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Khunti K, Almalki M, Chan JCN, Amod A. The Role of Real-World Evidence in Treatment Decision-Making, Regulatory Assessment, and Understanding the Perspectives of People with Type 2 Diabetes: Examples with Gliclazide MR. Diabetes Ther 2023; 14:1609-1625. [PMID: 37603144 PMCID: PMC10499769 DOI: 10.1007/s13300-023-01458-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/28/2023] [Indexed: 08/22/2023] Open
Abstract
Real-world evidence (RWE) plays an important role in the management of type 2 diabetes (T2D). It provides data about the effectiveness and safety of an intervention from outside the randomised controlled trial (RCT) setting and allows healthcare professionals (HCPs) to determine if RCT data are applicable to their patients in routine clinical practice. This review provides a discussion of the value of RWE in T2D management in day-to-day clinical practice, with a focus on RWE with sulfonylureas (SUs), and presents two examples of a new generation of international real-world studies in people with T2D managed in routine clinical practice. RWE plays a valuable role in advising HCPs in the day-to-day management of T2D, informing regulatory authorities with regard to pharmacovigilance and post-approval updates, and providing insights with regard to patients' treatment adherence and preference. RWE should be used alongside RCTs to increase HCP awareness and understanding of their patients' perspectives, potentially allowing for improvements in treatment adherence, glycaemic control and health-related quality of life (HRQoL). In addition, real-world studies must be conducted in a way that generates robust RWE by limiting the risks of bias and confounding as much as possible. A growing body of RWE is emerging from Asia. For example, in a preliminary HRQoL analysis of the Joint Asia Diabetes Evaluation (JADE) Register, Asian people with T2D had better HRQoL with gliclazide-based treatment than with other SU agents, despite being older and having more diabetes-related complications.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, LE5 4PW, UK.
| | - Mussa Almalki
- King Fahad Medical City, Obesity, Endocrine and Metabolism Centre, Riyadh, Saudi Arabia
| | - Juliana C N Chan
- Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity and Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Aslam Amod
- Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Flory JH, Guelce D, Goytia C, Li J, Min JY, Mushlin A, Orloff J, Mayer V. Prescriber Uncertainty as Opportunity to Improve Care of Type 2 Diabetes with Chronic Kidney Disease: Mixed Methods Study. J Gen Intern Med 2023; 38:1476-1483. [PMID: 36316625 PMCID: PMC10160326 DOI: 10.1007/s11606-022-07838-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/05/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Over 5 million patients in the United States have type 2 diabetes mellitus (T2D) with chronic kidney disease (CKD); antidiabetic drug selection for this population is complex and has important implications for outcomes. OBJECTIVE To better understand how providers choose antidiabetic drugs in T2D with CKD DESIGN: Mixed methods. Interviews with providers underwent qualitative analysis using grounded theory to identify themes related to antidiabetic drug prescribing. A provider survey used vignettes and direct questions to quantitatively assess prescribers' knowledge and preferences. A retrospective cohort analysis of real-world prescribing data assessed the external validity of the interview and survey findings. PARTICIPANTS Primary care physicians, endocrinologists, nurse-practitioners, and physicians' assistants were eligible for interviews; primary care physicians and endocrinologists were eligible for the survey; prescribing data were derived from adult patients with serum creatinine data. MAIN MEASURES Interviews were qualitative; for the survey and retrospective cohort, proportion of patients receiving metformin was the primary outcome. KEY RESULTS Interviews with 9 providers identified a theme of uncertainty about guidelines for prescribing antidiabetic drugs in patients with T2D and CKD. The survey had 105 respondents: 74 primary care providers and 31 endocrinologists. Metformin was the most common choice for patients with T2D and CKD. Compared to primary care providers, endocrinologists were less likely to prescribe metformin at levels of kidney function at which it is contraindicated and more likely to correctly answer a question about metformin's contraindications (71% versus 41%) (p < .05). Real-world data were consistent with survey findings, and further showed low rates of use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists (<10%) in patients with eGFR below 60 ml/min/1.73m2. CONCLUSIONS Providers are unsure how to treat T2D with CKD and incompletely informed as to existing guidelines. This suggests opportunities to improve care.
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Affiliation(s)
- James H Flory
- Endocrinology Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Dominique Guelce
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | | | - Jing Li
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Jea Young Min
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Al Mushlin
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Jeremy Orloff
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
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Williams DM, Jones H, Stephens JW. Personalized Type 2 Diabetes Management: An Update on Recent Advances and Recommendations. Diabetes Metab Syndr Obes 2022; 15:281-295. [PMID: 35153495 PMCID: PMC8824792 DOI: 10.2147/dmso.s331654] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/18/2022] [Indexed: 12/19/2022] Open
Abstract
Previous guidelines for the treatment of people with type 2 diabetes mellitus (T2D) have relied heavily upon rigid algorithms for the sequential addition of pharmacotherapies to achieve target glycemic control. More recent guidelines advocate a personalized approach for diabetes treatment, to improve patient satisfaction, quality of life, medication adherence and overall health outcomes. Clinicians should work with patients to develop personalized goals for their treatment, including targeted glycemic control, weight management, prevention and treatment of associated comorbidities and avoidance of complications such as hypoglycemia. Factors that affect the intensity of treatment and choice of pharmacotherapy should include medical and patient influences. Medical considerations include the diabetes phenotype, biomarkers including genetic tests, and the presence of comorbidities such as cardiovascular, renal, or hepatic disease. Patient factors include their treatment preference, age and life expectancy, diabetes duration, hypoglycemia fear and unawareness, psychological and social circumstances. The use of a personalized approach in the management of people with T2D can reduce the cost and failure associated with the algorithmic "one-size-fits-all" approach, to anticipate disease progression, improve the response to diabetes pharmacotherapy and reduce the incidence of diabetes-associated complications. Ultimately, the use of personalized medicine in people with T2D should improve medication adherence, patient satisfaction and quality of life to reduce diabetes distress and improve physical health outcomes.
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Affiliation(s)
- David M Williams
- Department of Diabetes and Endocrinology, Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 8NL, UK
- Correspondence: David M Williams, Diabetes Centre, Morriston Hospital, Swansea, SA6 6NL., UK, Tel +441792704078, Email
| | - Hannah Jones
- Department of Diabetes and Endocrinology, Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 8NL, UK
| | - Jeffrey W Stephens
- Department of Diabetes and Endocrinology, Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 8NL, UK
- Diabetes Research Group, Swansea University Medical School, Swansea University, Swansea, SA2 8PP, UK
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Tsapas A, Karagiannis T, Kakotrichi P, Avgerinos I, Mantsiou C, Tousinas G, Manolopoulos A, Liakos A, Malandris K, Matthews DR, Bekiari E. Comparative efficacy of glucose-lowering medications on body weight and blood pressure in patients with type 2 diabetes: A systematic review and network meta-analysis. Diabetes Obes Metab 2021; 23:2116-2124. [PMID: 34047443 DOI: 10.1111/dom.14451] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/19/2021] [Accepted: 05/23/2021] [Indexed: 12/23/2022]
Abstract
AIM To compare the effects of glucose-lowering drugs on body weight and blood pressure in adults with type 2 diabetes. METHODS We searched Medline, Embase, the Cochrane Library, and grey literature sources until 29 September 2020 for randomized controlled trials of at least 24 weeks' duration assessing the effects of glucose-lowering drugs on body weight and blood pressure in adults with type 2 diabetes. We performed frequentist network meta-analyses and calculated weighted mean differences and 95% confidence intervals combining trial arms of different approved doses of a given intervention into a single group. We evaluated the confidence in pooled estimates using the CINeMA (Confidence In Network Meta-Analysis) framework. RESULTS In total, 424 trials (276 336 patients) assessing 21 antidiabetic medications from nine drug classes were included. Subcutaneous semaglutide was the most efficacious in reducing body weight followed by oral semaglutide, exenatide twice-daily, liraglutide, and the sodium-glucose co-transporter-2 (SGLT-2) inhibitors empagliflozin, canagliflozin, dapagliflozin and ertugliflozin. The same agents also conferred the greatest reductions in systolic blood pressure. Metformin had a modest effect in reducing body weight and systolic blood pressure. Diastolic blood pressure was reduced with the SGLT-2 inhibitors pioglitazone, exenatide twice-daily and semaglutide. In subgroup analyses of trials with over 52 weeks' duration, semaglutide and SGLT-2 inhibitors reduced both body weight and systolic blood pressure. CONCLUSIONS Semaglutide and SGLT-2 inhibitors conferred reductions both in body weight and blood pressure that were sustainable for over 1 year of treatment. These agents may be preferable treatment options for patients with type 2 diabetes who are overweight/obese and/or hypertensive.
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Affiliation(s)
- Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, UK
| | - Thomas Karagiannis
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiota Kakotrichi
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Avgerinos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Chrysanthi Mantsiou
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Tousinas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Manolopoulos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aris Liakos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Malandris
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - David R Matthews
- Harris Manchester College, University of Oxford, Oxford, UK
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Eleni Bekiari
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Bimpas NG, Auyeung V, Tentolouris A, Tzeravini E, Eleftheriadou I, Tentolouris N. Adoption of and adherence to the Hellenic Diabetes Association guidelines for the management of subjects with type 2 diabetes mellitus by Greek physicians. Hormones (Athens) 2021; 20:347-358. [PMID: 33123974 DOI: 10.1007/s42000-020-00253-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 10/16/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to evaluate the level of adoption of and adherence to the Hellenic Diabetes Association (HDA) guidelines for the management of individuals with type 2 diabetes mellitus (T2DM) by Greek physicians. METHODS We used a constructed questionnaire distributed to physicians in Greece. The questionnaire assessed the adoption of and adherence to the general and treatment guidelines of the HDA, as well as factors affecting physicians' prescribing habits and demographic characteristics of the participating healthcare professionals. Factors affecting the preferred therapy or glycated hemoglobin target setting were evaluated using non-parametric tests. The likelihood of adherence was estimated by logistic regression models. RESULTS Adoption of the HDA guidelines was reported by 92.2% of physicians. Adherence to the treatment algorithm was reported by 53.5% and to the general HDA guidelines by 42.0% of healthcare professionals; overall adherence to both general and treatment guidelines was 26.1%. Multivariate analysis demonstrated that the likelihood of adherence to treatment guidelines was higher among individuals attending over five in comparison with those attending under two diabetes seminars per year (p = 0.037); in contrast, years of work (professional experience ≥ 21 vs. ≤ 5 years) affected adherence negatively (p = 0.031). No significant association was found between other parameters and adherence to either general or overall guidelines. CONCLUSIONS Adoption rates of the guidelines for the management of T2DM were high, while adherence rates to general and treatment guidelines were low. The rate of seminar attendance affected treatment adherence positively, while long professional practice affected treatment adherence negatively.
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Affiliation(s)
| | - Vivian Auyeung
- Kings College London, Institute of Pharmaceutical Science, London, UK
| | - Anastasios Tentolouris
- First Department of Propaedeutic Internal Medicine and Diabetes Center, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 17 Agiou Thoma St, 115 27, Athens, Greece
| | - Evangelia Tzeravini
- First Department of Propaedeutic Internal Medicine and Diabetes Center, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 17 Agiou Thoma St, 115 27, Athens, Greece
| | - Ioanna Eleftheriadou
- First Department of Propaedeutic Internal Medicine and Diabetes Center, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 17 Agiou Thoma St, 115 27, Athens, Greece
| | - Nikolaos Tentolouris
- First Department of Propaedeutic Internal Medicine and Diabetes Center, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 17 Agiou Thoma St, 115 27, Athens, Greece.
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Lee CG, Cefalu WT. The Right Diabetes Medication for the Right Patient for the Right Outcome: Can a Network Meta-analysis Help Us Decide? Ann Intern Med 2020; 173:311-312. [PMID: 32598225 DOI: 10.7326/m20-4266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Christine G Lee
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland (C.G.L., W.T.C.)
| | - William T Cefalu
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland (C.G.L., W.T.C.)
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Tsapas A, Avgerinos I, Karagiannis T, Malandris K, Manolopoulos A, Andreadis P, Liakos A, Matthews DR, Bekiari E. Comparative Effectiveness of Glucose-Lowering Drugs for Type 2 Diabetes: A Systematic Review and Network Meta-analysis. Ann Intern Med 2020; 173:278-286. [PMID: 32598218 DOI: 10.7326/m20-0864] [Citation(s) in RCA: 147] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Several pharmacologic options for type 2 diabetes are available. PURPOSE To compare benefits and harms of glucose-lowering drugs in adults with type 2 diabetes. DATA SOURCES Several databases from inception through 18 December 2019 and ClinicalTrials.gov on 10 April 2020. STUDY SELECTION English-language randomized trials that had at least 24 weeks of intervention and assessed the effects of glucose-lowering drugs on mortality, glycemic, and vascular outcomes. DATA EXTRACTION Pairs of reviewers extracted data and appraised risk of bias. DATA SYNTHESIS 453 trials assessing 21 antidiabetic interventions from 9 drug classes were included. Interventions included monotherapies (134 trials), add-on to metformin-based therapies (296 trials), and monotherapies versus add-on to metformin therapies (23 trials). There were no differences between treatments in drug-naive patients at low cardiovascular risk. Insulin regimens and specific glucagon-like peptide-1 receptor agonists (GLP-1 RAs) added to metformin-based background therapy produced the greatest reductions in hemoglobin A1c level. In patients at low cardiovascular risk receiving metformin-based background treatment (298 trials), there were no clinically meaningful differences between treatments for mortality and vascular outcomes. In patients at increased cardiovascular risk receiving metformin-based background treatment (21 trials), oral semaglutide, empagliflozin, liraglutide, extended-release exenatide, and dapagliflozin reduced all-cause mortality. Oral semaglutide, empagliflozin, and liraglutide also reduced cardiovascular death. Odds of stroke were lower with subcutaneous semaglutide and dulaglutide. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors reduced heart failure hospitalization and end-stage renal disease. Subcutaneous semaglutide and canagliflozin increased diabetic retinopathy and amputation, respectively. LIMITATION Inconsistent definitions of cardiovascular risk and low-level confidence in some estimates for patients at low cardiovascular risk. CONCLUSION In diabetic patients at low cardiovascular risk, no treatment differs from placebo for vascular outcomes. In patients at increased cardiovascular risk receiving metformin-based background therapy, specific GLP-1 RAs and SGLT-2 inhibitors have a favorable effect on certain cardiovascular outcomes. PRIMARY FUNDING SOURCE European Foundation for the Study of Diabetes, supported by an unrestricted educational grant from AstraZeneca. (PROSPERO: CRD42019122043).
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Affiliation(s)
- Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit and Diabetes Centre, Aristotle University of Thessaloniki, Thessaloniki, Greece, and Harris Manchester College, University of Oxford, Oxford, United Kingdom (A.T.)
| | - Ioannis Avgerinos
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece (I.A., T.K., K.M., A.M., A.L.)
| | - Thomas Karagiannis
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece (I.A., T.K., K.M., A.M., A.L.)
| | - Konstantinos Malandris
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece (I.A., T.K., K.M., A.M., A.L.)
| | - Apostolos Manolopoulos
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece (I.A., T.K., K.M., A.M., A.L.)
| | - Panagiotis Andreadis
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece, and North West Anglia NHS Foundation Trust, Peterborough City Hospital, Peterborough, United Kingdom (P.A.)
| | - Aris Liakos
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece (I.A., T.K., K.M., A.M., A.L.)
| | - David R Matthews
- Harris Manchester College, University of Oxford, and Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, United Kingdom (D.R.M.)
| | - Eleni Bekiari
- Clinical Research and Evidence-Based Medicine Unit and Diabetes Centre, Aristotle University of Thessaloniki, Thessaloniki, Greece (E.B.)
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