9 7.8*
Body weight (kg) 83.0 81.0*
Systolic BP (mmHg) 154.0 143.0*
Diastolic BP (mmHg) 95.0 87.0*
Cholesterol (mmol/L) 6.2 5.4*
Triglycerides (mmol/L) 2.8 2.1*
Impact of implementing an educational program via a multi-disciplinary team
*Significant improvement versus 0 months.
Gagliardino JJ et al. Diabetes Care. 2001;24:1001-1007.Gagliardino JJ et al. Diabetes Care. 2001;24:1001-1007.
Clear benefits of a multi-disciplinary team approach in type 2 diabetes care
1. Codispoti C et al. J Okla State Med Assoc. 2004;97:201-204. 2. Gagliardino JJ et al. Diabetes Care. 2001;24:1001-1007.1. Codispoti C et al. J Okla State Med Assoc. 2004;97:201-204. 2. Gagliardino JJ et al. Diabetes Care. 2001;24:1001-1007.
Improvedglycaemic control1,2
Improved quality of life1
Improved patient follow-up1
Higher patient satisfaction1
Decreased healthcare costs2
Lower risk of complications2
Improved treatment adherence1,2
Decreased CV risk2
Personalized care is paramount
• When dealing with a complex chronic disease such as type 2 diabetes:
“. . . the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drug they are considering.”
NICE Clinical Guidelines for the Management of Type 2 Diabetes. May 2009.NICE Clinical Guidelines for the Management of Type 2 Diabetes. May 2009.
Need for personalized care: the benefits versus risks of diabetes therapy must be assessed for each patient
Tolerability/Side Effects Improved Outcomes
β-cell deterioration
CV riskGlycaemic Control
Hypo
Poor management/ inertia
Weight gain
Personalised care in type 2 diabetes
• The healthcare professional must agree with the individual patient on their glycaemic target, how this can be achieved, and measures of success
Guidelines are guidelines, not absolutes
Summary and conclusions• Patient adherence to agreed management plans is
the major challenge in type 2 diabetes• Poor adherence is due to many factors, including:
– tolerability issues, complexity of the disease and its co-morbidities,lack of knowledge and support
• Therapeutic advances can help with the problem of adherence:– modern drugs may be better tolerated with lower risk of
hypoglycaemia and weight gain– increasing availability of fixed-dose combination therapies
• Multi-disciplinary care and a good relationship between the patient and healthcare professionals can improve long-term outcomesPersonalized care should be the
cornerstone of good diabetes management
Patient adherence in type 2 diabetes: What’s the issue and how
to addressAnthony Barnett
University of Birmingham and Heart of England NHS Foundation Trust, UK