Combination Therapies for Treatment of Type 2 Diabetes - Episode 9
Patient Adherence in Type 2 Diabetes
Experts Dhiren Patel, PharmD, CDE, BC-ADM, BCACP, and Javier Morales, MD, emphasize the importance of patient adherence in managing type 2 diabetes and discuss what methods might be undertaken to improve compliance.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: In terms of adherence, there are a lot of different strategies a pharmacist can employ to help patients. One of them, the big one, is pill burden. Having to take multiple pills in many cases for the same condition can become overwhelming and sometimes defeating to a patient. If there’s anything that you can do to simplify these regimens where they might be on 3 or 4 different medications for 1 condition, then using a combination therapy such as a dipeptidyl-peptidase-4 (DPP-4) inhibitor and a sodium—glucose cotransporter 2 (SGLT-2 inhibitor simplifies that for them to 1 pill that’s taken once a day. They’re not taking it multiple times a day, so that not only improves adherence, and also the likelihood that the patients are going to stay on the drug. It also affects persistence when these combination medications are used.
In addition, there’s cost. You have 2 different medications that can now have 1 co-pay that patients are dealing with. In many cases these medications are branded, so they allow for a voucher or a coupon from different manufacturers that will defray some of that cost for that patient.
When counseling patients regarding adherence, it’s important to sometimes talk to them about why it’s important to take their medications, other than just simply saying, “Hey, it’s really important that you take your medications.” When you take a condition like diabetes, it’s important that glycemic control is not just met for a short period of time—let’s say for 3 months—and that your glycated hemoglobin (A1C) is good, but then all of a sudden you go back to your ways where A1C is increasing again. There’s a lot of information and a lot of data to support getting to goal or reducing a patient’s A1C in gaining glycemic control early on and maintaining that.
We know from long-term trials that if a patient’s glycemic control is maintained, that prevents microvascular complications down the line. We have a lot of data now to support that there is benefit in just making sure that the A1C stays within goal. Many patients think, “Well, now that I’m at goal, I can start coming off…medications,” but that’s typically not the case. You could de-escalate in some cases, but in many cases the reason that they’re at goal is because they’ve been taking their medications and they have been adherent to them. It’s important to you bring that back to the patient by saying, “Hey, your A1C was well below your goal; continue doing a good job in terms of taking your medications” and giving them a reasoning, tying it back to why that’s important.
Javier Morales, MD: The management of type 2 diabetes, as well as type 1 diabetes, is never easy. Patients need to conform to appropriate lifestyle changes in order to try to achieve the best control possible. It’s recommended that these patients exercise at least 150 minutes per week, and try to consume as few calories as they actually need. After all, people tend to overindulge, which brings me to the next point, and that’s life oftentimes gets in the way. We have a lot of things to celebrate: birthdays, graduations, etcetera. Oftentimes, people may let themselves loose on their diets, which leads to hyperglycemia. Likewise, we need to reward ourselves with holidays. Sometimes, patients may actually forget or skip taking medications when they’re away on vacation.
All of this can actually weigh in on the degree of glycemic control that we see when we examine our patients in the office, especially if we’re looking at A1C; although, hemoglobin A1c is really not the best answer in terms of how well patients are controlled with their diabetes. Ultimately, hemoglobin A1C comprises 2 different items those being fasting plasma glucose and postprandial glucose.
However, patients with type 2 diabetes are often challenged with some of these lifestyle challenges and real-life things that can sometimes get in the way. Of course, one of the major barriers that’s shared by the patients and the practitioner is going to be hypoglycemia. In patients who do experience hypoglycemia, whether it’s for a minor or a major hypoglycemic event that includes the assistance of a third party, patients may want to liberalize their glycemic control just to avoid having that experience once again. It’s important to try to avoid hypoglycemia, and the appropriate therapeutic choices need to be exercised to try to minimize that risk.