A 48-year-old woman with type 2 diabetes (HbA₁c 8.2%) and hypertension (BP 150/95 mmHg) attends the village health guide's clinic in Uttar Pradesh for her 6-monthly NCD follow-up. She reports poor adherence to medications due to cost and side effects. Physical examination shows no acute complications. According to NPCDCS protocol, what is the most appropriate next step?

Explanation

## NPCDCS Approach to NCD Follow-up and Adherence **Key Point:** NPCDCS recognizes that **poor adherence is a major barrier to NCD control in India**, particularly in resource-limited settings. The program prioritizes **barrier identification, counselling, and community engagement** before escalating therapy. ### Rationale for Correct Answer The correct approach at the village health guide/PHC level is: 1. **Identify adherence barriers** (cost, side effects, complexity) 2. **Simplify the regimen** (e.g., switch to fixed-dose combinations; reduce pill burden) 3. **Leverage generic/cheaper formulations** (NPCDCS emphasizes affordability) 4. **Engage community health workers** (ASHA, ANM) for follow-up and motivation 5. **Schedule timely review** (4 weeks) to assess response before intensifying therapy **High-Yield:** NPCDCS **Adherence Strategy: SIMPLE** - **S**creening for barriers (cost, side effects, complexity, knowledge) - **I**ntensify counselling (behaviour change communication) - **M**odify regimen (simplify, use FDC, switch to cheaper alternatives) - **P**artner with community (ASHA, ANM, self-help groups) - **L**everage generic drugs (government formulary) - **E**valuate response at 4–6 weeks before escalation ### Why Intensifying Therapy Immediately Is Wrong | Scenario | Action | Outcome | |----------|--------|----------| | **Poor adherence to 1 agent** | Add 2nd agent immediately | Worse adherence; more side effects; worsening control | | **Poor adherence to 1 agent** | Address barriers; simplify; review in 4 weeks | Improved adherence; better control; cost-effective | **Clinical Pearl:** In Indian primary care, **adherence is often the limiting factor, not drug efficacy**. A patient on one drug poorly taken is worse off than on no drug. NPCDCS mandates a **patient-centred, barrier-focused approach** before pharmaceutical intensification. **Mnemonic — Why Adherence Matters in NPCDCS: ABCD** - **A**ffordability (cost of drugs) - **B**urden (pill count, frequency) - **C**omfort (side effects) - **D**uration (time to benefit; patient education) **Warning:** Do NOT assume the patient needs more drugs. Do NOT ignore cost and side effects — these are the **primary drivers of non-adherence in India**. Do NOT refer prematurely to tertiary care for what is a primary care management issue.