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Khunti K, Jabbour S, Cos X, Mudaliar S, Mende C, Bonaca M, Fioretto P. Sodium-glucose co-transporter-2 inhibitors in patients with type 2 diabetes: Barriers and solutions for improving uptake in routine clinical practice. Diabetes Obes Metab 2022; 24:1187-1196. [PMID: 35238129 PMCID: PMC9313799 DOI: 10.1111/dom.14684] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 02/06/2023]
Abstract
Recent advances in type 2 diabetes (T2D) research have highlighted the benefits of sodium-glucose co-transporter-2 (SGLT-2) inhibitors, including cardiovascular and renal protection. However, uptake rates of these drugs remain low in patients with T2D, particularly in subpopulations most likely to benefit from them. This review considers the potential barriers to prescribing SGLT-2 inhibitors in T2D in clinical practice and outlines potential multidisciplinary recommendations to overcome these barriers. Safety concerns and a lack of clarity in and divergence of guidelines around the introduction of SGLT-2 inhibitors into treatment regimens may represent a barrier to uptake from the clinicians' perspective, including a general lack of understanding of the benefits associated with SGLT-2 inhibitors. Patient characteristics, such as socioeconomic status, may influence uptake because of the cost of SGLT-2 inhibitors, especially in the United States, where health insurance coverage could be a concern. SGLT-2 inhibitor prescription rates vary between clinical specialty (endocrinology, primary care, cardiology, and nephrology) and country, with cardiologists the lowest prescribers, and endocrinologists the highest. Primary care practitioners may experience more challenges in following SGLT-2 inhibitor-related guidelines than diabetes specialists as there may be fewer opportunities for education on how this drug class improves cardiovascular and renal outcomes in patients with T2D. Uptake rates appear to vary between countries because of differences in guidelines and health insurance systems. The amendment of SGLT-2 inhibitor-related guidelines for more multidisciplinary use and the implementation of patient and clinician education may encourage uptake of these drugs, potentially improving long-term health outcomes among patients with T2D.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, College of Medicine, Biological Sciences and PsychologyUniversity of LeicesterLeicesterUK
- NIHR Applied Research Collaboration ‐ East MidlandsLeicesterUK
| | - Serge Jabbour
- Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Xavier Cos
- Sant Marti de Provençals Primary Care CentresBarcelonaSpain
- Institut Català de la Salut. IDIAP Jordi Gol. DAP_Cat Study Group CIBERDEMUniversitat Autonoma de BarcelonaBarcelonaSpain
| | - Sunder Mudaliar
- Department of MedicineUniversity of California, San Diego School of MedicineSan DiegoCaliforniaUSA
- Veterans Affairs Medical CenterSan DiegoCaliforniaUSA
| | - Christian Mende
- Department of MedicineUniversity of California San DiegoLa JollaCaliforniaUSA
| | - Marc Bonaca
- Department of Medicine, Division of CardiologyUniversity of Colorado School of Medicine, Aurora CO; CPC Clinical ResearchAuroraColoradoUSA
| | - Paola Fioretto
- Department of MedicineUniversity of Padua, Unite of Medical Clinic 3, Hospital of PaduaPaduaItaly
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Wilding JPH, Evans M, Fernando K, Gorriz JL, Cebrian A, Diggle J, Hicks D, James J, Newland-Jones P, Ali A, Bain S, Da Porto A, Patel D, Viljoen A, Wheeler DC, Del Prato S. The Place and Value of Sodium-Glucose Cotransporter 2 Inhibitors in the Evolving Treatment Paradigm for Type 2 Diabetes Mellitus: A Narrative Review. Diabetes Ther 2022; 13:847-872. [PMID: 35307801 PMCID: PMC8934539 DOI: 10.1007/s13300-022-01228-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
Over recent years, the expanding evidence base for sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapies has revealed benefits beyond their glucose-lowering efficacy in the treatment of Type 2 diabetes mellitus (T2DM), resulting in their recognition as cardiorenal medicines. While SGLT2is continue to be recommended among the second-line therapies for the treatment of hyperglycaemia, their true value now extends to the prevention of debilitating and costly cardiovascular and renal events for high-risk individuals, with particular benefit shown in reducing major adverse cardiac events and heart failure (HF) and slowing the progression of chronic kidney disease. However, SGLT2i usage is still suboptimal among groups considered to be at greatest risk of cardiorenal complications. The ongoing coronavirus disease 2019 (COVID-19) pandemic has intensified financial pressures on healthcare systems, which may hamper further investment in newer effective medicines. Emerging evidence indicates that glycaemic control should be prioritised for people with T2DM in the era of COVID-19 and practical advice on the use of T2DM medications during periods of acute illness remains important, particularly for healthcare professionals working in primary care who face multiple competing priorities. This article provides the latest update from the Improving Diabetes Steering Committee, including perspectives on the value of SGLT2is as cost-effective therapies within the T2DM treatment paradigm, with particular focus on the latest published evidence relating to the prevention or slowing of cardiorenal complications. The implications for ongoing and future approaches to diabetes care are considered in the light of the continuing coronavirus pandemic, and relevant aspects of international treatment guidelines are highlighted with practical advice on the appropriate use of SGLT2is in commonly occurring T2DM clinical scenarios. The 'SGLT2i Prescribing Tool for T2DM Management', previously published by the Steering Committee, has been updated to reflect the latest evidence and is provided in the Supplementary Materials to help support clinicians delivering T2DM care.
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Affiliation(s)
- John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK.
| | - Marc Evans
- University Hospital Llandough, Cardiff, UK
| | | | - Jose Luis Gorriz
- University Hospital Clinic, University of Valencia, Valencia, Spain
| | - Ana Cebrian
- Spanish Diabetes Association, Catholic University of Murcia, Service Murciano de Salud, Cartagena, Murcia, Spain
- Centro de Salud Casco Antiguo Cartagena, Murcia, Spain
- Primary Care Research Group, Biomedical Research Institute of Murcia (IMIB), 30120, Murcia, Spain
| | - Jane Diggle
- College Lane Surgery, Ackworth, West Yorkshire, UK
| | | | - June James
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Amar Ali
- Royal Blackburn Hospital, Lancashire, UK
| | - Stephen Bain
- Swansea University and Diabetes Research Unit, Swansea, UK
| | | | | | - Adie Viljoen
- Cambridge University Hospitals NHS Foundation Trust, Stevenage, UK
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Escobar C, Morales C, Capel M, Simón S, Pérez-Alcántara F, Pomares E. Cost-effectiveness analysis of dapagliflozin for the treatment of type 2 diabetes mellitus in Spain: results of the DECLARE-TIMI 58 study. BMC Health Serv Res 2022; 22:217. [PMID: 35177053 PMCID: PMC8851809 DOI: 10.1186/s12913-022-07567-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this study was to carry out a cost-effectiveness analysis of dapagliflozin, as an add-on therapy to standard of care (SoC), for the treatment of type 2 diabetes mellitus (T2DM) in Spain, based on the results of the DECLARE-TIMI 58 trial. METHODS A discrete event simulation model (Cardiff T2DM) based on the data observed in the DECLARE-TIMI 58 trial was adapted to the Spanish setting to estimate the costs and health outcomes of treatment with dapagliflozin in patients with T2DM who had or were at risk of atherosclerotic cardiovascular disease. Macrovascular events (hospitalization for heart failure, myocardial infarction, stroke, and unstable angina), end-stage renal disease and cardiovascular and non-cardiovascular mortality were modeled according to the survival equations of the DECLARE-TIMI 58 study. Microvascular events (blindness and ulcers) were estimated based on the risk equations of the UK Prospective Diabetes Study. The analysis was conducted from the Spanish National Health System perspective and the time horizon was 30 years. The results were evaluated in terms of cost per quality-adjusted life year (QALY) gained. Only direct health costs were included, and a 3% discount rate was applied to costs and health outcomes. Univariate and probabilistic sensitivity analyses (PSA) were made to assess the robustness of the results. RESULTS In the main analysis, dapagliflozin was a dominant therapeutic option compared with placebo, with greater effectiveness (0.08 QALYs) and lower associated total costs per patient (€ -2,921). The univariate sensitivity analysis and the PSA confirmed the robustness of the results. The PSA showed the probability that dapagliflozin was a dominant alternative compared with placebo was 84.2% and that it was cost-effective of 92.1%, under a willingness-to-pay of € 20,000/QALY gained. CONCLUSIONS The analysis of data from the DECLARE-TIMI 58 trial shows that dapagliflozin would be a cost-effective option in Spain for the treatment of adult patients with T2DM, as an add-on therapy to SoC, compared with placebo.
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Affiliation(s)
| | | | | | - Susana Simón
- HEOR & Market Access, AstraZeneca, Madrid, Spain
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Fadini GP, Morales C, Caballero I, González B, Tentolouris N, Consoli A. Efficacy of Dapagliflozin in Southern Europe Across the Spectrum of Characteristics of Type 2 Diabetes: An International Real-World Analysis. Diabetes Metab Syndr Obes 2022; 15:3533-3541. [PMID: 36411790 PMCID: PMC9675331 DOI: 10.2147/dmso.s390075] [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: 09/16/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To extend a prior real-world analysis (DARWIN-T2D) of patients with type 2 diabetes initiating dapagliflozin in Italy, Greece, and Spain by evaluating changes in glycemic and extra-glycemic endpoints after initiation of dapagliflozin. PATIENTS AND METHODS The association among demographic/clinical characteristics and the change in glycemic and extraglycemic effectiveness endpoints during the observation period was assayed using a mixed effects model. RESULTS A total of 1438 (860 males; 59.8%) patients were evaluated; patients were followed for a mean of 5.6 months. At baseline, 93.4% and 61.9% of patients were on concomitant metformin and insulin, respectively. A significant mean decrease in HbA1c from 8.7% to 7.5% was observed. The mixed model used also revealed several associations between different glycemic and laboratory parameters and patient characteristics at baseline; insulin use was significantly associated with lower HbA1c. Patients with BMI ≥30 kg/m2 experienced greater weight loss than those with BMI <30 kg/m2. A consistent glucose-lowering effect of dapagliflozin was seen in all subgroups of patients, including those with stage 2 renal impairment and cardiovascular disease. CONCLUSION The present analysis confirms the efficacy of dapagliflozin in diversified real-world settings with broadly similar effects on HbA1c across countries and baseline characteristics.
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Affiliation(s)
- Gian Paolo Fadini
- Division of Metabolic Diseases, Department of Medicine, University of Padova, Padua, Italy
- Correspondence: Gian Paolo Fadini, Department of Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy, Tel +39 049 8214318, Email
| | - Cristobal Morales
- Hospital Virgen Macarena (Sevilla); Hospital Vithas (Sevilla), Sevilla, Spain
| | - Irene Caballero
- Hospital Virgen Macarena (Sevilla); Hospital Vithas (Sevilla), Sevilla, Spain
| | - Beatriz González
- Hospital Virgen Macarena (Sevilla); Hospital Vithas (Sevilla), Sevilla, Spain
| | - Nikolaos Tentolouris
- Diabetes Centre, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Agostino Consoli
- Department of Medicine and Aging Sciences (DMSI) and Center of Advanced Studies and Technologies (CAST), University of Chieti, Chieti, Italy
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Bonora E, Cataudella S, Marchesini G, Miccoli R, Vaccaro O, Fadini GP, Martini N, Rossi E. Initial treatment of diabetes in Italy. A nationwide population-based study from of the ARNO Diabetes Observatory. Nutr Metab Cardiovasc Dis 2021; 31:2661-2668. [PMID: 34218990 DOI: 10.1016/j.numecd.2021.06.006] [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: 04/21/2021] [Revised: 05/24/2021] [Accepted: 06/03/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS To investigate diabetes treatment initiation and continuation in the next sixth months in newly diagnosed Italian subjects. METHODS AND RESULTS We analyzed administrative claims of 11,300,750 Italian residents. Subjects with incident diabetes were identified by glucose lowering drug prescriptions, disease-specific co-payment exemptions and hospital discharge codes occurring in 2018 but not in 2017. Incident cases were 65,932 of whom 91.4% received the prescription of a glucose lowering drug. Among the latter, those receiving a prescription of a noninsulin medication but no insulin were 84.8%, those receiving a prescription of insulin only were 9.4%, and those receiving prescriptions of both insulin and noninsulin drugs were 5.8%. Metformin was the most frequently drug initially prescribed in noninsulin treated subjects (~85%) and sulphonylurea receptor (SUR) agonists collectively ranked as second (~13%). Lispro (35%) and glargine (34%) were the most frequently prescribed molecules in subjects who were insulin treated. Differences in prescriptions were found in age categories, with increased use of SUR agonists across decades. In the first six months, as many as 50% of noninsulin treated patients continued with the initial drug, ~15% added a second agent, ~5% switched to another medication, and ~30% discontinued any glucose lowering treatment. CONCLUSIONS These data document that current guidelines are often neglected because prescriptions of SUR agonists as first agent are still quite common and insulin is prescribed more than expected. They point out the urgent need to improve the dissemination and implementations of guidelines in diabetes care.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Biomarkers/blood
- Blood Glucose/drug effects
- Blood Glucose/metabolism
- Child
- Child, Preschool
- Databases, Factual
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/diagnosis
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/epidemiology
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/epidemiology
- Drug Prescriptions
- Drug Substitution/trends
- Drug Therapy, Combination/trends
- Drug Utilization/trends
- Female
- Humans
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/therapeutic use
- Infant
- Infant, Newborn
- Insulin/therapeutic use
- Italy/epidemiology
- Male
- Metformin/therapeutic use
- Middle Aged
- Practice Patterns, Physicians'/trends
- Sulfonylurea Compounds/therapeutic use
- Time Factors
- Treatment Outcome
- Young Adult
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Affiliation(s)
| | | | | | | | | | | | | | - Elisa Rossi
- CINECA - Interuniversity Consortium, Bologna, Italy
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Real J, Vlacho B, Ortega E, Vallés JA, Mata-Cases M, Castelblanco E, Wittbrodt ET, Fenici P, Kosiborod M, Mauricio D, Franch-Nadal J. Cardiovascular and mortality benefits of sodium-glucose co-transporter-2 inhibitors in patients with type 2 diabetes mellitus: CVD-Real Catalonia. Cardiovasc Diabetol 2021; 20:139. [PMID: 34243779 PMCID: PMC8272340 DOI: 10.1186/s12933-021-01323-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
Background Evidence from prospective cardiovascular (CV) outcome trials in type 2 diabetes (T2DM) patients supports the use of sodium–glucose co-transporter-2 inhibitors (SGLT2i) to reduce the risk of CV events. In this study, we compared the risk of several CV outcomes between new users of SGLT2i and other glucose-lowering drugs (oGLDs) in Catalonia, Spain. Methods CVD-REAL Catalonia was a retrospective cohort study using real-world data routinely collected between 2013 and 2016. The cohorts of new users of SGLT2i and oGLDs were matched by propensity score on a 1:1 ratio. We compared the incidence rates and hazard ratio (HR) for all-cause death, hospitalization for heart failure, chronic kidney disease, and modified major adverse CV event (MACE; all-cause mortality, myocardial infarction, or stroke). Results After propensity score matching, 12,917 new users were included in each group. About 27% of users had a previous history of CV disease. In the SGLT2i group, the exposure time was 60% for dapagliflozin, 26% for empagliflozin and 14% for canagliflozin. The use of SGLT2i was associated with a lower risk of heart failure (HR: 0.59; 95% confidence interval [CI] 0.47–0.74; p < 0.001), all-cause death (HR = 0.41; 95% CI 0.31–0.54; p < 0.001), all-cause death or heart failure (HR = 0.55; 95% CI 0.47–0.63; p < 0.001), modified MACE (HR = 0.62; 95% CI 0.52–0.74; p < 0.001), and chronic kidney disease (HR = 0.66; 95% CI 0.54–0.80; p < 0.001). Conclusions In this large, retrospective observational study of patients with T2DM from a Catalonia, initiation of SGLT-2i was associated with lower risk of mortality, as well as heart failure and CKD. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01323-5.
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Affiliation(s)
- Jordi Real
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Bogdan Vlacho
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Emilio Ortega
- Department of Endocrinology and Nutrition, Institut d'Investigacions Biomèdiques August Pi i Suñer, Hospital Clinic, Barcelona, Spain.,CIBER of Physiopathology of Obesity and Nutrition (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Joan Antoni Vallés
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,Drug Area, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
| | - Manel Mata-Cases
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain.,Primary Health Care Center La Mina, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Sant Adrià de Besòs, Spain
| | - Esmeralda Castelblanco
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | | | - Peter Fenici
- Cardiovascular Renal Metabolisms, BioPharmaceuticals Global Medical, AstraZeneca, Cambridge, UK
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
| | - Dídac Mauricio
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain. .,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain. .,Department of Endocrinology and Nutrition, Hospital Universitari de la Santa Creu i Sant Pau, Autonomous Universtity of Barcelona, Sant Quintí, 89, 08041, Barcelona, Spain. .,Departament of Medicine, University of Vic-Central University of Catalonia, Vic, Barcelona, Spain.
| | - Josep Franch-Nadal
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain. .,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain. .,Primary Health Care Center Raval Sud, Gerència d'Atenció Primaria, Institut Català de la Salut, Av. Drassanes, 17-21, 08001, Barcelona, Spain.
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