Patients with diabetes often find it difficult to stick to their treatment.
DIABETES is one of the most common non-communicable diseases and a major public health concern not only in Malaysia but also around the globe.
Despite advances in medication and treatment, it remains a challenging disease to be managed successfully. As such, the illness and death rates continue to rise.
In 2019, there were 463 million patients living with diabetes worldwide.
Based on our National Health and Morbidity Survey (NHMS IV), the prevalence of diabetes among Malaysians is 11.2% in 2011,13.4% in 2015, and 18.3% in 2019.
The increasing numbers can be attributed to lifestyle factors such as obesity, lack of physical activity, diet, stress and urbanisation.
According to the Diabcare Study 2013 – an observational study of hospital-based diabetes care delivery in Malaysia – only 23.8% of diabetics achieved control of the disease.
Factors affecting management
Pantai Hospital Kuala Lumpur endocrinologist Dr Shalini Sree Dharan from Pantai Hospital Kuala Lumpur relates the failure of patients in achieving their blood sugar targets mainly to lack of knowledge, treatment inertia and non-adherence to their treatment.
“Patients need to be adequately educated in leading a healthy lifestyle; managing their disease, especially in relation to their diabetes control; preventing complications and recognising the symptoms; as well as identifying self-management problems and discuss with the caregivers and doctors on how to rectify it.
“Lack of such knowledge will cause them to struggle in coping with the high level of self-care neccessary, such as following a diabetes-friendly diet, blood glucose self-measurement and regular exercise, ” she explains.
She points out that treatment inertia also plays a major factor in unsuccessful diabetes management, be it caused by healthcare providers or the patient.
“Treatment inertia occurs when a healthcare provider does not start, intensify, use combination medication when necessary or does not review patients soon enough after starting treatment.
“This also applies to patients’ delay in wanting to start diabetes medications especially insulin, not wanting too many medications and not knowing how to adjust insulin doses.
“The way forward therefore is patient education and empowerment to make meaningful and right decision.
“For instance, healthcare providers need to know why a certain medication is needed, and the potential short term and long term side effects to look out for and warn a patient about. If patients do not understand and are not fully convinced (of the reasons or side effects), they might not want to comply with the treatment.
“On top of that, without adequate knowledge of the disease, many patients misunderstand that their kidneys will deteriorate if they take anti-diabetes medications.
“So they delay the treatment which could essentially causes kidney failure (nephropathy) and lead to other complications such as cardiovascular disease, nerve damage (neuropathy), eye damage (retinopathy), foot ulcers and infections.”
Problems with adherence
While studies have demonstrated that treatment adherence is associated with improved blood glucose control, almost half of patients with diabetes fail to reach their blood glucose goals.
She says: “Medication non-adherence poses a significant barrier to effective diabetes management.
“For example, some medications and injection frequency and timing, especially with insulin, can be quite complicated to follow, especially for the elderly and younger patients.
Many times, patients omit medications due to missed timing, forgetting to inject before a meal or are clueless on how to adjust the dose to their meal portions.
“Adjustment of medication dosage, especially insulin doses, needs close blood glucose monitoring, which is usually easily done via a finger prick test at home. Many are not aware that insulin can be brought along with them (when they go out) and easily self-administered.
“Diabetes management is highly dependent on patient self-management and those with hectic lifestyles may find adherence to treatment, resulting in poor outcome.”
Being one of the more potent glucose-lowering medications, insulin is capable of bringing down blood glucose level to normal when used correctly with the right dosage and timing.
“For type 2 diabetes, it can be given as once daily, twice, or even three times daily, combined with oral medications. Some doctors even recommend taking it up to four times a day to better control the high blood glucose throughout the day.
“But more frequent injections contributes to non-compliance, and at times, patients may omit injecting according to the prescribed frequency, causing their blood glucose to fluctuate, ” Dr Shalini says.
As diabetes is a progressive disease, effective therapies are critical. Insulin being one of the main treatments too have its short falls or down side. There are two main side effects with insulin – weight gain and hypoglycemia – which are commonly seen with short-acting insulin and high dose of insulin.
“To date, insulin remains as the main culprit of hypoglycemia, a state owhere blood glucose lower than 4.0mmol/L, which can be dangerous and may cause the patient to not inject insulin again, ” she says.
Two in one
Fixed-ratio combinations (FRC) of basal insulin and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a recently introduced treatment, combining both drugs in a single device for a single daily injection.
Says Dr Shalini: “This not only simplifies treatment, but also provides a synergistic effect on glucose-lowering by effectively targeting both fasting and post-prandial (after meal) glucose in a complementary manner.
“The GLP-1 RA also aids in limiting the weight gain and hypoglycemia typically associated with other more complex or intensive insulin regimens.
“GLP-1 RA has been proven to induce weight loss in patients.
“The FRC of these two agents has been proven to achieve meaningful HbA1c reductions in a wide variety of patients, bringing their blood glucose levels close to normal without increases in either hypoglycemia or weight, compared to basal insulin alone, and with lower gastrointestinal side effects due to slower titration of GLP-1 RA dose.”
In a nutshell, both pharmacological and non-pharmacological interventions play an important role in diabetes management.
Effective treatment and long-term management of diabetes requires good communication between the healthcare provider and patient.
This will help both healthcare provider and patient follow up closely with the patient’s condition and progress, and develop a patient-centred collaborative care approach to help increase the rates of medication adherence, look out for diabetes related complications and get it treated accordingly.