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A Major Diabetes Complication That We Fail to Address

Sep 15, 2018

Nonadherence to diabetes medications 2nd leading cause of hospitalizations. For tools that can aid compliance, see our Compliance Apps Starter List at the end of this article.

Many people who have been diagnosed with diabetes have a disciplined, daily medication routine. It’s not easy: To effectively manage diabetes, there must be meticulous long-term monitoring and early treatment of any potential complications, as well as ongoing and careful monitoring of blood glucose levels, blood pressure, cholesterol, and triglycerides. For a person with diabetes to sustain a high quality of life, they must maintain a healthy lifestyle and adhere to their prescription medication regimen, if they have one.


Given the complicated barrage of tests and drugs, it is understandable that people with diabetes do not always remember to take their meds. People undergoing treatment may, for a wide variety of reasons, neglect to take their prescribed medication. This phenomenon, known as drug non-adherence, can be alarmingly dangerous for people with diabetes. Without consistent use of medications as prescribed, people increase their risk of experiencing hyperglycemia and ketone build-up.

Drug non-adherence is an underappreciated issue, but one that affects millions of people. In fact, only 50% of people in developed countries adequately adhere to their medicines, according to a published report from the World Health Organization (WHO). People with diabetes are no exception to this veritable scourge. A 2013 study found that when hospitalizations caused by non-adherence were recorded at four different American hospitals, diabetes was the second leading cause. Only mental illness accounted for more.

Of course, the medical complications resulting from medication non-adherence can be disastrous for people with diabetes. So how can this phenomenon of medication non-adherence be explained?  While people with diabetes face a number of challenges with regards to adherence, the primary two are forgetfulness and lack of perceived benefit.

In the chaos of daily life, it’s easy to forget to take your insulin shots, or run to the store to refill a prescription. Compounding this is the fact that if you don’t feel the immediate effect of not taking a pill or shot, then you are more likely to forget to take it. Diabetes is initially asymptomatic: there are not always immediate noticeable consequences of missing an insulin injection or forgetting to take an oral diabetes medication. Due to this lack of symptoms secondary to medication nonadherence, it’s not always obvious to remember to take your medicine until it’s too late.

In addition, there are a myriad of other reasons explaining why people with diabetes sometimes fail to take the drugs designed to help them. For example, some people simply fear the pain or discomfort of administering shots to themselves. Another potential factor is the side effects of the drugs. A drug that is strong enough to help people with this condition can certainly be strong enough to bring about discomfort and weakness for an individual treating their diabetes. Medication side effects, such as nausea and vomiting, can be a deterrent from continued medication use. Knowing that these side effects could occur can even deter patients from taking their medications altogether in the first place.

Another factor, which is rather unique to the American healthcare system, is that of cost. Low-income patients are sometimes embarrassed to admit that they can’t afford their prescriptions. Many prescribers are unfortunately unaware of specific drug prices and what particular drugs a patient’s insurance may cover. This often leads to high-cost medical expenses for a patient in the future when complications arise from not adhering to medications. One of the many benefits of healthcare reform would be lowering non-adherence rates thanks to reduced medication cost.

Adherence habits can also vary between people with type 1 and type 2 diabetes. Children with type 1 diabetes are instructed at a very young age about the importance of taking their insulin as instructed. With this habit in place early on in a child’s life, they are more likely to adhere to their prescriptions throughout their life. This allows a child to ultimately lead a healthier life. For people with type 2 diabetes, however, that habit may not have been in place to begin with. To counteract older lifestyle habits, such as poor diet and a lack of exercise, new and healthier habits must be developed over time. By consuming a more simplified diet that eliminates refined carbohydrates and uses protein and fats as a source of energy, all while adding more physical activity to one’s lifestyle, people with type 2 diabetes can better manage their lives and live longer.

This idea about the importance of developing healthy habits is being applied to fight non-adherence in people living with diabetes at all levels. Proper timing and dosage of medication intake is crucial to the long-term and short-term treatment of diabetes, and this requires the conscious development of new routines. For example, just changing the way a patient takes their medicine could radically improve their experience with it. Changing the time of day a patient takes their medicine could eliminate side effects altogether, while insulin pumps and injection pens, which conceal needles, help reduce patient anxiety. These strategies increase drug adherence and make it easier for people with diabetes to lead happy and healthy lives.

While it’s important for a person with diabetes to track prescription dosage and timing, it’s natural for people to be forgetful at times. Having family and friends who can ensure that medication is taken properly is imperative. In the event a patient intentionally or unintentionally does not take their medication, family and friends can be there to serve as an encouraging reminder. New technologies have likewise made it possible for patients and their loved ones to receive reminders in the form of texts and other reminders.

Properly managing diabetes is becoming more important than ever. An estimated 194 million people around the world were diagnosed with diabetes in 2003, and this number is expected to increase to 333 million people by the year 2025. However, diabetes is always treatable for those who take their medication properly, maintain a healthy diet, and live a healthy, active lifestyle. For thousands of years, diabetes was practically a death sentence until modern science gifted us with tools to help manage it. As medical health professionals, we need to remember that designing medication is only the first step in managing diabetes. Helping people build consistent routines and avoid non-adherence is equally, if not more, important to optimize patient quality of life, but is too often a forgotten aspect of diabetes management.

Practice Pearls:

  • Only 50% of people in developed countries adequately adhere to their prescribed medication regimen.
  • For hospitalizations resulting from medication nonadherence, nonadherence to diabetes medications was the 2nd leading cause of hospitalization.
  • The two most common reasons for non-adherence are forgetfulness and lack of perceived benefit. For people with diabetes using insulin, fear of injection can be an additional barrier.
  • The cost of some medications can also result in patients not filling prescriptions.
  • Providing an app that patients can use to remind them to take their medications can play a major role in improving adherence.

Reviewed by: Joshua J. Neumiller, PharmD, CDE, FAADE, FASCP

Vice-Chair & Allen I. White Distinguished Associate Professor
Department of Pharmacotherapy
College of Pharmacy and Pharmaceutical Sciences
Washington State University

For a starter list of compliance apps, download this .pdf from Diabetes in Control.