A spoonful of education helps the medicine go down

While advice is frequently given it is not so frequently followed. Despite national initiatives and health messages such as the 5-a-day for fruit and vegetables, people are becoming heavier and less active. Because of this sedentary lifestyle type 2 diabetes is on the increase and so, therefore, is the number of medications required to control it. There are worrying statistics available showing that many people are just not taking their medicine (Peyrot et al, 2005; Cramer, 2004; Emslie-Smith et al, 2003).

The Diabetes Audit and Research in Tayside Scotland study (DARTS; Donnan et al, 2000; Donnan et al, 2002) assessed 2849 people with type 2 diabetes who were prescribed treatment over 12 months. The study results included the following.

• Only 31 % of those prescribed sulphonylureas as monotherapy took their medication as prescribed. 
• Only 34 % of people prescribed metformin as monotherapy took their medication as prescribed; on average only 300 days worth of diabetes tablets were collected per patient per year. 
• Just 13 % of people on more than one drug were taking their medication as prescribed; only 266 days worth of tablets were taken in this case.

Failure to take medication is widespread, expensive and potentially responsible for poor health outcomes. In the author’s opinion current levels of non-adherence imply a failure to address the needs and preferences of people with diabetes and represent a fundamental inefficiency in the delivery and organisation of the NHS. Peyrot and colleagues (2005) emphasise that psychological problems, including depression, anxiety, stress and burnout, may be the underlying causes for poor concordance with medication. The author also believes that an individual’s understanding of their treatment options and prescribed medication is fundamental to improvements in health and well-being. Adequate self-care takes time to achieve and it is only through supporting and engaging people with diabetes in the education process that a beneficial effect will be seen. 

Approximately 95 % of diabetes care is provided by the individual with the condition. These people need to understand not only what they are taking but why they are taking it – yet a recent survey found only 17 % were given information about their treatment every time they were given a prescription (Association of the British Pharmaceutical Industry [ABPI] et al, 2006a).

People who are prescribed preventive therapies are less likely to take their medication (Emslie-Smith et al, 2003). They may have negative beliefs about taking a substance they see as harmful or they may feel no different while they are taking it and see it as being of little value. Worse still, they may associate unpleasant side-effects with the medication and be reluctant to return to the GP or nurse to explain these as a reason for their discontinuation.

Simplified therapy regimens (Table 1) improve concordance with medication. People converting from multiple doses to combined doses appear to be more likely to take their medication (Cramer, 2004). 

Strategies to improve concordance
There are various methods that can be used in practice to improve concordance rates.

• Agree a suitable treatment schedule with the individual and enter it in their care plan or patient-held record.
• Provide Ask about your diabetes medicines (ABPI et al, 2006b) to encourage participation in education on therapy options
• Find out if local community pharmacies are able to offer Medicines Use Review (MUR; see Box 1) to people with diabetes. 
• Check computer records for those with poor control to see if they are ordering fresh supplies when expected.
• Boxes with compartments for each dose may be available through your local community pharmacy. This is especially useful for those with deteriorating memory.

In their report on Interventions to facilitate adherence, Horne and Kellar (2005) found that no single model for ensuring concordance to medication prescriptions could fit all circumstances. However they stressed that:

‘Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.’

Treatment options
Two of the therapeutic options available for improving concordance with diabetes control regimens by reducing pill burden are: switching to once-daily medication and combination therapy.

Once-daily medication
This method of control appeals to people with diabetes as it is easier for them to remember to take their medication and may interfere less with their day-to-day activities (Box 2). This has also been shown to improve adherence to treatment regimens (Kardas, 2005).

Combination therapy
Having two or more agents combined into one tablet will considerably reduce the pill burden of the individual with diabetes and this may help to improve concordance (Box 3).

Summary
The most expensive drug is not that which costs us the most money. It is the one which is prescribed and then is not taken. Reducing the total daily pill count has been shown to improve adherence to medication and can be achieved by combining two therapies into one tablet or by extending the duration of action enabling once-daily dosing. Side effects of drugs should be included in education plans and alternatives sought for those that are not well tolerated. Education in self-care is the key to better concordance but needs to be planned and structured in a format suitable to the individual. People with diabetes have the power to decide whether to take a particular medication – we should make sure they have the education to allow them to make that choice based on accurate information. It is clear that simplified medication options should be used if possible wherever non-adherence with medication is an issue.