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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 164-171

A descriptive cross-sectional study on medication adherence of oral antidiabetic agents in diabetes mellitus patients and an overview on clinical pharmacist’s role in medication adherence in government headquarters hospital Tiruppur


1 Department of Pharmacology, The Erode College of Pharmacy and Research Institute, Erode, India
2 Department of Pharmacy Practice, The Erode College of Pharmacy and Research Institute, Erode, India
3 Government Head Quarters Hospital, Tiruppur, India
4 Department of Pharmaceutics, The Erode College of Pharmacy and Research Institute, Erode, Tamil Nadu, India

Date of Submission02-Jul-2020
Date of Decision27-Aug-2020
Date of Acceptance01-Oct-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Royal Frank Prathap
Department of Pharmacology, The Erode College of Pharmacy and Research Institute, Erode 638112, Tamil Nadu.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_57_20

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  Abstract 

Aim and Objectives: In this study, the level of adherence to medications and factors influencing nonadherence to oral antidiabetic medications among patients with type 2 diabetes mellitus was assessed. This study also ascertained the clinical pharmacist role in improving medication adherence. Materials and Methods: This is a descriptive cross-sectional study based on prospective analysis of data collected from 150 cases in the general medicine department at the secondary care Government Headquarters Hospital, Tiruppur, Tamil Nadu state, India. The study was carried out over 6 months duration, from March 2019 to August 2019. Results: In the study, of 150 patients 60% were adherent, while 40% showed low adherence. Apparently, the subjects aged below 50 years showed 100% adherence and age group of 80–89 showed the least adherence of 12.5%. Out of 83 (55%) males and 67 (45%) females enrolled in the study, 50 (60.24%) of the former and 40 (59.70%) of the latter were found to be adherent. The rate of nonadherence in married and unmarried population was found to be 40.71% and 30%, respectively. Patients who had graduated from college/university showed 100% adherence whereas, the illiterate patients showed the least adherence of 32%. Moreover, the subjects who had their onset in the age between 20–29 years were 100% adherent and the least adherence of 33% were shown by subjects with onset age between 70–79. Patients with monotherapy were more adherent (77.8%) to the therapy when compared to the patients who were on polytherapy (43.6%) and the patients with diabetic complications showed 40% of adherence and the patients without any complications showed 86.15% of adherence. Eventually, the patients who did not experience any side effects showed good adherence (79.2%) compared to the ones with side effects who showed poor adherence (20.8%) to the therapy. Finally, the adherence among the patients who never consumed alcohol was found to be 69.9% whereas, patients who consumed alcohol everyday was found to be only 33.3%. Conclusion: Majority of the patients were found to be adherent towards oral antidiabetic agents; thus, influence of clinical pharmacist in adherence was evident in this study. The major barriers for medication adherence found were being older age, having low level of education, late onset of disease, presence of side effects and complications, polytherapy, and consumption of alcohol.

Keywords: Adherence, antidiabetics, barriers, complications, diabetes mellitus, nonadherence, risk factors


How to cite this article:
Prathap RF, Suresh M, Rajeev MM, Saji JC, Bharanidharan SE, Vellaichamy G. A descriptive cross-sectional study on medication adherence of oral antidiabetic agents in diabetes mellitus patients and an overview on clinical pharmacist’s role in medication adherence in government headquarters hospital Tiruppur. J Diabetol 2021;12:164-71

How to cite this URL:
Prathap RF, Suresh M, Rajeev MM, Saji JC, Bharanidharan SE, Vellaichamy G. A descriptive cross-sectional study on medication adherence of oral antidiabetic agents in diabetes mellitus patients and an overview on clinical pharmacist’s role in medication adherence in government headquarters hospital Tiruppur. J Diabetol [serial online] 2021 [cited 2021 Apr 12];12:164-71. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/2/164/312665




  Introduction Top


The International Diabetes Federation, Diabetes  Atlas More Details Eighth edition 2019 provides the latest figures, information, and projections on diabetes worldwide In 2000, the global estimate of adults living with diabetes was 151 million. By 2009 it had grown by 88% to 285 million. Today, we calculate that 9.3% of adults aged 20–79 years––a staggering 463 million people––are living with diabetes. A further 1.1 million children and adolescents under the age of 20, live with type 1 diabetes. IDF estimates that there will be 578 million adults with diabetes by 2030, and 700 million by 2045.[1]

Adherence to therapy is defined as the extent to which a person’s behavior in taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider.[2]

Reasons for nonadherence, whether intentional or not, can be related to:

  • Limited information given to patients (e.g., regarding treatment choices and their relative benefits/risks, the clarity of communication, available evidence-base and sources of information).


  • The impact of treatment on daily life, (burdensome, painful, significant social impact, cost).


  • Factors related to the disease (although severity of disease is not necessarily correlated with higher adherence).


  • Adverse effects (desire to manage/reduce physical, psychological, emotional side-effects such as mood swings, including depression and anxiety).


  • Complexity of the treatment, such as many different medications (polypharmacy).


  • Patients’ beliefs (about medicines generally and about the treatment specifically, for example, when there is no visible benefit from taking the medicine).


  • Health system-related factors (e.g., lack of care integration which leads to an increase in both the number of stages in an appointment and the number of separate visits required to a health facility).


  • Healthcare team-related factors (e.g., lack of data sharing, poor communication).


  • Access considerations (e.g., lack of reimbursement, co-payments, medicine shortages which involve unavailability of both essential life-saving medicines and very commonly used drugs).


  • Physical or mental incapacity or emotional issues, e.g., depression


  • Social isolation or lack of support network.[3]


  • Diabetes is a chronic disease that occurs when the pancreas is no longer able to make insulin, or when the body cannot make good use of the insulin it produces.[4],[5] There are three main types of diabetes:

    Type 1 diabetes is caused by an autoimmune reaction in which the body’s immune system attacks the insulin-producing beta cells of the pancreas. As a result, the body produces very little or no insulin.[5],[6]

    Type 2 diabetes is the most common type of diabetes. Initially, hyperglycemia (high blood glucose levels) is the result of the inability of the body’s cells to respond fully to insulin, a situation termed “insulin resistance.”[5],[7]

    Gestational diabetes (GDM) is characterized by high blood glucose levels during pregnancy. It may occur at any time during pregnancy (although most likely after week 24) and usually disappears after the pregnancy.[5],[8]

    Some of the risk factors which make a person more prone to developing diabetes include being overweight or obese, leading a sedentary lifestyle, a family history of diabetes, use of systemic corticosteroids, etc.[9]

    Some of the signs and symptoms of type 1 and type 2 diabetes are:

    Increased thirst, frequent urination, extreme hunger, unexplained weight loss, presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there’s not enough available insulin), fatigue, irritability, blurred vision, slow-healing sores, frequent infections, such as gums or skin infections and vaginal infections.[10]

    Diagnostic criteria for diabetes

  • Symptoms of diabetes plus casual or random plasma glucose ≥ 200 mg/dL


  • Fasting plasma glucose ≥ 126 mg/dL


  • 2h post 75g glucose ≥ 200 mg/dL (as part of OGTT)


  • Glycated hemoglobin (HbA1C) ≥ 6.5%


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    Any one positive test should be confirmed with another test subsequently.[11],[12]


      Complications Top


    Diabetes increases your risk for many serious health problems.[13]


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      Screening Top


    Patients with diabetes should be screened regularly, at least every 6 months, for retinopathy, nephropathy, and neurology complications. Those with uncontrolled diabetes should be examined more frequently.[14]


      Management of Diabetes Mellitus Top


    Nonpharmacological therapy

    Diet and lifestyle modifications

    For people living with all types of diabetes, a healthy eating plan is extremely important to meet blood glucose targets and avoid complications related to untreated or poorly managed diabetes.

    Follow a diet rich in vegetables, fresh fruits, whole grains, nuts and unsaturated fats and avoid chocolates, red meat, processed food, and unsaturated fats.

    Choose water, coffee or tea instead of fruit juice, soda, or other sugar-sweetened beverages and limit alcohol intake

    Do regular exercise and meditation for better physical and emotional fitness.[15],[16]

    Pharmacological therapy

    Pharmacological therapy is aimed at maintaining the glycemia and reducing the long term complications of Diabetes. Drugs used for the treatment of type 2 diabetes include the following:[15],[17],[18]


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    Role of pharmacist

    Improving the patient’s knowledge about their disease, diet control, lifestyle modifications and appropriate use of medications through education and medication counseling by a clinical pharmacist will have positive effects on patient medication adherence behavior and glycemic control in patients with diabetes mellitus.[19]

    Pharmacists in community and primary care settings can be a key resource working in an interdisciplinary model for improved medication management of patients with diabetes. This is consistent with the “medical care at home,” a concept of care that promotes health care providers working collaboratively to coordinate patient-centered care. In such a model, pharmacists can focus on managing medications to positively impact health outcomes, reduce overall healthcare system costs, and empower patients and consumers to actively manage their health.[20]

    Objectives

  • To reduce the disease burden of type 2 diabetes mellitus arising due to suboptimal glycemic control.


  • To determine factors influencing medication adherence.


  • To identify barriers affecting the adherence to medications and to manage them.


  • To review clinical pharmacist role in improving medication adherence.



  •   Materials and Methods Top


    Study site

    The study is to be conducted in the general medicine department at the secondary care Government Headquarters Hospital, Tiruppur, Tamil Nadu state, which is a large hospital with 500 beds.

    Study design

    A descriptive cross-sectional study design was used. Data were collected prospectively.

    Study period

    The study is carried out over 6 months duration, from March 2019 to August 2019.

    Study population

    The study population included the patients of Government Headquarters Hospital, Tiruppur. A total of 150 cases were selected.

    Study method

    The research proposal was certified and approved by Hospital Ethics Committee and the informed consent from study participants was obtained by the investigators before the commence of the study.

    Patients with confirmed diagnosis of diabetes, who visited the outpatient department was interviewed using a structured questionnaire over a period of 6 months.

    The MARS-5 (medication adherence reporting scale) was used, which consists of five questions.

    Questionnaires were filled based on the response by the patient.

    The sociodemographic information and respondents opinion on the possible barrier(s) to medication adherence were also obtained.

    Statistical analysis

    Data were entered and analyzed using Microsoft Excel (Windows 10, version 2007).

    Patient inclusion criteria

    The inclusion criteria of the study were patients diagnosed with diabetes mellitus who were taking one or more oral antidiabetic drug, visiting Government headquarters hospital, Tiruppur and who were able to respond to questionnaires.

    Patient exclusion criteria

    The exclusion criteria of the study were patients on insulin therapy who were not taking oral antidiabetic drugs and who were not willing to or unable to respond to questionnaire.


      Results and Discussion Top


    Age

    The age group of 50–59 years and below showed more adherence compared to age group 60 –69 years and above. The age group below 40 years and 40–49 years showed 100% adherence. Hence, it was observed that the adherence decreased as the age increased. The age group of 50- 59 years showed 68.8% adherence while the age group of 60–69, 70–79 and 80–89 years showed 47.61%, 34.6% and 12.5%, respectively. The decrease in adherence with increase in age maybe due to poor memory and presence of co-morbidities, this is similar to the results obtained in the study conducted by Shaimol et al.[21]

    Gender

    Of 83 (55%) males and 67 (45%) females enrolled in the study, 50 (60.24%) of the former and 40 (59.70%) of the latter were found to be adherent. Even though it was observed that there is slightly higher adherence among males compared to females, this difference was no statistically different. The results were similar to the findings of Lee et al.[22] and Shaimol et al.[21]

    Marital status

    In our study, the rate of nonadherence in married and unmarried population was found to be 40.71% and 30%, respectively. This contradicts the result obtained in the study conducted by Raum et al.[23] in which 22% nonadherence was observed in married population while 27.6% of nonadherence was observed in single/divorced/widowed population.

    Level of education

    It is seen that people who are educated showed more adherence compared to less educated or illiterate patients. Patients who had graduated from college/university showed higher adherence (100%), while the patients with secondary education showed 86% of adherence. The patients who had primary school level of education showed 60% of adherence and the illiterate patients showed the least adherence of 32%. It is significant that with decrease in level of education the medication adherence proportionally decreases. This may be due to increased knowledge and awareness about health, the disease condition and importance of medications, which lead to increased adherence among the more educated patients compared to less educated or illiterate patients. This was consistent with other studies conducted by Bruce et al.[24] and Jackson et al.[25]

    Onset of diabetes

    Maximum adherence was shown among the population with onset of 20–29 years (100%), while age onset of 30–39 years showed 70% adherence, 40–49 years showed 63% of adherence, 50–59 years showed 62% of adherence. The least adherence was observed among the age group of 60–69 years (35%) and 70–79 years (33%). These findings were similar to the findings of Shaimol et al.[21]

    Number of medications (drugs)

    Patients with monotherapy were more adherent (77.8%) to the therapy when compared to the patients who were on polytherapy, who showed only 43.6% of adherence to the therapy. The increase in adherence among the patients on monotherapy is likely due to ease of administration schedule and less burden compared to administration of more number of drugs as in polytherapy. The results were similar to the studies conducted by Lee and Leung.[26]

    Complic ations

    The patients with diabetic complications showed 40% of adherence and the patients who did not have any complications showed 86.15% of adherence. With presence of co-morbidities, which resulted as a complication of diabetes and taking number of medicines for it might have resulted in a poor adherence to the antidiabetic agents. On the contrary, patients without any diabetic complications who follow only the antidiabetic therapy showed better adherence maybe due to decreased disease and drug burden. The results obtained contradicted the results of study conducted by Lee et al.[22]

    Side effects

    Among the patients who did not experience any side effects 79.2% showed good adherence while 20.8% showed poor adherence to the therapy. The adherence was found to be more in patients who did not experience any side effects compared to the patients who experienced side effects. The poor adherence may be because of the patient’s reluctance to take medicines after experiencing side effects on taking the medicines. Our findings are similar to the results of Jackson et al.[25]

    Alcohol consumption

    The adherence among the patients who never consumed alcohol was found to be 69.9%, the adherence among patients who consumed alcohol sometimes was found to be 37.5% and among patients who consumed alcohol everyday was found to be only 33.3%. A decrease in adherence was found with an increased alcohol consumption. On consumption of alcohol the patient may not be conscious and oriented this may result in forgetting or neglecting to take the medication resulting in poor medication adherence.

    Percentage of medication adherence and low adherence in each category of subjects.


    Click here to view


    The MARS-5 scale

    In our study, the medication adherence report scale (MARS-5) was used to measure patient medication adherence. Lee et al.[22] also conducted studies using this scale.

    In the MARS-5 scale, the following five questions were asked to the patients:

    1. Do you forget to take medication?


    2. Do you change the dosage of medication?


    3. Do you stop taking medication for a while?


    4. Do you skip taking medication?


    5. Do you use medication less than prescribed?


    The patients with MARS-5 score above 20 were known to have good adherence while the patients with MARS-5 score below 20 were known to have poor adherence [Figure 1]. In the results [Figure 2], it was shown that the for the first question (forget to take the medication) total MARS score obtained among the total population was 570 which is 76% of adherence. For the second question (change in dosage of medication) the total score obtained was 685 which is 91.30% of adherence. For the third question (stop taking medication for a while) the total score obtained was 580 which is 77.30%. For the fourth question (skip taking medication) the total adherence score was found to be 561 which is 74.80%. For the fifth question (use medication less than prescribed) the adherence score was found to be 676 which is 90.10%.
    Figure 1: Distribution of patients according to medication adherence

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    Figure 2: Medication adherence report scale-5 (MARS-5)

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    Clinical pharmacist role in medication adherence

    The clinical pharmacist is in an important position in influencing the adherence to medications by patients, especially in primary and secondary care, and community settings, where collaborations amongst different healthcare providers exists. The clinical pharmacist can in such situations directly influence the medication taking behavior of patients by interacting with and educating them. He/she can also provide relevant information about the drug and disease through counseling the patients, in a multi-disciplinary collaborative approach amongst the healthcare providers. The clinical pharmacist can work in collaboration with the treating physician and nurse to execute an individualized care plan to the patients with continuous monitoring, thereby ensuring proper medication adherence.

    Limitations

    There is no single method which can be used as the gold standard in measuring medication adherence, so it is considered challenging in clinical practice.

    As the study was conducted in a secondary care hospital, the sample size was limited and findings cannot be generalized to the community. We used a self-reported adherence measurement, which is associated with recall and social desirability bias.

    The perception and response to the questions on adherence may differ in each patient as the study included patients who had diabetes mellitus for varying durations.


      Conclusion Top


    Majority of the patients were found to be adherent towards oral antidiabetic agents, thus influence of clinical pharmacist was evident in this study. While comparing the age of patients with adherence, patients who belonged to age of below 50 years showed maximum adherence and as the age of the patients increased medication adherence decreased. Finally, patients in the age group of 80–89 years showed very poor adherence. Thus, the study expounded significant relation between age and medication adherence. Males showed slight increase in adherence compared to females, which was not much pronounced. According to marital status the unmarried population showed better adherence compared to the married population. While comparing the occupational status with adherence, the professionals showed maximum adherence. Least adherence was observed in unemployed patients. This study manifests that higher the educational level, better the adherence to the medication. The subjects with onset of diabetes at younger age showed more adherence compared to the others. The patients on monotherapy were more adherent compared to the patients on polytherapy. Better adherence were shown by self-administered patients compared to the patients whose drug administration were assisted by a domestic helper.

    Ethical approval and patient consent

    This was an observational study and was conducted with the consent of participants. A total of 150 participants were enrolled in the study. This study has been conducted in accordance with the ethical principles mentioned in the Declaration of Helsinki (2013) (IRB approval and the approval number: IHEC NO: IHEC/GH–Tiruppur/ ECP/PD – 2019/008).

    Financial support and sponsorship

    This study was funded by the Erode College of Pharmacy and Research Institute, Erode, Tamil Nadu, India.

    Conflicts of interest

    There are no conflicts of interest.



     
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        Figures

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        Tables

      [Table 1], [Table 2], [Table 3], [Table 4]



     

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