Polypharmacy and compliance in diabetc patients - Essay Example

? Polypharmacy and Compliance in Diabetic Patients Total Number of Words: 2,031 Introduction As of a little more than 3 million people have been diagnosed with diabetes throughout the United Kingdom alone (Diabetes UK, 2012). In relation to the need to treat patients with diabetes, general description of common drugs used in treating diabetes will first be provided followed by discussing the adherence to medication when using more than one-type of pharmacological drug. Eventually, factors affecting the adherence to medication (i.e. socio-economic, healthcare system, condition-related, complexity of medication regimen, and patient related factors) will be tackled in details prior to discussing how these problems can be improved. 2. General Description of Each Drug used in Treating Diabetes 2.1 Metformin A type of oral anti-diabetic drug, metformin reduces the glucose output of the liver and augments the glucose uptake that occurs somewhere within the peripheral tissues like muscles. Metformin decreases the levels of blood sugar by decreasing the process of gluconeogenesis (Bosi, 2009). It activates the liver kinase B1 (LKB-1) – upstream kinase that regulates the adenosine monophosphate protein kinase (AMPK) – downstream kinase (Rojas and Gomes, 2013). AMPK regulation is necessary to control the synthesis of glucogenic enzymes (Rojas and Gomes, 2013; Shaw, Lamia and Vasquez, 2005). Metformin is contraindicated to patients with serum creatinine of more than or equal to 130 mmol/L (men) and more than or equal to 120 mmol/L (women), impaired hepatic, insufficient respiratory, alcohol abuse, infection, and heart failure (Joshi and Joshi, 2008). 2.2 Sulphonylurea (SU) Sulphonylurea (SU) pharmacological drugs such as gliclazide, glipizide, and globenclamide are anti-diabetic drug used in managing type II diabetes mellitus (Tirkkonen et al., 2010; Joshi and Joshi, 2008). The main action of SU is to enable the beta cells in pancreas to release more insulin (Aoyagi et al, 2009). This explains why SU is not suitable for patients with deficiency in the production of insulin (i.e. type 1 diabetes mellitus, after receiving pancreatectomy, etc.). 2.3 Pioglitazone hydrocholoride (Actos) Another oral anti-diabetic drug, pioglitazone hydrocholoride (Actos) is capable of decreasing the levels of blood sugar in patients with type II diabetes by increasing the sensitivity of insulin through activating the peroxisome proliferator-activated receptor (Rotenstein et al., 2012). Although pioglitazone has no significant positive or negative effects on the patients’ LDL-cholesterol level, this drug can somehow increase the patients’ HDL-cholesterol between 0.09 – 0.14 mmol/L and decrease the patients’ triglycerides between 0.29 – 0.60 mmol/L (Joshi and Joshi, 2008; Chiquette, Ramirez and DeFronzo, 2004). 2.4 Glucagon-like-petide-1 (GLP-1) injectible As one of the newest drugs for diabetes, glucagon-like-petide-1 (GLP-1) receptor antagonist is capable of increasing the insulin secretion from the pancreas as it reduces the production of glucagon and glycosylated haemoglobin (HbA1c), slows down the process of gastric emptying, and reduces the patients’ risk of experiencing hypoglycaemia (Kalra and Kalra, 2012; Gaber, 2011; McDougall, McKay and Fisher, 2011). In other words, GLP-1 functions by making the pancreas work more efficiently by allowing it to release more insulin when necessary. 2.5 Dipeptidyl peptidase IV (DPP-IV) inhibitors Dipeptidyl peptidase IV (DPP-IV) inhibitors such as sitagliptin or linagliptin are anti-hyperglyceaemic agent which aims to improve glycaemic control in patients with type II diabetes (Pathak and Bridgeman, 2010). The use of DPP-IV does not increase nor decrease the patients’ weight (Rajesh et al., 2010). DPP-IV is somehow related to GLP-1 in the sense that the main function of DPP-IV inhibitors is to avoid inactivation of GLP-1 and increase the concentration of GLP-1 by slowing down its actual breakdown process (Brown and Evans, 2012; McDougall, McKay and Fisher, 2011). As its concentration increases, McDougall, McKay and Fisher (2011) explained that the patients’ pancreas is able to release more insulin for further breakdown of glucose in the body. 2.6 Sodium glucose co-transport-2 (SGLT-2) inhibitors Sodium glucose co-transport-2 (SGLT-2) inhibitor is a new type of anti-diabetic drug that is taken orally to decrease the levels of plasma glucose (Musso et al., 2011). By allowing the excretion of renal glucose to increase up to the level of 180mg/dl, SGLT-2 is capable not only in making the proximal part of the kidney to reabsorb glucose but also in decreasing the levels of plasma glucose, HbA1c, the body mass index (BMI), serum uric acid, and blood pressure (BP) (Musso et al., 2011; Rajesh et al., 2010). Therefore, on top of reducing the patients’ weight, the administration of SGLT-2 inhibitors reduces the patients’ risk of experiencing hypoglycaemia (Rajesh et al., 2010). 2.7 Insulin In general, insulin can be injected subcutaneously or through the vein-to-liver portal or vein-to-peripheral arterial portal (Lebovitz, 2011). Applicable to patients with type II diabetes, insulin is commonly used for glycaemic control (Johnson et al., 2013; Peyrot et al., 2012; Lebovitz, 2011). In most cases, administering insulin therapy to diabetic patients who are in advanced stage is necessary (Hamaty, 2011). Receiving insulin pump therapy for 2 years time can help reduce HbA1c of 0.5% or 5.5 mmol/mol (Johnson et al., 2013). As compared to insulin injection, the use of insulin pump, when administered to patients with type I diabetes, can help reduce the risks of severe hypoglycaemia (Johnson et al., 2013; Pickup and Sutton, 2008). After examining the differences between administering insulin pump and insulin injection on patients with type I diabetes, Bergenstal et al. (2010) found out that the use of both methods has almost the same risks for hypoglycaemia and that both methods does not contribute to weight increase. Also, as compared to insulin injection, the use of sensor-augmented insulin pump therapy can help improve the patients’ glycated haemoglobin levels among patients with type I diabetes (Bergenstal et al., 2010). 2.8 Statin Statin, also known as HMG-CoA reductase inhibitor, is a type of drug that lowers cholesterol (Gazzerro et al., 2012). Basically, this type of drug purposely blocks the passageway where cholesterol synthesizes in the liver. Although statins are commonly administered to patients with cardiovascular diseases (Gazzerro et al., 2012), several previous studies pointed out that the use of statin is strongly associated with the risk of developing cardiovascular disease (Golomb and Evans, 2008; Lewington et al., 2007). 2.9 Angiotensin-converting-enzyme (ACE) inhibitors and Angiotensin-receptor blockers (ARB) Both Angiotensin-converting-enzyme (ACE) inhibitors and Angiotensin-receptor blockers (ARB) can be used when treating patients with hypertension (van Vark et al., 2012) and myocardial infarction or heart failure such as the left ventricular systolic dysfunction (Antman et al., 2004). However, to use ACE inhibitors is more advisable over the use of ARBs when treating patients with hypertension (Hunt et al., 2005; Chobanian et al., 2003). 2.10 Thiazide diuretics, calcium channel blockers, and ?-blockers Similar to Ace inhibitors and ARBs, thiazide diuretics, calcium channel blockers, and ?-blockers can also be used when treating patients with hypertension (Grossman et al., 2011; Mancia et al., 2007). Calcium channel blockers should be considered as the best option when treating hypertension since the use of ?-blockers does not protect the patients from the risk of stroke (Grossman et al., 2011). Furthermore, the use of thiazide diuretics or ?-blockers could somehow increase the patients’ risk of developing new-onset diabetes (Grossman et al., 2011; Elliott and Meyer, 2007). 3. Factors Affecting Adherence to Medication when Administering More than One Drug to Diabetic Patients The factors that affect adherence to medication can be classified as either “patient-related limitations” or simply caused by some barriers to medication (PhRMA, 2011, p. 3). Among the common patient-related limitations that can affect adherence to medication include not only psychological illnesses such as depression but also cognitive impairment, medications’ side effects, patients’ perception about the benefits of medication, failure to accept one’s own illnesses, and the presence of asymptomatic diseases. Barriers to healthcare services and medicine include not only the absence of the patients when it comes to making decisions for their treatment but also cases wherein the patients do not have knowledge on health maintenance, missed clinical appointments, miscommunication between the physician and the patient with regards to the dosage and time for the administration of the prescribed drugs, the absence of family support, and the absence of sufficient financial resources to support their medication requirements (Brown and Bussell, 2011; PhRMA, 2011, p. 3; Brunner et al., 2009; Molloy et al., 2008). Socio-demographic factors such as age can also affect adherence to medication. In line with this, Tiv et al. (2012) found out that patients less than 45 years of age who are non-European with financial difficulties, experiencing diabetes complications, inability to self-administer medications, the absence of family and social support, inacceptance of the disease, lack of information on necessary treatment, and being professionally active are the ones who often have a poor adherence to medication. In general, the lack of adherence to medication among the patients with diabetes can further complicate the patients’ health condition as it increases their risks of mortality. To determine factors affecting medication adherence among patients with diabetes, Grant et al. (2003) conducted a research survey study on 128 randomly selected patients. Based on the research findings, Grant et al. (2003) found out that there is a lower adherence to one or more medication among patients who do not feel any signs of improvements in their current or future health condition. Likewise, another significant factor affecting the patients’ adherence to medication includes the side effects of each medication (Grant et al., 2003). For instance, SU drugs like gliclazide, glipizide, and globenclamide are not the best choice of drug when treating patients with diabetes because if can trigger hypoglycaemia on patients aside from increasing the risk of weight gain, over-worked pancreas (Shafiee et al., 2012; Sarkar et al., 2011; Rajesh et al., 2010; Joshi and Joshi, 2008) whereas the use of pioglitazone can adversely affect the patients’ cardiovascular system causing ischemic cardiac arrest or the development of a chronic heart failure (Scheen, 2012; Lincoff et al., 2007). Both ACE inhibitors and ARB can be used when treating patients with hypertension (van Vark et al., 2012) and myocardial infarction or heart failure such as the left ventricular systolic dysfunction (Antman et al., 2004). Even though the use of both ACE inhibitors and ARBs could reduce the risks wherein the patients could develop type II diabetes, the use of these two drugs does not decrease the risks wherein the patients could face higher risks of mortality, cerebrovascular outcomes, or cardiovascular disease among patients with hypertension (Gillespie et al., 2005). Unlike the use of ACE inhibitors, the use of ARBs could somehow delay the development of type II diabetic nephropathy (Foreman and Chambliss, 2004). 4. Conclusion and Recommendations It is important to take note that the process of combining one or more drugs when treating patients with diabetes can either result to a positive or negative impact over the health of the patients. For instance, both ACE inhibitors and ARBs are commonly prescribed to patients with hypertension and/or heart failure (Ritter, 2011; Soloway, 2006). However, after examining the results of combining ACE inhibitors and ARBs, Fried et al. (2013) found out that even though the combination of these two drugs can somehow decrease the rate of proteinuria, the act of combining these two drugs can increase the patients’ risk of developing hyperkalemia and acute kidney injury among patients with diabetic neuropathy. In fact, the process of combining these two drugs can increase not only the patients’ serum creatinine level but also their risks of having end-stage renal disease or even untimely death (Fernandez Juarez et al., 2013). Therefore, physicians or pharmacists should avoid prescribing ACE inhibitors and ARBs to patients with type II diabetes. To solve problems with regards to adherence to medication, physicians and pharmacists should educate the patients with regards to the adverse effects of not being able to adhere to the prescribed medication. The use of this particular strategy should be extended not only to the patients but also to their family members (Osterberg and Blaschike, 2005). 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Angiotensin-converting enzyme inhibitors reduce mortality in hypertension: a meta-analysis of randomized clinical trials of renin–angiotensin–aldosterone system inhibitors involving 158 998 patients. European Heart Journal, doi: 10.1093/eurheartj/ehs075. Read More