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Adherence with Noninsulin Medication for Adolescents with Type 1 Diabetes

May 26, 2020
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Karlena Pope, PharmD Candidate, South College School of Pharmacy

What factors affect adherence with noninsulin medication for our young patients with type 1 diabetes? 

Patients with type 1 diabetes are typically diagnosed at a younger age than patients with type 2 diabetes. With patients that have diabetes type 1, adherence to treatment and self-management can be difficult, especially when these patients are young. Some studies show adherence to insulin or other diabetic medications with treatment and self-management for patients with diabetes can be very difficult for the individual. Still, no data is available about adolescent patients with type 1 diabetes for adjunct noninsulin medication.    

The Adolescent Type 1 Diabetes cardio-renal Intervention Trial (AdDIT) was a double-blind, randomized, placebo-controlled cohort study to assess rates of adherence with noninsulin medication and its changes over time, compare Medication Events Monitoring System (MEMS) and pill count as methods of assessing adherence, and factors predicting adherence in adolescents with type 1 diabetes. This study included 443 adolescents with type 1 diabetes from the ages 10-16 years old at 32 centers across the U.K., Canada, and Australia. The time frame for this clinical trial was 2-4 years, and patients were randomized using a two-by-two factorial design. Patients were either given quinapril 5 mg or quinapril 10 mg, atorvastatin 10 mg, a combination of both drugs or a matched placebo. The medications were delivered in a container with electronic monitoring caps called MEMS. Tablets that were not taken were brought back to the facilities, and the tablets were counted. MEMS was able to record the date and time each cap was opened to determine the adherence rate, and tablets that were not taken were brought back to the facilities, and the tablets were counted.  

There was no clinical significance between patients taking quinapril vs. placebo or atorvastatin or placebo. The adherence between the ACE-I and statin medications and placebo-placebo is P= 0.54. The adherence rate from the first visit of the trial for MEMS was 92.3%, and for pills counted was 96.3%, and the adherence at the last visit was 76.3% and 79.0%, respectively; P < 0.001.  For the relationship, MEMS and the pills that were counted had a P < 0.001. Patients that had a suboptimal blood glucose control were less likely to adhere to the oral medication during the trial than patients that had better control of blood glucose—adherence to oral medications correlated with the patient’s A1C levels at baseline. Patients with the highest A1C levels of > 8.5% had the lowest adherence rate of 76.9%, patients with an A1C of 7.5% – 8.5% had an adherence rate of 81.9%, and patients with the lowest A1C of < 7.5% had the highest adherence rate of 88.1%. It was reported that Australia did show a slightly higher adherence rate than the U.K. and Canada; 83.4%, 78.9%, and 73.8%, respectively. After the trial had been going on for two years, 58% of the patients showed adherence of about 75%, but after four years, the adherence rate dropped to an average of 53%. It was reported that adherence to oral medications decreased due to the effect of patients dropping out of the trial after two years.  

This study was able to determine that adolescents with type 1 diabetes overall had an excellent adherence rate. Still, it was determined that over time adherence rate dropped, especially in older patients with higher A1C at baseline. The patients that were taking ACE-I and statins had an average of 80% for adherence. This study was able to highlight the need to improve adherence not only in the clinical setting but also in daily clinical practice. The MEMS had a disadvantage when it came to calculating the adherence rate. Even though it could capture the date and time of the bottle being opened, it could not determine if the patient was taking the medication, also if it was opened, or if the patient was taking more than the recommended dose.  

Practice Pearls: 

  • Patients with type1 diabetes can experience suboptimal adherence to insulin 
  • The older patients with a higher A1C level of > 8.5% were less likely to be adherent to the medications. 
  • Strategies need to be made to improve adherence rates in patients with diabetes type 1 in clinical practices. 

Reference for “Adherence with Noninsulin Medication for Adolescents with Type 1 Diabetes”:
Elżbieta, et al. “Medication Adherence During Adjunct Therapy With Statins and ACE Inhibitors in Adolescents With Type 1 Diabetes.” Diabetes Care, U.S. National Library of Medicine, February 27. 2020, www.ncbi.nlm.nih.gov/pubmed/32108022. 


Karlena Pope, PharmD Candidate, South College School of Pharmacy