American Journal of Advanced Drug Delivery

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Review Article Medication Adherence in Diabetes Mellitus: An Overview on Pharmacist Role S.Z. Inamdar1*, R.V. Kulkarni1, S.R Karajgi1, F.V.Manvi2, M.S.Ganachari2, B.J.Mahendra Kumar2

1Department of Pharmacy practice BLDEA college of Pharmacy, Bijapur 586103 2Department of Pharmacy practice KLE college of Pharmacy, Belgaum 590001

Date of Receipt- 16/07/2013 ABSTRACT Date of Revision- 20/07/2013 Date of Acceptance- 26/07/2013 Diabetes mellitus is chronic disease where the medication regimen contains many aspects that make compliance difficult. Whatever is the efficacy of a drug, it cannot act unless the patient takes it. Treatment may be complex, intrusive and inconvenient. Many patients are prescribed very complicated regime of diet, exercise, and medication including several pills a day. Such complexity of treatment and factors like age, duration of diseases, depression, disabilities, psychosocial issues and life style changes directly or indirectly influences diseases self management. Adherence to treatment regimen is the key link between treatment and outcome in medical care. Low medication adherence has assumed importance as it seriously undermines the benefits of current medical care and imposes a significant financial burden on individual patients and the health care system as a whole. Poor adherence to the prescribed medication regimen is a critical health care concern for the health care providers all over the world. The problem of making sure the Address for patient follow prescriptions is as old as medicine itself. Pharmacist Correspondence can contribute and play major role in the assessment of patients S.Z Inamdar understanding of the illness and therapy, communicate the benefits or Asst Prof. treatment, assess the patient’s readiness to the care plan, and discuss BLDEA’s College of any barriers to adherence that patients may have. Medication Pharmacy adherence richly deserves attention and much impetus is needed to Bijapur 586103 develop new ideas and theories to improve it. WHO has emphasized Karanataka the pressing need to undertake more research in developing countries INDIA as data from developing country concerning the prevalence and E-mail: treatment adherence in diabetes patients are particularly scarce. syedzia.inamdar @gmail.com Keywords: Adherence, Diabetes Mellitus, Adherence barriers, Pharmacist, compliance

American Journal of Advanced Drug Delivery www.ajadd.co.uk Inamdar et al______ISSN 2321-547X

INTRODUCTION measure medication adherence, lack of experimental evidence for many models, In the fifth Century BC Hippocrates failure of measurement methods to gather reminded physicians ‘….to check patients valid information on the extent of patient behavior because often they lie about having adherence, uncertain reliability and validity taken prescribed drugs. This unadmitted of some scales used in medication adherence negligence may lead the physician into ’1-34 research studies, lack of patient centric error . information and lack of long term follow up Medication adherence is defined as data. High quality research studies in this the extent to which a patient medication area would perhaps establish the causes of taking behavior coincides with the intention medication non-adherence, and suggest of the health advice he or she has been strategies to improve medication adherence1- given. It is the most important factors that 3. determine therapeutic outcome, especially in patient suffering from chronic illness like 1 Adherence Importance diabetes mellitus . There are many situations in clinical Diabetes mellitus is term that practice where adherence is extremely describes a series of complex and chronic important for better therapeutic outcomes. heterogeneous metabolic disorder These include: characterized by symptomatic glucose  Chronic diseases: such as diabetes and intolerance as well as disordered lipid and hypertension protein metabolism. Whatever is the  Replacement therapy: e.g. Thyroxin and efficacy of drug it cannot act unless the insulin. patient takes it, as the treatment may be  Maintenance of pharmacological effect: complex, intrusive and inconvenient many antihypertensive and oral hypoglycemic patients are prescribed very complicated agents. regimen of diet, exercise, and medication  Maintenance of serum drug concentration including several pills a day. Such to control a particular disorder: e.g. complexity of treatment and factors like age, anticonvulsants. duration, depression, disabilities or psychosocial issues and life style  Some diseases of public health modification directly or indirectly influences importance where non-adherence is a adherence to treatment. Behavioral changes major obstacle to achieving control: tuberculosis, HIV, and related and adherence to pharmacological treatment 1 are essential for improving the prognosis of opportunistic infections . diabetes mellitus2-4. The majority of adherence research Adherence has been carried out by healthcare providers As far as adherence is concerned, the and by the pharmaceutical industry, and has term implies passive submission of the patient focused on patient determinants of non- to the prescriber’s authority and obeys adherence rather than on shared treatment regimens. Adherence Implies the responsibilities of the doctor and patient. self-initiated choice of the patient to closely The first three decades of compliance follow a treatment plans. The prescribers have research from 1970 to 2000 have yielded to monitor the patient’s adherence to the medication, usage instruction so that they are little information to improve medication 1 adherence1. The reasons for this inadequacy benefited from the therapy . include the lack of a gold standard to

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Even after careful diagnosis and concern depending on the patient beliefs about given to improve the patient’s quality of life, the need for and efficacy of a particular the patient often deviates from the medication1. instructions. Patient who are adherent in one Medication adherence and non- situation may not so be in another. Stimuli adherence is the result of a complex that have positive influences on one interaction among many factors. Some individual may have a negative influence on of these factors are seen to improve another. Non-adherence may have many medication adherence and some factors different manifestations none of which are may negatively influence the medication mutually exclusive1,2. adherence of a patient. The situation is The extent of non-adherence in the almost unique to each patient and this is general population in the out patient setting one of the reasons why it is so difficult estimated that as many as 50 percent of to predict medication adherence1. prescriptions fail to produce desired results because of improper use and 14-21 percent of Factors Influencing Adherence patient’s never even fill their original The factors, which may influence prescriptions. It has been noted that adherence adherence, or for that matter any health tends to decrease with time, and prospective related behavior, can be divided into three long-term studies should ideally be categories: considered when evaluating therapeutic Predisposing factors include efficacy new drugs and its outcome1,2. demographic factors (age, gender, educational There are different situation in which achievements, socio-economic status, patient’s demonstrate medication Non- employment) also include the patient’s adherence. They have been categorized knowledge, attitudes, beliefs and perceptions whether the prescriptions was honored, about illness and its severity, cause, underused or overuse of the prescription prevention and treatment1. medication or use of non-prescription Enabling factors are the skills and medicines. Non-adherence has been further resources needed for adherence. the term categorized based on whether it was done on skills refers to the patients ability to adopt the patient’s own volition. It is possible that behaviors which will assist adherence and each condition and each doctor–patient resources includes the availability and involve different motivating factors, which accessibility of healthcare facilities such as affect adherence1,2,3. doctors, pharmacies, clinics or hospitals1. Reinforcing factors are those factors, Categorizing medication adherence which determine whether adherence is  Adherent supported by family members, peers,  Partially adherent healthcare providers, the local community,  Non-adherent and society in general. The reinforcement Partially adherent is defined as may be positive or negative depending on the adherence to more than 70 percent of attitudes or behavior of significant people, the medication regimen, while some of whom will be more influential than complying with more than 80 percent of others. Reinforcing factors such as the prescribed regimen is termed as communication with the patient, the ability to adherent. Patient medication adherence resolve the patient’s concern regarding their may vary on a day-to-day basis, and disease and medication, regular follow up, may vary for different medications and quality and quantity of time spent with

AJADD[1][3][2013]238-250 Inamdar et al______ISSN 2321-547X patient and family members, giving written Health belief model instructions to the patients may improve Knowledge and attitude of the patient medication adherence1. also affects adherence. Patient feels that the consequences of the disease could have a Potential risk factors for Non-adherence serious impact on their well-being1-3.

Demographic Social factors Age, gender, educational achievements, Social factors such as strong family socio-economic status, and employment cohesiveness local help from family, friends, affect adherence. and associates would help adherence1,7. Drug and treatment related Number of drugs and doses to be taken (complexity of Strategies to improve medication adherence treatment), treatment duration, cost of  Correct and complete instruction medication, compatibility of dose regimen of regarding medication should be given to daily activities1,7. the patient. Both verbal and written Diseases related presence or absence instructions may be given. of symptoms, intermittent or variable  Simple and affordable treatment regimen condition, chronic or acute illness. should be prescribed as far as possible.  Effective physician-patient-pharmacist Patient related communication should be conducted in Understanding of the diseases and its the atmosphere of trust and confidence. consequences, perception of the threat pose  Patient perception about medication use by the diseases, acceptance of the diseases, should be assessed. comprehension of the cost benefit of the  Patient should be encouraged to correlate treatment, motivation of the patient family, drug intake with daily events/habits, involvement of the patient in decisions, 1,7 maintain required modifications, use in decreased physical abilities . case of chronic disease and family members should be motivated. Patient-healthcare professional relationships  Counseling involves providing verbal Circumstances surrounding the patient information onto patients about their visit (easy access to physician/health care), illness and its treatment, life style quality and effectiveness of the interaction, modification. After counseling, the patient time spent by the health care provider, understands and recall should be attitude of the physician towards the patient’s evaluated. Counseling is a two way and treatments, quality of the communication process and involves listening as well as and adequacy of the information provider, 1,7 talking. interval between the visits .  Clarify the patient’s expectations for treatment and answering questions. Psychological factors  Explaining how each medication works to Some feel guilty about taking control or prevent symptoms. medication whereas others see it as a social stigma. Fear of becoming dependent on  Determine whether the patient can afford treatment is another reason for Non- to buy the medication prescribed and if adherence1,7. not considering alternatives therapies or payment methods.  Patient may benefit from the use of reminder devices such as calendars,

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Pillboxes, strategically placed notes, Management Plan reminder telephone calls1,2,3,7. Management plan is required for to achieve glycemic control to prevent the long- Monitoring and assessment of medication term complications of diabetes. adherence  A management plan include the Various methods to assess medication following non-adherence are as follows:  Establishment of targets of treatment  Patient interview / direct questioning  Diet plan  Diary keeping  Education in self-monitoring, adjustment  Pill count, prescription refills methods: of treatment in approaches to cop in the  Adherence % = emergencies Total no. of doses since last appointment  Exercise program x 100 Total no. of doses to be consumed since last appointment  Use of oral hypoglycemic agents, if required  Electronic medication containers usage,  Use of insulin, if required Home blood glucose and blood pressure  Risk factor reduction, e.g. smoking measurement, weighing of inhaler cessation. canister.  Screening for and treatment of 4-6  Measurement of plasma drug complications of diabetes . concentration/blood or urine levels of drugs. Pharmacist Role in Diabetes Management  Utilization of healthcare services like As a member of the diabetes care clinic attendance, appointment making, team, the pharmacist has a useful contribution appointment keeping1,2,7. to increasing the quality of care, as:  Pharmacist has daily contact with a large Treatment Objectives for Diabetes Mellitus number of people  Normalize glucose metabolism  People with diabetes have easy access to  Normalize glycosylated hemoglobin the pharmacist  Urine glucose and ketones negative  Many people look to the pharmacist for  Fasting blood glucose: 3.9-6.6 mmol/L advice on health care (70-120 mg/dL)  Patients listen to and understand the  2 hr postprandial glucose level less than instructions given by the pharmacist 8.8 mmol/L (160mg/dL)  Pharmacists have considerable knowledge  Avoid symptoms of diabetes mellitus of diabetes  Avoid hypoglycemia  Diabetes has a high incidence  Normalize nutrition and maintain  Diabetes induces severe ad irreversible reasonable weight late complications  Achieve normal growth and development  There is a high rate of diabetes morbidity  Minimize or prevent complications and mortality  Diabetes often diagnosed late  Accept diabetes with a realistic but 1,2 positive attitude  Patient education .  Enjoy normal and flexible lifestyle Numerous studies have been  Promote emotional well-being; have performed to identify therapeutically patient take charge of condition4-6. non-adherent patients, to measure the degree of non-adherence, to characterize

AJADD[1][3][2013]238-250 Inamdar et al______ISSN 2321-547X the reasons and to develop strategies for minimizing the development of improving adherence. Educating the complication. Accessed information and patients about their disease state and education to assist the skills to assist medication will result in the management of the disorder is critical4- improvement of their knowledge 6. regarding medications and can increase According to WHOM the present their active participation in therapy and review of studies has revealed that improve medication adherence, this may research on adherence to treatment for ultimately improve the outcomes1,2. diabetes yields some inconsistent Pharmacists with their professional findings and may have several causes knowledge irrespective of their working including variability in research design, place in either hospital or community study instruments, sampling size, can play a vital role in educating the sampling frames, and the use of general patients and can improve medication measures and lack of control of co adherence and clinical outcome. The founding variables. WHO has national pharmaceutical council of US emphasized the pressing need to estimated the medical cost related to undertake more research in developing prescription medicine misuse and countries as data from developing adverse drug reaction total more than 20 country concerning the prevalence and billion US dollar a year. When treatment adherence in diabetes patients consequences such as lost productivity are particularly scarce. WHO estimate are included, annual are as high as 100 indicate that by 2025 the largest billion US dollar this is particularly true absolute increase in prevalence rates of for chronic diseases1-3. diabetes worldwide will occur in Diabetes mellitus is a complex, developing countries. Patients and heterogeneous endocrine disorder that health care providers in developing necessitates a health team effort to nations face additional barriers to achieve treatment objectives through a achieve adequate diabetic care and a combination of diet, exercise host of other priorities that compete for medications, and most importantly national and individual attention7. education that results in the patients Sridhar GR in his article has taking change of the condition, the highlighted the facts and figures about outlook for the diabetes is improving diabetes mellitus in India, which is continually. Pharmacist can educate becoming more prevalent and may be their patients about the proper use of consider as model of non- medications, screen for drug communicable disease. He has interactions, explain monitoring devices emphasized the predisposing factors like and make recommendations for stress and obesity as a forerunner of the ancillary products and services. metabolic syndrome8. Educating the patient with diabetes is Sudhakar BL et al, in their article critical to the successful management of has emphasized the role of pharmacist in this chronic disease. Education is self- patient medication adherence. monitoring adjustment of treatment and Pharmacist with their knowledge can in approaches to coping with employ technique in educating the emergencies useful in management of patients; enhance adherence, medication diabetes. Continuing care required knowledge assessment and counseling

AJADD[1][3][2013]238-250 Inamdar et al______ISSN 2321-547X to overcome the barriers associated with specific approach on the part of health medication adherence of the patients2. care team to have some protocol to Ponnusankar S et al., carried out assess noncompliance which can lead a a study with the aim to asses the impact step towards improving adherence11. of medication counseling on patients Lerman I, in his article medication knowledge and compliance emphasized on the working out in in out patient clinic. Their medication partnership with patients to improve self knowledge was assessed by a management and behavioral changes as questionnaire at base line and these are fundamentals of the treatment subsequent follow up’s and adherence of chronic illness. Counseling the was assessed by pill count method and patient on how to improve adherence a self- assessment by the patient. After combination of keeping regime as counseling It was observed a significant simple as possible, negotiating priorities improvement in medication knowledge with the patients providing education, and adherence levels of the patient3. monitoring adherence to treatment and Palaian S et al., in their study reinforcing the patients to adhere at visit evaluating impact of counseling on provide practical and effective help for Knowledge attitude and practice many patients12. outcomes in diabetic patients concluded Kilbourne AM, et al., and Chao J, that patient counseling by a clinical et al. carried out independent studies on pharmacist improved medication depression influencing diabetes knowledge score but this improved medication adherence in older patients knowledge did not lead to appropriate and depressive symptoms associated attitude and practices9. with diabetes medication usage as a Whitely HP et al., carried out a factor of non-adherence. They have study with aim to assess to patient observed that depression is knowledge of diabetic goals, self independently associated with reported medication adherence and goal inadequate medication adherence. The attainment. The majority of the patients effect of depressive symptom on did not reach goals and were diabetes medication was mediated unknowledgeable of goals. Patients with through perceived general barriers, diabetes mellitus who have poor perceived side effect barriers and self adherence may have less knowledge of efficacy which may partly explain the overall therapeutic goals and may be association of depression with patients less likely to attain these goals. It is belief about diabetes medication use. imperative to all healthcare team The findings were beneficial towards the members to discuss the importance of development of strategies to improve medication adherence with every patient self management of diabetes and may at every visit10. have a positive impact on medication Leichter SB in his article adherence and well being13,14. emphasized that the patient with non- Cramer JA, in his review article compliance should be evaluated for why stated that from the through literature a patient may be non-compliant rather survey of retrospective and prospective than to complete an assessment with a analysis of adherence to oral conclusion that the patient is a non- hypoglycemic agents and insulin (from compliant. It is important to have a 1966-2003), he reported that there

AJADD[1][3][2013]238-250 Inamdar et al______ISSN 2321-547X exists poor adherence rates for oral Morris AD, et al., in hypoglycemic agents and insulin, but collaboration with Diabetes Audit and improved adherence rates with Research in Tayside (DARTS) database electronic medication devices for oral found direct evidence of poor adherence hypoglycemic agents. However, the with insulin therapy in young patients author identified that the brief treatment with type 1 diabetes, which contributes persistence is major issue that could lead to long term poor glycemic control and to deleterious health outcomes, and diabetic ketoacidosis episodes in this suggested for the development of age group. The non-adherence is related method that may assess medication to adolescence behavioral factors adherence as a behavior, which may secondary to the hormonal changes of significantly improve glycemic purbety18. control15. Snoek FJ, et al., has recognized Lewin AB, in his studies stated diabetes as one of the most emotionally that family factors as predictors of and behaviorally demanding chronic metabolic control in children with type 1 illness. Psychosocial adaptation is an diabetes and reported that family important outcome of diabetes care from functioning and adherence behavior are the perspective of both quality of life strongly related to a child health status. and the effectiveness of treatment He conducted his studies by adherence patient in poor psychological health lack interviews taking children in the age the motivation and emotional strength to group of (8-18yrs) and a parent and self manage their diabetes in the long glycosylated hemoglobin (HbA1c) was term. Also the fact that “good” behavior the index of metabolic control. does not always translate into good Assessment of diabetes specific family results, which is a major cause of functioning in addition to adherence is frustration that leads to diabetes burnout an important factor in understanding and patient find it difficult to adhere to metabolic control16. this treatment regime all of the time. Hill-Briggs F, et al., carried out Lack of knowledge or limited studies on medication adherence and intellectual capacity, attitudes and diabetes control in urban African beliefs regarding diabetes may be Americans with type 2 diabetes. The dysfunctional and adversely affect self specific behaviors associated with care practice. Theory based self poorer diabetes control were due to management education program (e.g. patients who forgot to take medication, DESMOND) can help to empower to running out of medication and achieve and maintain behavioral knowledge of blood glucose goals changes and improve psychological and differed for adherers and non-adherers, metabolic out comes19. also medication adherence rates are not Grant RW carried out a study to associated with actual levels of blood determine medication adherence (for pressure or lipids respectively. These oral hypoglycemic agents, insulin, data suggest that specific medication antihypertensive, lipid lowering behavior are important to diabetes medicines and aspirin) and predictors of control and constitute logical targets for suboptimal adherence in a community, interventions17. the hypothesis that adherence decreases with increased number of medication

AJADD[1][3][2013]238-250 Inamdar et al______ISSN 2321-547X prescribed. The study conducted by multidisciplinary patient care team, the structured telephone based interviews to severity of the problem and the determine self adherence to diabetes consequences for non-compliance related medicines, patient’s attitudes demands attention from the profession21. towards their medicine and barriers to Brain Haynes et al., in is article medication use. The findings reported has stated low adherence to prescribed are very high medication adherence medical regimen is a ubiquitous problem rates regardless of number of medicines; and can undermine the effectiveness of patients with suboptimal adherence were care at many steps in treatment perfectly adherent to all but one processes. One of the important medicine because of side effects and a difficulties in managing low adherence lack of confidence in immediate or is lack of accurate and affordable future benefits were significant measures. Clinicians must frequently predicators of suboptimal adherence20. rely on their own judgment but Krueger KP, et al., in their article unfortunately demonstrate no better than on the Pharmacist’s role in improving chance accuracy in predicting the patient adherence with the medication adherence of their patients, even among regimes has categorized adherence patients for whom they feel confident measures into four broad categories: about their prediction. So to reap the behavioral measures, biochemical benefits of modern medical therapies, measures, clinical measures and direct better, more effective and efficient observation. The first three categories interaction to be employed for helping are indirectly measures of adherence and people to follow treatment regimens. are most commonly used in practice. Adherence can be increase by Behavioral measures include pill counts, combinations of interventions like prescription refill counts, self-reported keeping regimen as simple a possible, adherence, and electronic measures of negotiating priorities with patients, pill-taking. Biochemical measures detect providing clear instructions, reminding the concentration of medication in a about opportunities, monitor adherence patient’s blood or urine and are a with treatments, counseling and reliable gauge of adherence during the continuing support involving the help of previous 12 to 48 hr. Clinical measures family members and significant others, can be assessed on the basis of it has also shown that adherence therapeutic outcomes like blood intervention was cost effective22. pressure, blood glucose monitoring etc, Ponsident CJ et al., in their article since there is no perfect measure of has emphasized the importance of non- adherence the limitations of the methods adherence to treatment regimen on should be kept in mind and multiple health and well being of the patient methods should be used wherever which has cost financial implications possible. A pharmacist can use and causes mortality 10% of hospital, principles of motivational interviewing and 23% of nursing home admission. to identify problems and address each The problem of medication non- barrier on a patient-by-patient basis. adherence is pervasive and found that Addressing problems with treatment interaction can enhance medication adherence is another contribution adherence. One such intervention is pharmacist can make to the motivational interviewing, which is a

AJADD[1][3][2013]238-250 Inamdar et al______ISSN 2321-547X skillful clinical method and style of compliance is a significant barrier to counseling, psychologically designed treatment efficacy25. for assisting patients to commit change. Chotai N.P et al had studied It is a client centered method intended to patient’s non compliance in patients initiate change by creating dissonance with chronic diseases like Diabetes, between patient current status and the Hypertension and Asthma. They found target behavior without making the that high profile of non compliance patient fell threatened or pressured. amongst patients with asthma (53.48%), This can be an important tool to improve Diabetes (57.8%), Hypertension medication adherence23. (54.09%).The main reason of non Johnson SB in his article state compliance were deliberate deviation that the prevalence of non-adherence (32.8%), frequency (26.7%), side effects varies across the different components (11.6%)26. of the diabetes regimen, during the Morris W et al., in their study course of the disease, and across the emphasized that Pharmacists may be patient life span. Conceptual problems able to enhance patients compliance and in defining and measuring adherence outcomes by engaging in include; the absence of explicit pharmaceutical care activities (e.g. adherence standards against which the monitoring symptoms, providing patient behavior can be compared, medication counseling, helping resolve patient-provider miscommunication and drug-related problems, facilitating patient knowledge and skill deficits and communication with physicians)27. behavioral complexity of the diabetes Dimatteo R et al., in their meta regimen. Measurement method should analysis research study to correlates be selected on the basis of reliability, adherence with treatment outcomes validity, non reactivity and sensitivity to analyzed according to disease the complexity of diabetes behavior24. (acute/chronic/severity), population Lee YWV in their study of (adult/child), type of regimen glycemic control and medication (preventive/treatment, use of compliance in diabetic patients in a medication)and type and sensitivity of pharmacist managed clinic in Hongkong adherence. They found that adherence is has evaluated the program impact on the most strongly related to outcomes in care of diabetic patients with drug studies of non medication regimens and compliance problem and has concluded where the disease is chronic. Higher that medication non compliance has a adherence outcomes related to studies of significant impact on morbidity, less serious conditions and in studies mortality and quality of life of diabetic using self reports of adherence28. patients. These problems may be related Kyo YF et al., The aim of their to patient demographic, complexity of study was to examine the relationship drug regimen, dosage frequency, between inconsistency in use of diabetes adverse effects or some combination of drugs and risk of renal, eye, and above factors. The percentage of non circulation problems and death over a 7- compliance between the genders, year period in community-dwelling however patients with more education older Mexican Americans. Diabetes and appeared to have better compliance then complications were by self-report. those with less education and found non Subjects with poor consistency in use of

AJADD[1][3][2013]238-250 Inamdar et al______ISSN 2321-547X medication were those who, at any time compliance as well as the ability of the during the 7-year follow-up, physician to understand, detect, and discontinued or inconsistently used their improve compliance and are described diabetes medications and those who had in relation to a new model of health no diabetic medications at home despite decisions and patient behavior. The self-report of taking medicine for health decisions model combines diabetes .Inconsistent use of diabetic decision analysis; behavioral decisions medication was associated with an theory and health beliefs. This model increased risk of kidney problems and provides a frame work for modifying deaths over a 7-year period in older general health beliefs, treatment Mexican Americans29. recommendations, therapeutic regimens, Austin RP in his article describe patient knowledge and social Polypharmacy is a term that has been interactions patterns which can be used in health care for decades. In utilized to encourage patient compliance conventional use, it has meant the with treatment31. concurrent use of multiple medications Patel MX et al., in their article in the same patient. However, this have outlined the general factors that definition understates the potential for predict variance in adherence and harm that polypharmacy may pose to the stressed on behavioral techniques which patient. Polypharmacy may be are more likely to succeed in enhancing unavoidable, given that multiple drug adherence. The need to strive to therapy has become the standard of care understand patients from their individual in most chronic conditions.6 The perspectives, giving them the comorbidities of diabetes commonly opportunity to have their voices include hypertension, dyslipidemia, adequately heard will reduce the adverse depression, and coagulopathies, each of clinical and economic impact of non which may require one or more drugs adherence32. for adequate control. Add to this other Osterberg L et al., in their article conditions that often accompany on adherence to medication has diabetes, such as hypothyroidism, heart emphasized poor adherence to failure, and osteoporosis, and the total medication regimens is contributing to number of possible medications needed substantial worsening of disease, death become significant. Multiple drug and increase health care costs. Patients therapy has become the standard of care who have difficulty in maintaining in the treatment of most chronic adequate adherence need more intensive diseases. Patient’s drug regimens need strategies than do patients who have less regular review and evaluation to ensure difficulty with adherence, with the help that unnecessary and redundant of new technologies and innovative medications are discontinued. and methods a collaborative approach is address concerns about adherence, cost, urged to care and augments adherence side effects, and other matters of in managing chronic diseases33. significance in achieving an Marie T. Brown and Jennifer K. individualized and realistic therapeutic Bussell, in their review study had concluded plan30. that strong evidence persists which shows Eraker SA et al., in their article that many patients with chronic illnesses emphasized the problem of patient have difficulty adhering to their

AJADD[1][3][2013]238-250 Inamdar et al______ISSN 2321-547X recommended medication regimen and Education and Counseling 2003; 137:1- believing that medication non adherence is 6. the “fault” of the patient is an uninformed 4. Steil CF. Diabetes mellitus. and destructive model that is best Pharmacotherapy A Pathophysiologic abandoned. “Drugs don’t work in patients Approach. Dipiro JT, Talbert RL, Yee GC. Appleton and Lange 1999; 4:1219- who don’t take them.” Thus Physicians and 41 Pharmacist as an integral part of health 5. Setter MS,White JR,Campbell care team must recognize that poor KR.Diabetes.Text Book of Therapeutics medication adherence contributes to Drugs and Disease Management. suboptimal clinical benefits, particularly in Herfindal ET, Gourley DR. Lippincott light of the WHO’s statement that increasing William and Willkins 2000; 377-406. adherence may have a greater effect on 6. Carlisle BA, Kroon LA, Koda-kimble health than any improvement in specific MA.Diabetes Mellitus. Applied medical treatments7. Hippocrates’ Therapeutics: The Clinical Use of exhortation to the physician to “not only be Drugs. Koda-kimble MA, Young LY, prepared to do what is right himself, but also Kradjan WA. Lippincott William and Willkins 2000; 50-1-50-85. to make the patient…cooperate” has 7. World Health Organization, Report on consistently failed for more than 2000 years. Medication Adherence, Disease Specific Today’s ever more complicated medical Reviews, Section 3, Chapter 10, WHO regimens make it even less likely that Geneva 2003, Pages 93-107 physicians will be able to compel 8. Sridhar GR. Diabetes in India: Snapshot compliance and more important that they of a Panorama. Current Science partner with patients in doing what is right 2002;83(7):791 together. The multi factorial nature of poor 9. Palaian S,Acharya LD, Madhavrao PG, medication adherence implies that only a Shankar PR, Nair NM, Nair NP. sustained, coordinated effort will ensure Knowledge Attitude and Practice optimal medication adherence and Outcomes: Evaluating the impact of Counseling in Hospitalized Diabetic realization of the full benefits of medication 34 Patients in India. P&T Around the therapies . World 2006;31 (7):383-96. 10. Whitley HP, Fermo JD, Ragucci K, REFERENCES Chumney EC. Assessment of Patient Knowledge of Diabetic Goals, Self- 1. Mahesh PA, Parthasarathi G. Reported Medication Adherence and Medication Adherence, Text Book of Goal Attainment. J Pharm Pract 2006; Clinical Pharmacy Practice, Essential 4(4): 183-90. Concepts and skills. Parthasarathi G, 11. Leichter SB. Making Out Patient care of Hansen KN, Nahata MC, Orient Diabetes More Efficient:Analyzing Longman, Pvt Ltd 2004;54-71. Non- Compliance. Clinical Diabetes 2. Sudhakar BL, Nagavi BG. The Role of 2005;23:187-90 Pharmacist in Patient Medication 12. Lerman I, Adherence to Treatment: The Adherence. Ind. J Hosp.Pharm, 2006; Key for Avoiding Long-Term 174-77. Complications of Diabetes. Current 3. Ponnusankar S, Surulivelrajan M, Trends in Diabetes, Archives of Med Anandamoorthy N, Suresh B. Res. 2005; 36(3): 300-6. Assessment of Impact of Medication 13. Kilbourne AM, Reynolds CF, Good CB, Counseling on Patients Medication Sereika SM, Justice AC, FineMJ. How Knowledge and Compliance in an Out Does Depression Influence Diabetes Patient Clinic in South India. J Patient Medication Adherence In Older

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