CME: Key Determinants for Diabetes Drug Adherence

CME: Key Determinants for Diabetes Drug Adherence
Author Information (click to view)

M. Sue Kirkman, MD

Professor of Medicine
Division of Endocrinology and Metabolism
University of North Carolina, Chapel Hill

M. Sue Kirkman, MD, has indicated to Physician’s Weekly that she receives research support from Novo Nordisk.

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Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:


  1. Discuss the findings of a study that used a large national database to look at adherence to oral diabetes medications in more than 200,000 adults with type 2 diabetes in the United States.
  2. Explain the implications of these findings.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at

Credit Available(click to view)


CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.


AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)


Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
M. Sue Kirkman, MD
Discloses being Research Support for Novo Nordisk, Inc.

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.


M. Sue Kirkman, MD (click to view)

M. Sue Kirkman, MD

Professor of Medicine
Division of Endocrinology and Metabolism
University of North Carolina, Chapel Hill

M. Sue Kirkman, MD, has indicated to Physician’s Weekly that she receives research support from Novo Nordisk.

Several modifiable and non-modifiable factors appear to be associated with adherence to anti-diabetic medications. Providers and healthcare system leaders should collaborate to develop strategies to reduce out-of-pocket costs in order to improve adherence.
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Multiple medications are often prescribed to help adults with type 2 diabetes manage hyperglycemia, diabetes-associated conditions like hypertension and dyslipidemia, and other comorbidities. “Prior studies have shown that non-adherence to diabetes medications is associated with many adverse outcomes,” says M. Sue Kirkman, MD. Research indicates that better adherence to diabetes medications improves control of intermediate risk factors. It also reduces the likelihood of being hospitalized, can lower healthcare costs, and may decease mortality.

Taking a Closer Look

Studies aiming to estimate rates of adherence to diabetes medications vary widely depending on the types of patients involved in the analysis and how investigators define adherence. Most analyses tend to look at either individual-level or system-level factors independently, but few have used large generalizable cohorts. To address this research gap, Dr. Kirkman and colleagues had a study published in Diabetes Care that used a large national database to look at adherence to oral diabetes medications in more than 200,000 adults with type 2 diabetes in the United States.

For the investigation, the study team used the medication possession ratio, which Dr. Kirkman notes is a fairly standard way to assess adherence. “We pre-specified a number of variables related to patient, provider, and prescription factors, and then looked at their association with adherence,” she says. “A multivariate model was then developed to look at the independent effects of each variable since many of them correlate with one another.”

Important Findings

Overall, about 70% of patients involved in the study were adherent to their medications. “We identified several factors that were associated with non-adherence, including younger age, being new to diabetes therapy, being female, and being on few other medications,” explains Dr. Kirkman (Table 1). Specifically with regard to age, patients aged 25 to 44 were 49% less likely to be adherent when compared with patients aged 45 to 64. Patients between the ages of 65 and 74 were 27% more likely to be adherent, and those aged 75 and older were 41% more likely to be adherent when compared with the 45-to-64 age group. The study team also found that patients who were new to therapy were 61% less likely to adhere to their diabetes medications.

With regard to demographics, men were significantly more likely to adhere to their diabetes drugs than women. Education was also associated with adherence, with patients being more likely to adhere to their medications if they had a higher estimated academic achievement. Patients who completed graduate school were 41% more likely to be adherent than those with a high school equivalent education. Patients with an annual income that topped $60,000 were also more likely to be adherent when compared with those making less than $30,000. Little variation was seen across geographic regions, but patients living in the Midwest were 12% more likely to be adherent than those in the West.

Other Key Factors

“Non-adherence was also associated with higher out-of-pocket costs and use of retail pharmacies versus mail order pharmacies,” says Dr. Kirkman. Patients using mail order pharmacies were more than twice as likely to be adherent to their medications when compared with those who filled their prescriptions at retail pharmacies (Table 2). Total daily pill burden was also an adherence factor. For each additional pill that patients took per day, adherence to antidiabetic drugs increased by 22%. The authors also found that diabetes medication adherence decreased by 11% for each additional $15 that was spent in out-of-pocket costs per month.

Several prescriber factors were also examined in the analysis. No significant differences were seen in patient adherence by sex of the prescriber and the effect size of prescriber age was very small. In addition, no significant differences in adherence were observed between primary care and endocrinologist prescribers. However, patients with non-endocrinologist specialists who were their prescribers had slightly but significantly lower adherence than those with primary care prescribers.

Examining the Implications

“More research is needed to gain a better understanding about why being new to diabetes therapy or being on fewer medications overall was associated with lower adherence in our study,” Dr. Kirkman says. “We can only speculate on the potential rationale behind this, but it’s possible that that these patients may not view themselves as truly being ‘ill’ and may be less likely to take medications, especially when the disease is asymptomatic. Regarding patient age as a factor, it’s possible that older patients have more comorbidities and are used to taking medications regularly. Their daily routine might make them more likely to adhere to their diabetes medications.”

Dr. Kirkman says findings of the study are helpful to healthcare providers in raising awareness of both modifiable and non-modifiable factors that are associated with lower adherence. “Clinicians need to be aware of these factors and target programs or interventions to improve adherence,” she says. “Healthcare providers and system leaders should work together to target potentially modifiable factors, such as getting more patients to use mail order pharmacies and doing more to lower patients’ out of pocket costs.”


Readings & Resources (click to view)

Kirkman MS, Rowan-Martin MT, Levin R, et al. Determinants of adherence to diabetes medications: findings from a large pharmacy claims database. Diabetes Care. 2015;38:604-609. Available at:

American Diabetes Association. Standards of Medical Care in Diabetes—2015. Diabetes Care. 2014;38:S1-S93. Available at:

Asche C, LaFleur J, Conner C. A review of diabetes treatment adherence and the association with clinical and economic outcomes. Clin Ther. 2011;33:74-109.

Bogner HR, de Vries HF, O’Donnell AJ, Morales KH. Measuring concurrent oral hypoglycemic and antidepressant adherence and clinical outcomes. Am J Manag Care. 2013;19:e85-e92.

Juarez DT, Tan C, Davis J, Mau M. Factors affecting sustained medication adherence and its impact on health care utilization in patients with diabetes. J Pharm Health Serv Res. 2013;4:89-94.

1 Comment

  1. Interesting research. Definitely one of the frustrations in educating patients with diabetes.


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