Diabetes Oral Medication Initiation and Intensification

PURPOSE: The purpose of this study was to compare patient perceptions about medication management with principles underlying American Diabetes Association (ADA) published treatment algorithms. METHODS: Six focus groups (4 English and 2 Spanish) were conducted with 50 patients with type 2 diabetes. Patients were asked about their prior experiences with initiating and changing oral medicines. They were also shown a medication plan for a hypothetical patient depicting future potential changes to achieve glycemic control. Coded responses were mapped to 3 concepts implicit in the ADA recommended treatment algorithm: (1) prescribing medicines to achieve A1c goal is beneficial, (2) medical regimens are generally intensified, and (3) intensification should be timely. RESULTS: Patient perceptions contrasted markedly with the treatment algorithm: (1) most patients had negative perceptions of medication initiation, viewing this event as evidence of personal failure and an increased burden; (2) patients equated medication intensification with increased risk for diabetes-related complications (rather than a step to reduce future risk) and viewed de-escalation as a primary goal; and (3) no patients expressed concerns about delays in medication intensification. Patients responded very favorably to an individualized medication plan depicting future potential changes. CONCLUSIONS: Patients in this study described a conceptual model for medication therapy that contrasted in critical ways from the principles of current treatment guidelines. Underscoring the key role of patient-provider communication, the results suggest that effective counseling should also include an informed discussion of future medication intensification.