The importance of the cut-off point for considering good adherence in diabetes

Escribano-Serrano, Jose; Michán-Doña, Alfredo; López-Simarro, Flora

doi:10.1016/j.medcle.2019.07.022

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The MPR (medication possession ratio) and a cut-off point of 80% were used to arrive at these results, and estimate adequate adherence.Since the almost universal introduction of electronic prescriptions in our country, there are a great number of files with huge amounts of data waiting to be investigated. For studies that evaluate adherence to medication prospectively, we can find various measurement methods, however the number of methods is more limited for retrospective studies.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> The MPR and its quasi-synonym PDC (Proportion of Days Covered) are effective tools which are increasingly used to measure adherence to medication in chronic diseases.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> Another complementary tool would be the measurement of persistence, that is, the amount of time a patient continues to take the prescribed medication.Both measurements are being widely used in diabetes-related studies.<a class="elsevierStyleCrossRefs" href="#bib0030">1,3,4</a> In our country these tools allow us to measure the volume of drugs withdrawn from the pharmacy and assume that the dispensed tablets are consumed by the patient, but this would be the closest we can get, retrospectively, to the actual consumption/use of the drug in time and place. This leads to the greatest limitation, that is, estimating that one day with the medicinal product in the patient's possession is equal to one day having consumed/used the medicinal product.However, we would like to emphasise the «value of the cut-off point», which is something that has always been overlooked<a class="elsevierStyleCrossRef" href="#bib0050">5</a>. To evaluate adherence, Moreno-Juste et al.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> take the MPR value as a dichotomous variable, adherence or non-adherence, with 80% of the MPR as the cut-off point. The use of ‘80%’ is common in the most recent publications,<a class="elsevierStyleCrossRefs" href="#bib0040">3,4</a> although its use is due more to habit than to sustainable evidence. If we go back in time, that value seems to come from osteoporosis studies conducted at the start of the century.But what does it really mean? What do we assume when we take ‘80%’ as an adequate value? Well, from a negative point of view, it would be the same as saying that it is appropriate for a patient to stop taking 20% of the prescribed medication for, for example, a year. If we consider a drug that is only taken once-a-day, this would mean that this patient does not have their medication for 2.5 months, 10 weeks or 72 days a year. Or looking at it from another angle, it is seen as acceptable that the patient may not take the medication for almost a week out of each month.Things get even more complicated in situations where there is a ‘shadow effect’. A ‘shadow effect’ is that produced when, after stopping a drug for just a couple of days, its levels and therapeutic effect disappear. When the patient starts to take the medicinal product again, it takes time to reach the appropriate therapeutic level, and it includes the possibility of adverse effects when restarting full doses (e.g., metformin, which takes up to 3 days to reach full doses). The risk of adverse effects may also increase when restarting full-dose medicinal products.Therefore, we do not consider 80% as an adequate cut-off point for a disease such as diabetes, regardless of whether the patient is undergoing treatment with a single drug<a class="elsevierStyleCrossRef" href="#bib0030">1</a> or with 2 drugs,<a class="elsevierStyleCrossRefs" href="#bib0040">3,4</a> and much less, if the treatment includes any combination therapy with insulin. Today, when individualisation of treatment and objectives is advocated, it is not viable to be flexible with drug adherence, this should always be as close as possible to 100%.So in conclusion, if the results of Moreno-Juste et al. on their own are a cause of concern, we cannot imagine what would have happened if there had been greater demand on the value of adherence.Conflict of interestsThe authors declare no conflict of interest." 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Med Clin (Barc). 2020;155:467–468." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adherence to treatment of hypertension, hypercholesterolaemia and diabetes in an elderly population of a Spanish cohort" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Moreno Juste" 1 => "A. Gimeno Miguel" 2 => "B. Poblador Plou" 3 => "F. González Rubio" 4 => "M.M. Aza Pascual-Salcedo" 5 => "E. 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Engel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/1753-0407.12461" "Revista" => array:6 [ "tituloSerie" => "J Diabetes" "fecha" => "2017" "volumen" => "9" "paginaInicial" => "677" "paginaFinal" => "688" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27531167" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparing medication adherence and persistence among patients with type 2 diabetes using sodium-glucose cotransporter 2 inhibitors or sulfonylureas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K.F. Bell" 1 => "K. Cappell" 2 => "M. Liang" 3 => "A.M. 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Coyne" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.18553/jmcp.2014.20.7.650" "Revista" => array:6 [ "tituloSerie" => "J Manag Care Spec Pharm" "fecha" => "2014" "volumen" => "20" "paginaInicial" => "650" "paginaFinal" => "651" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24967518" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015500000010/v1_202011260800/S2387020620304927/v1_202011260800/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015500000010/v1_202011260800/S2387020620304927/v1_202011260800/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620304927?idApp=UINPBA00004N"]

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Vol. 155. Issue 10.

Pages 467-468 (November 2020)

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