When Advice on Diabetes Is Sound, But Ignored Gina Kolata. New York Times October 17, 2006
The questions explored in this article are easy to grasp, difficult to resolve, and profoundly important to understand if compliance management is to advance:
How long does the clinician wait (and, in the process, allow a disorder to persist) if noncompliance negates the best possible course of therapy (i.e., the safest effective treatment) for a disorder such as type 2 diabetes to recommend another treatment that is either less effective or less safe but more likely to be followed by the patient? And, by extension is the optimal initial treatment recommendation for a disorder such as type 2 diabetes (1) the best possible course of therapy (i.e., the safest effective treatment) for which compliance is known to be low or (2) another treatment, either less effective or less safe, for which compliance is known to be higher?
In the case of diabetes 2, for example, research findings clearly indicate that diet and exercise can delay onset of symptom for years if not indefinitely. Moreover, among fully compliant patients, exercise and diet have been shown to be more successful in preventing diabetes than metformin, the most frequently recommended medication. (Rosiglitazone may be more effective than either metformin or diet and exercise but does have a risk of side-effects.)
The clinker in the equation, of course, is that, without an extensive and prohibitively expensive reinforcement program, a very low percentage of patients adhere to the exercise and diet programs.
This noncompliance has resulted in a change in the international treatment guidelines, which have traditionally hedged by recommending that patients with full spectrum Type 2 diabetes first attempt a program of exercise and weight loss with medications prescribed only after that trial failed. As of August, however, the guidelines recommend starting patients on metformin immediately since most are unable to follow the lifestyle recommendations. By the time the lifestyle change attempt was acknowledged to have failed, the patients could have suffered from uncontrolled diabetes for months or years. The new guidelines are the result of the reasoning that the consequences of untreated diabetes are too severe to risk noncompliance.
Commentary
Type 2 diabetes is a good example of this problem but hardly the only one. Grappling with this concept is key to redefining “patient compliance” into a model that provides clinical guidance and utility.
