Reasonable glycemic control can be achieved by delivering aggressive insulin-adherence interventions to targeted patients with diabetes.
Delivering adequately targeted insulin-adherence interventions on a targeted group of adults with poorly controlled type 2 diabetes, with the likelihood to improve both insulin persistence and the mean glycemic control by continuous filling of insulin prescription, yielded some improvement in glycemic control in the targeted group compared with the untargeted group of patients who received a lower-intensity intervention. This suggests that targeting patient populations for more intensive interventions has the potential to be more effective than non targeted approaches. The high-intensity interventions tend to result in more significant improvements in mean glycemic control.
Type 1 diabetes mellitus (T1DM) is an autoimmune disease characterized by the failure of pancreatic islet β-cells to produce insulin, with treatment being most times multiple-dose insulin injections or continuous insulin infusion. Type 2 diabetes mellitus (T2DM) is characterized by insulin resistance, subsequent insulin deficiency with progressive loss of β-cell function. Being a progressive disease, it often requires intensified treatment as pathology progresses, eventually requiring insulin. Timely optimization of insulin therapy is paramount in diabetes management and prevention of long-term complications. Initiation, adherence and persistence to insulin therapy induce early glycemic control, micro- and macro-vascular protection with an ultimate improvement of patient well-being.
Despite the addition of numerous new therapies and delivery means, poor adherence to insulin therapy remains one of the most commonly reported difficulties with insulin treatment in people with diabetes, leading to adverse outcomes, frequent hospitalization, frequent emergency room visits, and increased costs.
Adherence is the extent to which a patient uses a prescribed medication according to recommendations on timing, dosing, and consistency. Arguably, adherence is a critical factor in ensuring diabetes medication success. Adherence behaviors generally affect the patient’s treatment response and narrow therapeutic options. Typically, the reasons why most patients with diabetes do not adhere to their treatment are multifaceted, with complicated interplay between contributing factors – patient-related, provider-related, and external. However, improving and sustaining diabetes medication adherence is a critical component and priority in diabetes management.
Knowing that good adherence patterns are urgently needed to ensure the continued success and clinical sustainability in diabetes management, and that most adherence interventions have only been modestly effective, partly because they are not targeted to patients likely to benefit most, Lauffenburger et al., conducted a three-arm pragmatic randomized clinical trial evaluating the effects of delivering more intensive insulin-adherence interventions to targeted subgroups of patients with type 2 diabetes, and delivering a lower-intensity response to a larger group of unselected patients.
The Targeted Adherence Intervention to Reach Glycemic Control with Insulin Therapy for Patients with Diabetes (TARGIT-Diabetes) trial evaluated the effect on insulin persistence usage and glycemic control on 6,000 adults with type 2 diabetes with prescribed basal insulin therapy using a pharmacist-delivered intervention with three levels of increasing intensity to progressively more-targeted groups of patients.
All the three arms on the study were designed to be cost-neutral, but the number of follow-up calls by pharmacists varied. Arm one had untargeted patients and they received usual care. In arm two, they were selected based on their risk for non-persistence, 60% of patients were targeted and the patients with moderate risk received a moderate-intensity intervention. In arm three, again, they were selected based on their risk for non-persistence and their baseline glycemic control; only about 40% of patients were targeted. The high-intensity intervention was given to the patients predicted to have poor adherence to their medication and so at higher risk for poor glycemic control. All other non-targeted patients in each arm received usual care.
At the end of the study, there was an initial outcome where there was no significant difference between the insulin non-persistence amongst the groups. For glycemic control, patients in arm one had a 0.06% reduction in HbA1c o vs. 0.21% for patients in arm two, and patients in arm three had 0.31% reduction in their HbA1c, meaning a significant glycemic control improvement and, ultimately a meaningful outcome in diabetes care.
Given that more intensive interventions tend to result in more significant improvements in glycemic control, focusing on target patient populations based on both the risk of non-adherence and their level of disease control would most likely be beneficial and useful, allowing more resources to be devoted to fewer individuals rather than delivering a blanket intervention to patients.
- Despite many new therapies and insulin delivery models, the management of diabetes has remained a challenge in part because of poor adherence to medications.
- Effectively focusing adherence interventions to a targeted group of patients who are most likely to benefit increases both insulin therapy effect and efficiency.
- With factors affecting patient adherence to antidiabetic medications, especially insulin being complex and varied, it is necessary to look into tailoring interventions according to individual patient’s peculiar problems
Lauffenburger, Lewey, et al. “Effectiveness of Targeted Insulin-Adherence Interventions for Glycemic Control Using Predictive Analytics Among Patients with Type 2 Diabetes” JAMA Netw Open. 2019; doi:10.1001
Onyi Ibeji, PharmD. Candidate, LECOM School of Pharmacy