Adherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus

doi:10.1016/S0140-6736(97)06234-X

The Lancet

Volume 350, Issue 9090, 22 November 1997, Pages 1505-1510

https://doi.org/10.1016/S0140-6736(97)06234-X Get rights and content

Summary

Background

Intensive insulin treatment effectively delays the onset and slows the progression of microvascular complications in insulin-dependent diabetes mellitus (IDDM). Variable adherence to insulin treatment is thought to contribute to poor glycaemic control, diabetic ketoacidosis, and brittle diabetes in adolescents and young adults with IDDM. We assessed the association between the prescribed insulin dose and the amount dispensed from all community pharmacies with the Diabetes Audit and Research in Tayside Scotland (DARTS) database.

Methods

We studied 89 patients, mean age 16 (SD 7) years, diabetes duration 8 (4) years, and glycosylated haemoglobin (HbA_1c) 8·4 (1·9)%, who attended a teaching hospital paediatric or young-adult diabetes clinic in 1993 and 1994. The medically recommended insulin dose and cumulative volume of insulin prescriptions supplied were used to calculate the days of maximum possible insulin coverage per annum, expressed as the adherence index. Associations between glycaemic control (HbA_1c), episodes of diabetic ketoacidosis, and all hospital admissions for acute complications and the adherence index were modelled.

Findings

Insulin was prescribed at 48 (19) IU/day and mean insulin collected from pharmacies was 58 (25) IU/day. 25 (28%) of the 89 patients obtained less insulin than their prescribed dose (mean deficit 115 [68; range 9–246] insulin days/annum). There was a significant inverse association between HbA_1c and the adherence index (R²=0·39; p<0·001). In the top quartile (HbA_1c≥10%), 14 (64%) of individuals had an adherence index suggestive of a missed dose of insulin (mean deficit 55 insulin days/annum). There were 36 admissions for complications related to diabetes. The adherence index was inversely related to hospital admissions for diabetic ketoacidosis (p<0·001) and all hospital admissions related to acute diabetes complications (p=0·008). The deterioration in glycaemic control observed in patients aged 10–20 years was associated with a significant reduction (p=0·01) in the adherence index.

Interpretation

We found direct evidence of poor compliance with insulin therapy in young patients with IDDM. We suggest that poor adherence to insulin treatment is the major factor that contributes to long-term poor glycaemic control and diabetic ketoacidosis in this age group.

Introduction

The Diabetes Control and Complications Trial (DCCT),¹ together with other clinical trials,2, 3 has confirmed that intensive insulin therapy and improved metabolic control in patients with insulin-dependent diabetes mellitus (IDDM) delays the onset and slows the progression of clinically important microvascular complications. Adolescents and young adults with IDDM are often characterised by glycaemic control which is unstable and generally poor.⁴ In addition, so-called brittle diabetes occurs most commonly in younger people.5, 6, 7 Brittle diabetes occurs in a small subgroup of patients with IDDM who have severe glycaemic instability leading to life disruption and repeated hospital admissions often with diabetic ketoacidosis. Clearly, there is an urgent need to identify the underlying factors that predispose patients to poor metabolic control in this age group. One possible explanation is that a lack of insulin is caused by poor compliance. This is perceived to be the major factor in the development of brittle diabetes; 93% of diabetologists in the UK consider psychosocial factors, such as the manipulation of insulin therapy, as the most common underlying cause.⁸ Additionally, there are reports that intentional omission of insulin occurs more often in women than men with IDDM,9, 10 but previous studies have failed to show an association between adherence and metabolic control.9, 11 One distinct limitation of these studies is that questionnaires and patient self-reports were used; such descriptive methods are generally regarded as unreliable.¹² There is therefore no direct confirmation of intentional omission of insulin and no reliable valid measures of adherence.

We investigated the hypothesis that poor glycaemic control in young people with IDDM is associated with failure to take insulin treatment and that hospital admission for complications related to diabetes is associated with poor adherence to insulin treatment. We therefore studied the association between the medically recommended prescription of insulin therapy, insulin therapy dispensed at community pharmacies, glycaemic control, and acute hospital admissions for symptoms related to diabetes in a group of young people with IDDM.

Section snippets

Methods

We studied all patients with IDDM who were younger than 30 years who attended the paediatric and young-adult diabetes clinics at Ninewells Hospitals, Dundee, Scotland, UK. All patients were resident in Tayside and registered with a Tayside general practitioner in May, 1993, and were still alive and resident in Tayside in December, 1994. All patients attending these clinics had details of their clinical care recorded on a computerised database.

The study was done by the Diabetes Audit and

Results

The characteristics of the 89 patients in the study are shown in table 1. SMR1 data and case record validation confirmed that 16 (18%) of patients had been admitted to hospital on a total of 37 occasions during the study. 36 admissions were for acute complications related to diabetes. There were 15 admissions for diabetic ketoacidosis in ten patients, and 21 admissions for hypoglycaemia in eight patients. Three patients were admitted for repeated episodes of hyperglycaemia and hypoglycaemia,

Discussion

The DCCT has set the challenge to identify clinical strategies that will improve glycaemic control in people with diabetes. In a selected group of patients willing to participate in the trial, it showed the benefits of intensification of diabetes management—eg, multiple injection regimens, frequent monitoring, aggressive dietary therapy, and increased contact with health-care workers. In every day practice, not taking insulin regularly is perceived to be a reason for poor control. However, the

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ArticlesAdherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Methods

Results

Discussion

N Engl J Med

Lancet

J Chronic Dis

Lancet

The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus

N Engl J Med

The effect of long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus

N Engl J Med

Age-related changes in glycated haemoglobin in patients with insulin-dependent diabetes mellitus

Diabetic Med

The outcome of brittle diabetes—a follow up study of young female diabetic patients with recurrent ketoacidosis

BMJ

Brittle diabetes—present concepts

Diabetologia

Prevalence and characteristics of brittle diabetes in Britain

QJM

The relationship between the health belief model and compliance of persons with diabetes mellitus

Diabetes Care

Supportive and nonsupportive family behavoiurs: relationships to adherence and metabolic control in persons with type I diabetes

Diabetes Care

Adherence to diabetes regimens: empirical status and clinical implications

Diabetes Education

Articles
Adherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus