Antidiabetic prescriptions and glycemic control in German patients with type 2 diabetes mellitus: a retrospective database study

Assessment of quality of care provided to adults with type 2 diabetes mellitus at public hospitals in Gamo Gofa zone, Southern Ethiopia: Facility based Cross‐Sectional study

Purpose

Proactive management of type 2 diabetes is important for restoring beta‐cell function and improving sustained blood glucose control. Evidence on quality of diabetes care in Ethiopia is inadequate.

Method

Facility‐based cross‐sectional study was conducted to assess level of quality of care provided to adult type 2 diabetes patients at three public hospitals in Gamo Gofa Zone, Southern Ethiopia.

Results

A total of 210 adult type 2 diabetes patients were included. The mean age of patients was 44.1 ± 9.94 years. Fifty‐one (24.3%) of patients adhered to prescribed medicines. Sixty‐seven (31.9%) patients could benefit from neuropathy screening and referral. Diabetes‐specific evidence‐based guidelines, operational plan to reduce overweight and obesity were not available. There was no periodic lipid profile, renal function and glycated haemoglobin testing. Sixty‐three (30%) patients achieved fasting blood glucose (FBG) level. Only 41 (19.5%) achieved the recommended target value for composite intermediate outcomes. All three sub‐components of quality care structure, process and outcome (SPO) were below the agreed minimum score and the quality of care provided to adult type 2 diabetes was poor. Only 41 (19.5%) achieved agreed quality indicator targets for type 2 diabetes (fasting blood glucose blood pressure and low‐density lipoprotein cholesterol).

Conclusion

The quality of care provided to adult type 2 diabetes patients was poor particularly in areas such as availability of evidence‐based guidelines, operational plan to reduce obesity, monitoring of lipid profile and glycaemic control. Therefore, developing strategies for addressing structure, process and outcome‐related gaps by involving all stakeholders is critical for improving the quality of care provided to these patients.

Patterns of drug therapy, glycemic control, and predictors of escalation - non-escalation of treatment among diabetes outpatients at a tertiary care center

OBJECTIVES

The study was conducted to assess patterns of prescribed drug therapy and clinical predictors of need for therapy escalation in outpatients with diabetes mellitus (DM).

METHODS

This was a prospective cohort study, conducted at an apex tertiary care teaching hospital in central India for a period of 18 months. The demographic, clinical, and treatment details on the baseline and follow up visits were collected from the patients' prescription charts. Glycemic control, adherence, pill burdens along with pattern of antidiabetic therapy escalation, and deescalations were analyzed.

RESULTS

A total of 1,711 prescriptions of 925 patients of diabetes with a mean age of 53.81 ± 10.42 years and duration of disease of 9.15 ± 6.3 years were analyzed. Approximately half of the patients (n=450) came for ≥1 follow up visits. Hypertension (59.35%) was the most common comorbidity followed by dyslipidemia and hypothyroidism. The mean total daily drugs and pills per prescription were 4.03 ± 1.71 and 4.17 ± 1.38, respectively. Metformin (30.42%) followed by sulphonylureas (SUs) (21.39%) constituted majority of the AHA's and dual and triple drug therapy regimens were most commonly prescribed. There were improvements in HbA_1c, fasting/postprandial/random blood sugar (FBS/PPBS/RBS) as well as adherence to medication, diet, and exercise in the follow up visits. Among patients with follow ups, therapy escalations were found in 31.11% patients, among whom dose was increased in 12.44% and drug was added in 17.28%. Apart from Hb1Ac, FBS, and PPBS levels (p<0.001), characteristics such as age, BMI, duration of diagnosed diabetes, presence of hypertension and dyslipidemia, and daily pill burdens were found to be significantly higher in the therapy escalation group (p<0.05). Inadequate medication adherence increased the relative risk (RR) of therapy escalation by almost two times.

CONCLUSIONS

Disease and therapy patterns are reflective of diabetes care as expected at a tertiary care center. Higher BMI, age, pill burden, duration of diabetes, presence of comorbidities, and poor medication adherence may be the predictors of therapy escalation independent of glycemic control and such patients should be more closely monitored.

Antidiabetic and Other Therapies Used in Subjects with Diabetes and Chronic Kidney Disease in a Hospital-Based Clinic Population in Greece

(1) Background: Type 2 diabetes mellitus (T2DM) is the main cause of chronic kidney disease (CKD). In Greece, in a population from hospital-based diabetes clinics (n = 1759), the overall prevalence of diabetic chronic kidney disease (DCKD) was 45% including mild, moderate, and severe CKD. The aim of this study was to describe and analyze how T2DM patients with mild-to-severe CKD are managed by diabetologists in Greece and assess the achievement rates in glycemic, blood pressure and low-density lipoprotein-cholesterol (LDL-C) control. (2) Methods: This cross-sectional multicenter study took place from June 2015 to March 2016 and collected data from diabetes centers in public hospitals all over Greece. (3) Results: With regard to the anti-diabetes treatment, most participants were on metformin, DPP-4 (Dipeptidyl Peptidase-4 inhibitors) inhibitors and insulin. Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were the most prescribed medications for hypertension. For the management of dyslipidemia, most participants were on statins. For patients with DCKD, the levels of HbA1c, blood pressure and LDL-C were 7.2%, 137.7/76.9 mmHg and 95.9 mg/dL, respectively (mean values). (4) Conclusions: The outcomes of this study suggest that management of DCKD can be further improved and should be enhanced. These results may contribute to the whole health care system in Greece. In addition, the better understanding of therapeutic strategies used by diabetologists treating these patients offers educational benefits to primary care physicians, which can result in an overall more successful and efficient management of subjects with T2DM and DCKD.

Long-term trends in the prescription of antidiabetic drugs: real-world evidence from the Diabetes Registry Tyrol 2012-2018

INTRODUCTION

Prescription patterns of antidiabetic drugs in the period from 2012 to 2018 were investigated based on the Diabetes Registry Tyrol. To validate the findings, we compared the numbers with trends of different national registries conducted in a comparable period of time.

RESEARCH DESIGN AND METHODS

Medication data, prescription patterns, age groups, antidiabetic therapies and quality parameters (hemoglobin A1c, body mass index, complications) of 10 875 patients with type 2 diabetes from 2012 to 2018 were retrospectively assessed and descriptively analyzed. The changes were assessed using a time series analysis with linear regression and prescription trends were plotted over time.

RESULTS

Sodium/glucose cotransporter 2 inhibitors (SGLT-2i) showed a significant increase in prescription from 2012 to 2018 (p<0.001), as well as metformin (p=0.002), gliptins (p=0.013) and glucagon-like peptide-1 agonists (GLP-1a) (p=0.017). Significant reduction in sulfonylurea prescriptions (p<0.001) was observed. Metformin was the most frequently prescribed antidiabetic drug (51.3%), followed by insulin/analogs (34.6%), gliptins (28.2%), SGLT-2i (11.7%), sulfonylurea (9.1%), glitazones (3.7%), GLP-1a (2.8%) and glucosidase inhibitors (0.4%).

CONCLUSIONS

In this long-term, real-world study on prescription changes in the Diabetes Registry Tyrol, we observed significant increase in SGLT-2i, metformin, gliptins and GLP-1a prescriptions. In contrast prescriptions for sulfonylureas declined significantly. Changes were consistent over the years 2012-2018. Changes in prescription patterns occurred even before the publication of international and national guidelines. Thus, physicians change their prescription practice not only based on published guidelines, but even earlier on publication of cardiovascular outcome trials.

Antidiabetic Therapy and Rate of Severe Hypoglycaemia in Patients with Type 2 Diabetes and Chronic Kidney Disease of Different Stages - A Follow-up Analysis of Health Insurance Data from Germany

BACKGROUND

The presence of chronic kidney disease (CKD) influences the type of antiglycaemic therapy and the risk for hypoglycaemia.

METHODS

In 2006, 2011 and 2016 health insurance data of people with diabetes type 2 were screened for CKD and the presence of severe hypoglycaemia (sHypo). The type of antihyperglycaemic therapy was recorded due to Anatomical Therapeutic Chemical (ATC) codes up to 3 months before suffering sHypo.

RESULTS

The prevalence of CKD increased from 5.3% in 2006 to 7.3% in 2011 and 11.2% in 2016. Insulin-based therapies were used in 39.0, 39.1, and 37.9% of patients with, but only in 17.7, 17.4, and 18.8% of patients without CKD. Although the proportion of the CKD stages 1, 2 and 5 decreased, CKD stages 3 and 4 increased. The proportion of sHypo in CKD declined from 2006 (3.5%) to 2011 (3.0%) and 2016 (2.2%) but was still more than 10 times higher as compared to type 2 diabetic patients without CKD (0.3/0.2/0.2%) conferring a significantly higher probability of sHypo (OR 9.30, 95%CI 9.07-9.54) in CKD. The probability of sHypo was significantly lower in 2016 than in 2006 both in patients with (OR 0.58; CI 0.55-0.61) and without CKD (OR 0.70; CI 0.68-0.73).

CONCLUSION

The prevalence of CKD increased from 2006 to 2016. Patients with CKD exhibited a 9-fold increased probability of sHypo, especially in patients treated with insulin plus oral anti-diabetic drugs. However, the rate and risk for sHypo decreased over time, probably as a consequence of new antidiabetic treatment options, better awareness of sHypo, and changed therapy goals.

Trends in global prescribing of antidiabetic medicines in primary care: A systematic review of literature between 2000-2018

The aim of this review was to examine changes in the use of diabetes medicines prescribed to treat type 2 diabetes in the primary care setting. Five electronic databases were searched using strict inclusion/exclusion criteria. The quality of eligible studies was appraised using the Newcastle-Ottawa Scale. Findings show the trend has been away from using sulfonylurea and towards the use of metformin. The introduction of newer drugs has not shifted treatment outcomes and glycaemic control. It was not possible to determine how clinicians make choices about the medicines they prescribe for T2DM, or what influences those choices.

A Greek registry of current type 2 diabetes management, aiming to determine core clinical approaches, patterns and strategies

BACKGROUND

To analyze data in terms of the glycaemic control and therapeutic regimens used for Type-2 Diabetes Mellitus (T2DM) management in Greece, identify factors that influence clinical decisions and determine the level of compliance of T2DM management with the latest international and local guidelines.

METHODS

'AGREEMENT' was a national-multicenter, non-interventional, cross-sectional disease registry. A total of 1191 adult T2DM patients were enrolled consecutively from 59 sites of the National Health System (NHS) or University Hospitals, representing the majority of Diabetes centers or Diabetes outpatient clinics in Greece with a broad geographic distribution. Patients were stratified by gender and analysis was done according to 3 treatment strategies: A (lifestyle changes or use of one oral antidiabetic agent), B (up to 3 antidiabetic agents including injectables but not insulin) and C (any regimens with insulin).

RESULTS

Mean (±SD) HbA1c % of the total population was 7.1 (±1.2) while mean (±SD) FPG (mg/dl) was measured at 136 (±42). The proportion of patients who achieved HbA1c < 7% was 53% and ranged from 74.2% for group A, to 60.6% for group B and 35.5% for group C. Median age of the studied population was 65.0 year old (Interquartile Range-IQR 14.0) with an equal distribution of genders between groups. Patients on insulin therapy (treatment strategy C) were older (median age: 67 years vs 63 or 65 for A and B, respectively) with longer diabetes duration (mean duration: 15.3 years vs 5.2 and 10.1 for A and B, respectively). Patients who received insulin presented poor compliance. There was a consensus for a series of decision criteria and factors that potentially influence clinical decisions, used by physicians for selection of the therapeutic strategy among the three groups. Compliance with international and Greek guidelines received a high score among groups A, B and C. No significant differences were presented as per sites' geographic areas, NHS or University centers and physicians' specialty (endocrinologists, diabetologists and internists).

CONCLUSIONS

The presented findings suggest the need for improvement of the glycaemic control rate, especially among insulin treated patients as this group seems to achieve low glycaemic control, by setting appropriate HbA1c targets along with timely and individualised intensification of treatment as well as post-therapy evaluation of the compliance with the proposed treatment.

The Status of Metabolic Control in Patients With Type 2 Diabetes Attending Dasman Diabetes Institute, Kuwait

Purpose: To evaluate metabolic control in patients with type 2 diabetes at Dasman Diabetes Institute (DDI, Kuwait), a specialist diabetes clinic and research center, and to investigate its association with patient demographics and clinical characteristics. Methods: Data from 963 patients with type 2 diabetes were retrospectively collected from the Knowledge Based Health Records maintained at DDI for patients who attended DDI during 2011-2014. The collected data included patient demographics, clinical characteristics, and anti-diabetic medications. Student's t-test was used to evaluate the differences in mean values between poor and good glycemic control groups. Categorical variables were assessed using chi-square analysis with Fisher's exact test for small data sets. Results: The patients' mean age was 53.0 ± 9.5 years with equal number of males and females. Females (34.4 ± 7.2 kg/m²) had a higher mean body mass index than males (32.1 ± 6.4 kg/m²). The mean fasting blood glucose and HbA1c levels were 9.6 ± 3.8 mmol/L and 8.5 ± 1.8%, respectively. Dyslipidemia (46%) and hypertension (40%) were the most common comorbidities, whereas nephropathy (36%) and neuropathy (35%) were the most common diabetic complications. The most commonly used anti-diabetic medication was metformin (55%). Factors significantly associated with poor glycemic control (HbA1c level ≥ 7%) included insulin use; neuropathy or foot ulcers as diabetic complications; and elevated systolic blood pressure and total cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, and fasting blood glucose levels. Factors significantly associated with good glycemic control included metformin use and elevated high-density lipoprotein cholesterol level. The proportion of patients with good glycemic control (HbA1c level < 7%) was 29.5%. A large proportion of the patients with poor glycemic control were only administered monotherapy drugs, and two-thirds of the patients were obese. Further, the American Diabetes Association (ADA) recommendations for blood pressure and LDL cholesterol level were met (62 and 63%, respectively) by follow-up year 4. Conclusion: The therapeutic management of type 2 diabetes in Kuwait is suboptimal. Therapeutic strategies should ensure better adherence to ADA guidelines, evaluate the high obesity rates, and adherence to lifestyle recommendations by patients, and continually promote diabetes education and self-empowerment.

Effects of metformin exposure on neurodegenerative diseases in elderly patients with type 2 diabetes mellitus

Epidemiological evidence reveals that patients with type 2 diabetes mellitus (T2DM) have an increased risk of neurodegenerative diseases (NDs), including dementia and Parkinson's disease (PD). The effects of metformin exposure on dementia and PD risk in patients with T2DM are unknown. We evaluated the effects of metformin exposure on the risk of dementia and PD in patients with T2DM. We performed a cohort study by using Taiwan's National Health Insurance Research Database. We recruited 4651 patients in the metformin cohort and a comparable number of nonmetformin controls by using propensity score matching. Multivariate Cox proportional hazards regression was used to estimate the effects of metformin on the risk of dementia and PD after adjustment for several confounding factors. During the 12-year follow-up, the metformin cohort exhibited a higher risk of PD than the nonmetformin cohort (hazard ratio [HR]: 2.27, 95% confidence interval [CI]=1.68-3.07). The metformin cohort had an increased risk of all-cause dementia (HR: 1.66, 95% CI=1.35-2.04). Moreover, metformin exposure increased the risk of Alzheimer's disease (HR: 2.13, 95% CI=1.20-3.79) and vascular dementia (HR: 2.30, 95% CI=1.25-4.22). The effects of exposure duration and dosage on dementia and PD occurrence were also observed. Long-term metformin exposure in patients with T2DM may lead to the development of NDs, including dementia and PD. Additional large-scale, prospective controlled trials are required to confirm the observed association in patients with T2DM.

Metformin Safety Warnings and Diabetes Drug Prescribing Patterns for Older Nursing Home Residents

OBJECTIVE

Diabetes mellitus is common in US nursing homes (NHs), and the mainstay treatment, metformin, has US Food and Drug Administration (FDA) boxed warnings indicating safety concerns in those with advanced age, heart failure, or renal disease. Little is known about treatment selection in this setting, especially for metformin. We quantified the determinants of initiating sulfonylureas over metformin with the aim of understanding the impact of FDA-labeled boxed warnings in older NH residents.

DESIGN AND SETTING

National retrospective cohort in US NHs.

PARTICIPANTS

Long-stay NH residents age ≥65 years who initiated metformin or sulfonylurea monotherapy following a period of ≥6 months with no glucose-lowering treatment use between 2008 and 2010 (n = 7295).

MEASUREMENTS

Measures of patient characteristics were obtained from linked national Minimum Data Set assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare claims. Odds ratios (ORs) comparing patient characteristics and treatment initiation were estimated using univariable and multivariable multilevel logistic regression models with NH random intercepts.

RESULTS

Of the 7295 residents in the study population, 3066 (42%) initiated metformin and 4229 (58%) initiated a sulfonylurea. In multivariable analysis, several factors were associated with sulfonylurea initiation over metformin initiation, including heart failure (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.1-1.4) and renal disease (OR 2.1, 95% CI 1.7-2.5). Compared with those aged 65 to <75 years, residents 75 to <85 (OR 1.3, 95% CI 1.2-1.5), 85 to <95 (OR 2.0, 95% CI 1.7-2.3), and ≥95 (OR 4.3, 95% CI 3.2-5.8) years were more likely to initiate sulfonylureas over metformin.

CONCLUSIONS

In response to FDA warnings, providers initiated NH residents on a drug class with a known, common adverse event (hypoglycemia with sulfonylureas) over one with tenuous evidence of a rare adverse event (lactic acidosis with metformin).

Drug-class-specific changes in the volume and cost of antidiabetic medications in Poland between 2012 and 2015

Aim

to investigate the drug-class-specific changes in the volume and cost of antidiabetic medications in Poland in 2012–2015.

Methods

This retrospective analysis was conducted based on the National Health Fund database covering an entire Polish population. The volume of antidiabetic medications is reported according to ATC/DDD methodology, costs—in current international dollars, based on purchasing power parity.

Results

During a 4-year observational period the number of patients, consumption of antidiabetic drugs and costs increased by 17%, 21% and 20%, respectively. Biguanides are the basic diabetes medication with a 39% market share. The insulin market is still dominated by human insulins, new antidiabetics (incretins, thiazolidinediones) are practically absent. Insulins had the largest share in diabetes medications expenditures (67% in 2015). The increase in antidiabetic medications costs over the analysed period of time was mainly caused by the increased use of insulin analogues.

Conclusions

The observed tendencies correspond to the evidence-based HTA recommendations. The reimbursement status, the ratio of cost to clinical outcomes and data on the long-term safety have a deciding impact on how a drug is used.

Glycaemic control and antidiabetic therapy in patients with diabetes mellitus and chronic kidney disease - cross-sectional data from the German Chronic Kidney Disease (GCKD) cohort

Background

Diabetes mellitus (DM) is the leading cause of end-stage renal disease. Little is known about practice patterns of anti-diabetic therapy in the presence of chronic kidney disease (CKD) and correlates with glycaemic control. We therefore aimed to analyze current antidiabetic treatment and correlates of metabolic control in a large contemporary prospective cohort of patients with diabetes and CKD.

Methods

The German Chronic Kidney Disease (GCKD) study enrolled 5217 patients aged 18–74 years with an estimated glomerular filtration rate (eGFR) between 30–60 mL/min/1.73 m² or proteinuria >0.5 g/d. The use of diet prescription, oral anti-diabetic medication, and insulin was assessed at baseline. HbA1c, measured centrally, was the main outcome measure.

Results

At baseline, DM was present in 1842 patients (35 %) and the median HbA1C was 7.0 % (25^th–75^th percentile: 6.8–7.9 %), equalling 53 mmol/mol (51, 63); 24.2 % of patients received dietary treatment only, 25.5 % oral antidiabetic drugs but not insulin, 8.4 % oral antidiabetic drugs with insulin, and 41.8 % insulin alone. Metformin was used by 18.8 %. Factors associated with an HbA1C level >7.0 % (53 mmol/mol) were higher BMI (OR = 1.04 per increase of 1 kg/m², 95 % CI 1.02–1.06), hemoglobin (OR = 1.11 per increase of 1 g/dL, 95 % CI 1.04–1.18), treatment with insulin alone (OR = 5.63, 95 % CI 4.26–7.45) or in combination with oral antidiabetic agents (OR = 4.23, 95 % CI 2.77–6.46) but not monotherapy with metformin, DPP-4 inhibitors, or glinides.

Conclusions

Within the GCKD cohort of patients with CKD stage 3 or overt proteinuria, antidiabetic treatment patterns were highly variable with a remarkably high proportion of more than 50 % receiving insulin-based therapies. Metabolic control was overall satisfactory, but insulin use was associated with higher HbA1C levels.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-016-0273-z) contains supplementary material, which is available to authorized users.

A multicenter, epidemiological study of the treatment patterns, comorbidities and hypoglycemia events of patients with type 2 diabetes and moderate or severe chronic kidney disease - the 'LEARN' study

Objective Management of patients with type 2 diabetes (T2DM) and stage 3 to 5 chronic kidney disease (CKD) is challenging. The aim of the 'LEARN' study was to describe treatment patterns employed in this population and to record comorbidities, glycemic control and hypoglycemia episodes in routine clinical practice in Greece. Research design and methods 'LEARN' was a non-interventional, multicenter, cross-sectional study conducted in Greece between 15 February 2013 and 4 July 2013. A total of 120 adult patients were enrolled from four hospital sites in different geographic regions of Greece. Results Participants had a mean age of 69.1 ± 10.3 years and a male:female ratio of 2:1. Nearly all patients (99.2%) suffered from at least one comorbidity, with hypertension (95.8%) and hyperlipidemia/dyslipidemia (78.3%) being the most prevalent. Of the overall study population, 57.5% was managed with insulin therapy only, 30.8% with oral antidiabetics only and 11.7% with a combination of insulin and oral antidiabetics. The overall rate of glycemic control, defined as glycated hemoglobin (HbA1c) ≤ 7.0% during the most recent assessment, was 55.0%. This rate was significantly higher among those receiving oral antidiabetics only (73.0%) compared to insulin only (47.8%) or a combination of both types of treatment (42.9%) (p = 0.03). Moreover, patients receiving oral antidiabetics only had experienced fewer hypoglycemia episodes over the last 7 days prior to the study visit (0.1 ± 0.4) compared to patients receiving insulin only (0.9 ± 1.7) (p = 0.03). Conclusions Although this is an observational study, it seems that oral antidiabetic therapy might be advantageous for heavily burdened T2DM patients with moderate or severe CKD in terms of glycemic control and hypoglycemia episodes. More data preferably from randomized trials is needed in order to validate this hypothesis.

Trends in incidence, prevalence and prescribing in type 2 diabetes mellitus between 2000 and 2013 in primary care: a retrospective cohort study

OBJECTIVE

To investigate trends in incident and prevalent diagnoses of type 2 diabetes mellitus (T2DM) and its pharmacological treatment between 2000 and 2013.

DESIGN

Analysis of longitudinal electronic health records in The Health Improvement Network (THIN) primary care database.

SETTING

UK primary care.

PARTICIPANTS

In total, we examined 8,838,031 individuals aged 0-99 years.

OUTCOME MEASURES

The incidence and prevalence of T2DM between 2000 and 2013, and the effect of age, sex and social deprivation on these measures were examined. Changes in prescribing patterns of antidiabetic therapy between 2000 and 2013 were also investigated.

RESULTS

Overall, 406,344 individuals had a diagnosis of T2DM, of which 203,639 were newly diagnosed between 2000 and 2013. The incidence of T2DM rose from 3.69 per 1000 person-years at risk (PYAR) (95% CI 3.58 to 3.81) in 2000 to 3.99 per 1000 PYAR (95% CI 3.90 to 4.08) in 2013 among men; and from 3.06 per 1000 PYAR (95% CI 2.95 to 3.17) to 3.73 per 1000 PYAR (95% CI 3.65 to 3.82) among women. Prevalence of T2DM more than doubled from 2.39% (95% CI 2.37 to 2.41) in 2000 to 5.32% (95% CI 5.30 to 5.34) in 2013. Being male, older, and from a more socially deprived area was strongly associated with having T2DM, (p<0.001). Prescribing changes over time reflected emerging clinical guidance and novel treatments. In 2013, metformin prescribing peaked at 83.6% (95% CI 83.4% to 83.8%), while sulfonylureas prescribing reached a low of 41.4% (95% CI 41.1% to 41.7%). Both remained, however, the most commonly used pharmacological treatments as first-line agents and add-on therapy. Thiazolidinediones and incretin based therapies (gliptins and GLP-1 analogues) were also prescribed as alternate add-on therapy options, however were rarely used for first-line treatment in T2DM.

CONCLUSIONS

Prevalent cases of T2DM more than doubled between 2000 and 2013, while the number of incident cases increased more steadily. Changes in prescribing patterns observed may reflect the impact of national policies and prescribing guidelines on UK primary care.

Evaluation, intervention, and follow-up of patients with diabetes in a primary health care setting in Brazil: the importance of a specialized mobile consultancy

BACKGROUND

Studies show that educational interventions improve glycemic control in patients with diabetes mellitus (DM), reducing the occurrence of complications associated with the disease.

OBJECTIVES

To evaluate the effects of a mobile DM consultancy on clinical and laboratory parameters, disease knowledge, and quality of life in patients with type 2 DM (T2DM) at a primary health care network in Brazil.

METHODS

Randomized clinical trial conducted in a city in southern Brazil with 52 patients with T2DM receiving care at a primary health care setting. The intervention lasted for 6 months and consisted of a follow-up with an endocrinologist (five meetings), treatment adjustment based on clinical evaluation and laboratory tests, and educational activities with conversation maps in DM. The statistical analysis included comparison and association tests, considering p values ≤0.05 as statistically significant.

RESULTS

The mean age of the patients was 63.8 years. Most participants were female (63.5 %), had low educational level (59.6 %) and family history of T2DM (71.2 %), used only oral hypoglycemic agents to manage their DM (73.2 %), presented unfavorable anthropometric and laboratory parameters, a high or medium risk of complications (84.6 %), and inadequate glycemic control (67.3 %; with 71 % of the high-risk patients presenting a HbA1c level >9 %). Adjustment in pharmacological treatment was required in 63.5 % of the patients. After the intervention, we observed a significant 0.46 % decrease in mean HbA1c level (p = 0.0218), particularly among individuals with inadequate glycemic control (0.71 %; p = 0.0136). Additionally, there was an increase in disease knowledge scores and a significant decrease in mean body mass index, waist circumference, and disease impact scores.

CONCLUSION

The intervention improved glycemic control and disease knowledge, reduced the values of body mass index and waist circumference, and the impact of the disease on patients' lives. This indicates that care and educational measures improve the experience of the patients with DM and control of the disease.

Distinct HbA1c trajectories in a type 2 diabetes cohort

AIMS

The aim of this study was to identify subgroups of type 2 diabetes mellitus patients with distinct hemoglobin A1c (HbA1c) trajectories. Subgroup characteristics were determined and the prevalence of microvascular complications over time was investigated.

STUDY DESIGN AND SETTING

Data from a cohort of 5,423 type 2 diabetes patients from a managed primary care system were used [mean follow-up 5.7 years (range 2-9 years)]. Latent class growth modeling was used to identify subgroups of patients with distinct HbA1c trajectories. Multinomial logistic regression analyses were conducted to determine which characteristics were associated with different classes.

RESULTS

Four subgroups were identified. The first and largest subgroup (83 %) maintained good glycemic control over time (HbA1c ≤53 mmol/mol), the second subgroup (8 %) initially showed severe hyperglycemia, but reached the recommended HbA1c target within 2 years. Patients within this subgroup had significantly higher baseline HbA1c levels but were otherwise similar to the good glycemic control group. The third subgroup (5 %) showed hyperglycemia and a delayed response without reaching the recommended HbA1c target. The fourth subgroup (3.0 %) showed deteriorating hyperglycemia over time. Patients within the last two subgroups were significantly younger, had higher HbA1c levels and a longer diabetes duration at baseline. These subgroups also showed a higher prevalence of retinopathy and microalbuminuria.

CONCLUSION

Four subgroups with distinct HbA1c trajectories were identified. More than 90 % reached and maintained good glycemic control (subgroup one and two). Patients within the two subgroups that showed a more unfavorable course of glycemic control were younger, had higher HbA1c levels and a longer diabetes duration at baseline.

Prescribing pattern and efficacy of anti-diabetic drugs in maintaining optimal glycemic levels in diabetic patients

CONTEXT

Despite the availability of efficacious anti-diabetic drugs, which act by different mechanisms to reduce the blood-glucose, the majority of people with diabetes on anti-diabetic drug therapy, have poor glycemic control and diabetic vascular complications.

AIM AND OBJECTIVES

The aim was to study the prescribing pattern and efficacy of anti-diabetic drugs in maintaining optimal glycemic levels in diabetic patients attending tertiary care teaching hospital in Navi Mumbai.

MATERIALS AND METHODS

A prospective, cross-sectional, observational survey was carried out in 100 patients of diabetes mellitus attending diabetes outpatient/medicine outpatient departments, to assess their prescribing pattern of anti-diabetic drugs, and their blood-glucose level was measured by Accu-Chek Active glucometer to determine their glycemic control.

RESULTS

Average number of anti-diabetic drugs per prescription was 1.4. Sulfonylureas were the most commonly prescribed class, but metformin (biguanide) was the commonest prescribed individual drug among oral hypoglycemic agents (OHA). Fixed dose combination of biguanide and sulfonylurea was prescribed commonly. Monotherapy dominated over polytherapy and there was a higher percentage of use of insulin in Type 2 diabetics. Only 41% of patients on anti-diabetic therapy had optimal glycemic control. The association between anti-diabetic therapy along with lifestyle modification and glycemic control was statistically significant (P = 0.0011).

CONCLUSIONS

OHAs still dominate the prescribing pattern, but there was a shifting trend toward the use of insulin preparations in the management of Type 2 diabetes mellitus. In achieving optimal glycemic control, the efficacy of the anti-diabetic drugs was only 41%; therefore intensification of current drug treatment as well as planning multiple drug interventions with lifestyle modification is necessary.

Glycemic control among patients with type 2 diabetes at a primary health care center in Oman

AIMS

To determine the status of blood sugar control by using fasting blood sugar (FBS) of ≤6.1 mmol/l and glycosyted hemoglobin A1c (HbAc1) of <7% as indictors of glycemic control and to assess the influence of demographic, blood pressure (BP) and lipid characteristics on glycemic control.

METHODS

This retrospective study included all Omani patients with type 2 diabetes (N=177) attended a primary health care center in Al-Dakhiliya region, Oman.

RESULTS

The overall mean age of the cohort was 53±12 years (range: 24-91) with females representing 60% (n=106) of the study sample. The study found that only 9.6% (n=17) and 35% (n=62) of the patients attained optimal FBS and HbAc1 levels, respectively. Higher HbA1c was significantly associated with higher diastolic BP (84 versus 80 mm Hg; p=0.006), higher total cholesterol (5.2 versus 4.7 mmol/l; p=0.002) and higher low-density lipoprotein cholesterol (3.8 versus 3.0 mmol/l; p=0.034).

CONCLUSIONS

The results demonstrated poor glycemic control in Oman type 2 diabetic patients comparable to local and global studies especially in those hypertensive and dyslipidemic patients. Implementation of early and aggressive management of diabetes mellitus at the primary care setting is warranted.

Risk factors for periprosthetic joint infection after total hip arthroplasty and total knee arthroplasty in Chinese patients

Purpose

The purpose of this hospital-based case–control study was to evaluate the risk factors for periprosthetic joint infection (PJI) of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Chinese patients.

Method

From January 2000 to December 2012, 45 patients undergoing THA and TKA who developed PJI were recruited for case subjects; controls were 252 without PJI, matched by year of index for surgery and type of surgery. Conditional logistic regressions were run to compute odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Demographic factors and comorbid conditions associated with an increased adjusted risk of PJI (in decreasing order of significance) were diabetes (OR = 5.47, 95% CI: 1.77–16.97; p = 0.003), age (65–75 vs. 45–65 years) (OR = 3.36, 95% CI: 1.30–8.69; p = 0.013), BMI (≥28 vs. 18.5–28 kg/m²) (OR = 2.77, 95% CI: 1.20–6.40; p = 0.017), place of residence (rural) (OR = 2.63, 95% CI: 1.13–6.10; p = 0.025) and alcohol abuse (OR = 2.95, 95% CI: 1.06–8.23; p = 0.039).

Conclusion

Patients with diabetes, older age, BMI of ≥28 kg/m² and alcohol abuse or living in rural areas, had increased PJI risk. Additional systematic large-scale studies are needed to verify these results.

Sex differences in cardiovascular outcomes, pharmacological treatments and indicators of care in patients with newly diagnosed diabetes: Analyses on administrative database

BACKGROUND

The impact of diabetes on cardiovascular disease in both sexes is known, but the specifics have not been fully clarified. We investigated whether sex-related differences exist in terms of management and hospitalization in patients with newly diagnosed diabetes.

METHODS

We examined the rates of hospitalization for cardiovascular causes, mortality, treatments and management of patients with diabetes compared to subjects without, from administrative database. Interaction between sex and diabetes on clinical outcomes were calculated using a Cox regression model. Pharmacological treatments and recommended examinations by sex were calculated using logistic regression.

RESULTS

From 2002 to 2006, 158,426 patients with diabetes and 314,115 subjects without were identified and followed up for a mean of 33 months (± 17.5). Diabetes confers a higher risk for all clinical outcomes. Females with diabetes have a risk profile for hospitalization for coronary heart disease comparable to males without (4.6% and 5.3%). Interaction between sex and diabetes shows that females with diabetes had an added 19% higher risk of total death (95% CI 1.13-1.24). No differences were observed in hospitalizations, although females with diabetes were less likely to undergo revascularization after myocardial infarction. Females received cardiovascular prevention drugs less frequently than males and had a slight tendency to get fewer examinations.

CONCLUSION

Diabetes is linked to a higher increase of mortality in females relative to males. This might reflect sex differences in the use of revascularization procedures or therapeutic regimens. Closer attention and implementation of standard care for females are necessary from the onset of diabetes.

Influence of chronic comorbidity and medication on the efficacy of treatment in patients with diabetes in general practice

BACKGROUND

Evidence on the influence of comorbidity and comedication on clinical outcomes in patients with type 2 diabetes mellitus is scarce.

AIM

To ascertain the effect of five chronic diseases (joint disorder, respiratory disease, anaemia, malignancy, depression) and three chronically used drugs (non-steroid anti-inflammatory drugs [NSAIDs], corticosteroids, antidepressants) on treatment for hypoglycaemia in patients with type 2 diabetes.

DESIGN AND SETTING

Retrospective cohort study in a variety of practices across Flanders, Belgium.

METHOD

A retrospective cohort study was conducted, based on data from Intego, a general practice-based continuous morbidity registry. Multiple logistic regression analysis was used to predict the change in glycosylated haemoglobin (HbA1c) levels related to comorbidity, comedication, and a combination of both in 3416 patients with type 2 diabetes. Adjustments were made for age, sex, and diabetes-treatment group (diet, oral antidiabetic drugs, combination treatment, insulin).

RESULTS

Concomitant joint and respiratory disorders, as well as the chronic use of NSAIDs and corticosteroids, either separately or in combination, were significantly associated with the worsening of HbA1c levels. Anaemia, depression, malignancy, and antidepressants had no statistically significant influence on the efficacy of treatment for hypoglycaemia.

CONCLUSION

The presence of some comorbid diseases or drug use can impede the efficacy of treatment for type 2 diabetes. This finding supports the need to develop treatment recommendations, taking into account the presence of both chronic comorbidity and comedication. Further research must be undertaken to ascertain the effect other combinations of chronic diseases have on the efficacy of treatment of this and other diseases.

Prescribing pattern of glucose lowering drugs in the United Kingdom in the last decade: a focus on the effects of safety warnings about rosiglitazone

AIM

In the last decade, new glucose lowering drugs (GLDs) have been launched, and also several warnings regarding their safety. The cardiovascular safety of thiazolidinediones (TZD) has been questioned. We analyzed the prescription pattern of GLDs from 2000 to November 2009 in the United Kingdom (UK) using the THIN database with special focus on the effects of the safety warnings about rosiglitazone issued in May 2007 and January 2008.

METHODS

Annual prevalence and incidence of GLD prescriptions were measured. For TZD, the monthly prevalence and incidence of prescription were calculated from May 2006 to January 2009. The switching pattern around the FDA alert and the characteristics of subjects starting treatment with TZD before and after the alerts were observed.

RESULTS

The prevalence of prescriptions of GLDs increased during the 10 year period, metformin increasing more than three times. Rosiglitazone prevalence showed an increased trend until May 2007, (2.3/1000 person-years) and decreased thereafter (January 2009: 1.1/1000 person-years). The use of pioglitazone increased surpassing rosiglitazone from April 2008 onwards. The incidence of rosiglitazone use decreased sharply after May 2007 (0.8/1000 person-years). The prevalence of use of other therapies remained rather stable from 2000 to 2007 but increased afterwards. After May 2007, rosiglitazone users were increasingly switched to pioglitazone. There was an increased proportion of new users of pioglitazone with cardiovascular risk after the alerts.

CONCLUSIONS

The prescription of GLDs in the UK has increased in the last decade. For TZDs, it changed after May 2007 as well as the characteristics of the subjects treated with them.

Type 2 diabetes in East Asians: similarities and differences with populations in Europe and the United States

There is an epidemic of diabetes in Asia. Type 2 diabetes develops in East Asian patients at a lower mean body mass index (BMI) compared with those of European descent. At any given BMI, East Asians have a greater amount of body fat and a tendency to visceral adiposity. In Asian patients, diabetes develops at a younger age and is characterized by early β cell dysfunction in the setting of insulin resistance, with many requiring early insulin treatment. The increasing proportion of young-onset and childhood type 2 diabetes is posing a particular threat, with these patients being at increased risk of developing diabetic complications. East Asian patients with type 2 diabetes have a higher risk of developing renal complications than Europeans and, with regard to cardiovascular complications, a predisposition for developing strokes. In addition to cardiovascular-renal disease, cancer is emerging as the other main cause of mortality. While more research is needed to explain these interethnic differences, urgent and concerted actions are needed to raise awareness, facilitate early diagnosis, and encourage preventive strategies to combat these growing disease burdens.

National trends in anti-diabetic treatment in Taiwan, 2000-2009

BACKGROUND/PURPOSE

The impact of the introduction of newer anti-diabetic agents on the treatment pattern in the booming diabetic population remains unclear. We examined the patterns and temporal trends of anti-diabetic drug use in Taiwan, with particular emphasis on combination therapy.

METHODS

We searched the Taiwan National Health Insurance Database during 2000-2009 to identify outpatient prescriptions of anti-diabetic drugs, including human insulins and insulin analogues, sulfonylureas, glinides, metformin, thiazolidinediones, alpha-glucosidase inhibitors, and dipeptidyl peptidase-4 inhibitors. Glucose-lowering treatments were classified according to pattern (oral agents only, insulins only, and oral agents and insulins combined) and a number of different classes of anti-diabetic drugs. Insulin therapy and combination therapy with two oral anti-diabetic drugs (OAD) were further classified according to individual drug combination patterns.

RESULTS

Although metformin remained the mainstay of anti-diabetic treatment, patients receiving combination therapy of oral glucose-lowering agents, either with or without insulin, significantly increased, from approximately 40% in 2000 to 60% in 2009, particularly in relation to the newer agents, including glinides, alpha-glucosidase inhibitors, and long-acting insulin analogues. Use of sulfonylureas and thiazolidinediones decreased substantially. For insulin therapy, the most commonly prescribed drugs were premix insulin analogues and basal insulin analogues, accounting for one-third of total insulin prescriptions in 2009.

CONCLUSION

We found an increasing complexity of anti-diabetic therapy during the past decade in Taiwan. Further studies are needed to evaluate whether this treatment pattern will lead to improved clinical outcomes in terms of cost-effectiveness.

Glucose-lowering treatment and clinical results in 163 121 patients with type 2 diabetes: an observational study from the Swedish national diabetes register

AIMS

To analyse clinical characteristics and treatment results in unselected type 2 diabetes mellitus (T2DM) patients, with non-pharmacological treatment as well as the most commonly used pharmacological glucose-lowering treatment regimens, in everyday clinical practice.

METHODS

In this population-based cross-sectional study, information was linked from the Swedish National Diabetes Register, Prescribed Drug Register and Patient Register. T2DM patients with non-pharmacological treatment and T2DM patients continuously using the 12 most common pharmacological treatment regimens were included in the study (n = 163121).

RESULTS

There were statistically significant differences in clinical characteristics between the groups. Patients with insulin-based treatment regimens had the longest duration of diabetes and more cardiovascular risk factors than the T2DM-population in general. The proportion of patients reaching HbA1c ≤ 7% varied between 70.1% (metformin) and 25.0% [premixed insulin (PMI) + SU) in patients with pharmacological treatment. 84.8% of the patients with non-pharmacological treatment reached target. Compared to patients on metformin, patients on other pharmacological treatments had a lower likelihood, with hazard ratios ranging from 0.58; 95% confidence interval (CI), 0.54-0.63 to 0.97;0.94-0.99, of having HbA1c ≤ 7% (adjusted for covariates). Patients on insulin-based treatments had the lowest likelihood, while non-pharmacological treatment was associated with an increased likelihood of having HbA1c ≤ 7%.

CONCLUSION

This nation-wide study shows insufficiently reached treatment goals for haemoglobin A1c (HbA1c) in all treatment groups. Patients on insulin-based treatment regimens had the longest duration of diabetes, more cardiovascular risk factors and the highest proportions of patients not reaching HbA1c target.

Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis

BACKGROUND

Diabetes and obesity are common in patients undergoing joint replacement. Studies analyzing the effects of diabetes and obesity on the occurrence of periprosthetic joint infection have yielded contradictory results, and the combined effects of these conditions are not known.

METHODS

The one-year incidence of periprosthetic joint infections was analyzed in a single-center series of 7181 primary hip and knee replacements (unilateral and simultaneous bilateral) performed between 2002 and 2008 to treat osteoarthritis. The data regarding periprosthetic joint infection (defined according to Centers for Disease Control and Prevention criteria) were collected from the hospital infection register and were based on prospective, active surveillance. Patients diagnosed with diabetes were identified from the registers of the Social Insurance Institution of Finland. The odds ratios (ORs) for infection and the accompanying 95% confidence intervals (CIs) were calculated with use of binary logistic regression with adjustment for age, sex, American Society of Anesthesiologists risk score, arthroplasty site, body mass index, and diabetic status.

RESULTS

Fifty-two periprosthetic joint infections occurred during the first postoperative year (0.72%; 95% CI, 0.55% to 0.95%). The infection rate increased from 0.37% (95% CI, 0.15% to 0.96%) in patients with a normal body mass index to 4.66% (95% CI, 2.47% to 8.62%) in the morbidly obese group (adjusted OR, 6.4; 95% CI, 1.7 to 24.6). Diabetes more than doubled the periprosthetic joint infection risk independent of obesity (adjusted OR, 2.3; 95% CI, 1.1 to 4.7). The infection rate was highest in morbidly obese patients with diabetes; this group contained fifty-one patients and periprosthetic infection developed in five (9.8%; 95% CI, 4.26% to 20.98%). In patients without a diagnosis of diabetes at the time of the surgery, there was a trend toward a higher infection rate in association with a preoperative glucose level of ≥6.9 mmol/L (124 mg/dL) compared with &lt;6.9 mmol/L. The infection rate was 1.15% (95% CI, 0.56% to 2.35%) in the former group compared with 0.28% (95% CI, 0.15% to 0.53%) in the latter, and the adjusted OR was 3.3 (95% CI, 0.96 to 11.0). The type of diabetes medication was not associated with the infection rate.

CONCLUSIONS

Diabetes and morbid obesity increased the risk of periprosthetic joint infection following primary hip and knee replacement. The benefits of joint replacement should be carefully weighed against the incidence of postoperative infection, especially in morbidly obese patients.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Prescription patterns for diabetes mellitus and therapeutic implications: a population-based analysis

OBJECTIVE

To analyze drug prescriptions for insulin and oral antidiabetic drugs in type 1 and type 2 diabetes mellitus patients seen in the Brazilian Public Healthcare System (Unified Health System - SUS) in Ribeirao Preto, SP, Brazil.

SUBJECTS AND METHODS

All the patients with diabetes seen in the SUS in the western district of Ribeirao Preto, SP, Brazil between March/2006 and February/2007 were included in the study.

RESULTS

A total of 3,982 patients were identified. Mean age of the patients was 60.6 years, and 61.0% were females. Sixty percent of the patients were treated with monotherapy. Doses of oral antidiabetic drugs were lower in monotherapy than in polytherapy. Ten patients received doses of glibenclamide or metformin above the recommended maximum doses, and in elderly patients there was no reduction in drug doses.

CONCLUSION

Monotherapy with oral antidiabetic drugs was the predominant procedure, and the doses were not individualized according to age.

Time to treatment initiation with oral antihyperglycaemic therapy in US patients with newly diagnosed type 2 diabetes

AIM

To compare the time from initial diagnosis to initiation with oral antihyperglycaemic treatment in younger versus older patients with type 2 diabetes, and to evaluate factors associated with initiating treatment.

METHODS

This was a retrospective US cohort study with a 2-year follow-up period after diagnosis of type 2 diabetes. Using the General Electric Healthcare's Clinical Data Services electronic medical record database, eligible patients included those aged ≥30 years at initial diagnosis of type 2 diabetes between January 2003 and December 2005. In the 2-year period following diagnosis, the time to the first prescription of an oral antihyperglycaemic agent was compared between younger (30-64 years) and older (≥65 years) patients. Factors associated with time to treatment with an oral antihyperglycaemic agent were examined using Cox proportional hazards regression.

RESULTS

Of the 10 743 patients with newly diagnosed type 2 diabetes, 43% were ≥65 years old. The mean age at diagnosis was 73 years for older patients and 52 years for younger patients. Compared to younger patients, a greater proportion of older patients had a baseline haemoglobin A1c (HbA1c) value <7% (38 vs. 32%; p < 0.001). In the 2-year follow-up period, a significantly greater proportion of younger patients (59%) received oral antihyperglycaemic treatment compared to older patients (44%; p < 0.001). The median time between diagnosis and initiating treatment with an oral antihyperglycaemic agent was 350 days for younger patients and >2 years for older patients. After adjusting for covariates, older patients had a greater risk of not receiving treatment with oral antihyperglycaemic therapy than younger patients [adjusted hazard ratio = 0.82 (95% confidence interval: 0.75, 0.90)].

CONCLUSIONS

In patients with newly diagnosed type 2 diabetes, the time to initiation of oral antihyperglycaemic therapy was significantly longer in older patients (≥65 years old) than younger patients (<65 years).

Reasons given by general practitioners for non-treatment decisions in younger and older patients with newly diagnosed type 2 diabetes mellitus in the United Kingdom: a survey study

BACKGROUND

Older patients with newly diagnosed type 2 diabetes mellitus are less likely to receive antihyperglycaemic therapy compared to their younger counterparts. The purpose of this study was to assess the reasons of general practitioners (GPs) for not treating younger and older patients with newly diagnosed type 2 diabetes mellitus with antihyperglycaemic agents.

METHODS

In a survey conducted between November 2009 and January 2010, 358 GPs from the United Kingdom selected reasons for not initiating antihyperglycaemic therapy in younger (< 65 years) and older (≥65 years) patients with newly diagnosed type 2 diabetes mellitus and untreated with any antihyperglycaemic agent for at least six months following diagnosis. Thirty-six potential reasons were classified into four major categories: Mild hyperglycaemia, Factors related to antihyperglycaemic agents, Comorbidities and polypharmacy, and Patient-related reasons. Reasons for non-treatment were compared between younger (n = 1, 023) and older (n = 1, 005) patients.

RESULTS

Non-treatment reasons related to Mild hyperglycaemia were selected more often by GPs for both younger (88%) and older (86%) patients than those in other categories. For older patients, Factors related to antihyperglycaemic agents (46% vs. 38%) and Comorbidities and polypharmacy (33% vs. 19%), both including safety-related issues, were selected significantly (p < 0.001) more often by GPs. No between-group difference was observed for the Patient-related reasons category. The GP-reported HbA1c threshold for initiating antihyperglycaemic therapy was significantly (p < 0.001) lower for younger patients (mean ± standard deviation: 7.3% ± 0.7) compared to older patients (7.5% ± 0.9).

CONCLUSIONS

GPs selected reasons related to Mild hyperglycaemia for non-treatment of their untreated patients with newly diagnosed type 2 diabetes mellitus, despite nearly one-third of these patients having their most recent HbA1c value ≥7%. The findings further suggest that safety-related issues may influence the non-treatment of older patients with type 2 diabetes mellitus.

Trends in drug prescriptions to diabetic patients from 2000 to 2008 in Italy's Lombardy Region: a large population-based study

OBJECTIVE

To analyze the prescribing patterns of antidiabetic and cardiovascular medications among diabetics in the most highly populated Italian Region, from 2000 to 2008.

METHODS

Data were obtained from the Lombardy Region administrative health databases. The standardized prevalence of antidiabetic and cardiovascular drugs use was calculated within each study year. The prescription trends of initial treatment with antidiabetic drugs were also analyzed.

RESULTS

From 2000 to 2008 there was an increase in the proportion of patients treated with biguanides (from 53.4% to 66.5%; p<0.0001) while those receiving sulfonylurea decreased (from 78.6% to 56.4%; p<0.0001). A sharp increase of metformin (as monotherapy) as initial treatment was also observed (from 15.2% to 48.8%; p<0.0001). The percentage of patients receiving renin-angiotensin system inhibitors, lipid-lowering drugs and antiplatelets increased between 2000 and 2008, from respectively 45.1% to 63.3%, 13.6% to 43.2% and 21.6% to 40.9 (p<0.0001). Multivariate analyses indicated that changes in prescriptions were statistically significant for both antidiabetic and cardiovascular drugs.

CONCLUSION

This study documents progressive changes in the prescription of antidiabetic and cardiovascular drugs in accordance with guidelines. However, the use of metformin as first line therapy was still suboptimal and cardiovascular preventive strategies were only partially implemented in community practice.

The status of glycemic control: A cross-sectional study of outpatients with type 2 diabetes mellitus across primary, secondary, and tertiary hospitals in the Jiangsu province of China

OBJECTIVES

The aims of the study were to determine the following: the status of glycemic control in patients with type 2 diabetes mellitus (DM) at primary, secondary, and tertiary hospitals in the Jiangsu province of China; and the factors associated with achieving glycemic targets.

METHODS

This study, in which patients were enrolled from July 20 to 31, 2009, at 56 diabetes centers, used a multiple-stage, stratified sampling method to select a representative sample of the population with DM in Jiangsu. The sampling process was stratified by geographic and demographic regions, and by the outpatient numbers in the hospitals. A primary hospital was defined as a community medical institution that provided primary health services; a secondary hospital was a local medical institution that provided comprehensive health services; and a tertiary hospital was a regional medical institution that provided comprehensive and specialist health services. In primary hospitals, patients with DM were treated by general physicians; at secondary and tertiary hospitals, they were seen by specialists. Also, primary and tertiary hospitals treated patients in cities, whereas secondary hospitals treated patients from towns or rural areas. Patients with a medical history of type 2 DM for >6 months and registration at each diabetes center for > or = 6 months, and who were residents of Jiangsu province, were recruited. During the patient enrollment visit, information about DM complications and comorbidities, as well as DM management, was obtained by retrospectively reviewing medical records; basic patient data (eg, date of birth, sex, weight, height) were obtained by patient interview. Blood samples were collected for assessment of glycosylated hemoglobin (HbA1c) at a central laboratory.

RESULTS

Of 3046 sampled subjects, the analysis was performed in 2966 subjects with complete data. The mean (SD) HbA1c value for analyzed patients was 7.2% (1.6%). The proportion of patients with tight glycemic control was 40.2% (1193/2966) when a threshold of HbA1c <6.5% was used, and 56.1% (1665/2966) when a threshold of HbA1c <7.0% was used. Compared with patients who had inadequate glycemic control, those with tight control were younger (P < 0.001), had shorter duration of DM (P < 0.001), had lower body mass index (BMI) (P = 0.005 for HbA1c <6.5% and P = 0.01 for HbA1c <7.0%), had more education (P < 0.001) and income (P = 0.003 for HbA1c <6.5% and P = 0.008 for HbA1c <7.0%), were more likely to monitor their glucose (P = NS for HbA1c <6.5% and P = 0.043 for HbA1c <7.0%) and attend DM education (P = 0.027 for HbA1c <6.5% and P = 0.002 for HbA1c <7.0%) at least once a month, and were more likely to receive oral antidiabetic drugs (OADs) (P < 0.001). Age, BMI, and DM duration did not differ significantly between hospital types. Compared with primary (36.2%) and secondary hospitals (36.5%), tertiary hospitals (42.2%) had more patients with HbA1c <6.5% (P = 0.043); tertiary hospitals also had more patients with once-monthly glucose self-monitoring (P = 0.001), patients with higher income (P < 0.001) and education (P < 0.001), and those who were more likely to use > or = 2 OADs or insulin with OADs (P < 0.001).

CONCLUSION

The overall status of glycemic control was unsatisfactory during the study period, although patients at tertiary hospitals appeared to have better control than those at primary or secondary hospitals.

Clinical analysis of elderly patients with elderly-onset type 2 diabetes mellitus in China: assessment of appropriate therapy

Patients with elderly-onset diabetes have specific characteristics. This study was designed to investigate these characteristics and to evaluate methods for appropriate control of glycaemia and cardiovascular risk factors in elderly-onset diabetes patients. A total of 155 elderly patients with type 2 diabetes mellitus were divided into those diagnosed at >or= 65 years of age (elderly-onset group, 75 patients) and those diagnosed at < 60 years of age (usual-onset group, 80 patients). Differences in clinical variables, diabetic complications, diagnosed comorbidities and the use of medications were analysed. Mean glycosylated haemoglobin, fasting plasma glucose and fasting insulin levels were significantly lower in the elderly-onset group than in the usual-onset group. The usual-onset group showed significantly greater homeostasis model assessment insulin resistance than the elderly-onset group. Microvascular complications and insulin use were significantly more common in the usual-onset group. In conclusion, insulin resistance was less severe in elderly-onset diabetes than in usual-onset diabetes. As hyperglycaemia was relatively mild or moderate, oral hypoglycaemic agents might be effective for elderly-onset diabetes.

Monitoring modifiable cardiovascular risk in type 2 diabetes care in general practice: the use of an aggregated z-score

BACKGROUND

Because many patients in usual care reach the diabetes treatment goals, it may be more efficacious to focus quality improvement efforts on those general practice populations requiring additional support. We therefore developed a tool based on a composite end point considering blood pressure, lipids, and glycaemia.

METHODS

We created an aggregated z(A)-score, calculated as the average of 3 z-scores testing whether the mean practice values of hemoglobin A1c, low density lipoprotein cholesterol, and systolic blood pressure are significantly higher than the corresponding ADA-target (respectively 7%, 100 mg/dL, and 130 mm Hg). This score was used with 100 general practitioners who participated in a Quality Improvement Program. We defined the cut-off value (COV) to determine "Practices Requiring Support" (z(A) <COV) using a receiver's operating characteristics curve with the mean practice CHD risk as gold standard. To further test the z-score validity, we calculated the correlation coefficient between the z-score and the mean practice CHD risk and the improvement in the z-score after the Quality Improvement Program.

RESULTS

The COV was -1.22 and was valid to discriminate between practices at higher risk from practices at lower CHD risk (24% +/- 4% vs. 19% +/- 4%). The correlation coefficient was -0.515 (P = 0.001). The average z-score increased from -1.21 +/- 0.97 at baseline to 0.49 +/- 1.01 after the intervention (P < 0.001).

CONCLUSION

This scoring system is useful to picture practice populations with diabetes who are at high cardiovascular risk because of modifiable risk factors. Although the unadjusted z-score cannot be used to compare physicians, this technique can be used to evaluate improvement efforts over time.

Baseline characteristic differences between patients prescribed sitagliptin vs. other oral antihyperglycemic agents: analysis of a US electronic medical record database

AIMS

This study examined the relationship of baseline characteristics and medication use in patients with type 2 diabetes who were prescribed sitagliptin versus other oral antihyperglycemic agents in clinical practice settings in the United States.

METHODS

The General Electric Healthcare's Clinical Data Services electronic medical record (EMR) database, covering 12 million US patients of all ages from 49 states, was used to identify patients with type 2 diabetes, aged >or=30 years, who received their first sitagliptin, metformin, sulfonylurea, or thiazolidinedione prescription between October 2006 and June 2008 (index period) as part of new mono-, dual, or triple therapy regimens. Patient demographics, diagnoses, prescriptions, and laboratory results were extracted for the 12-month period (baseline) prior to the index date (i.e., date of first prescription). Data were stratified by mono-, dual, or triple therapy and compared between sitagliptin regimens and non-sitagliptin regimens with other oral agents (metformin, sulfonylureas, or thiazolidinediones). Adjusted logistic regression analyses were used to estimate odds ratios (OR) associated with prescribing sitagliptin versus other oral monotherapy in relation to patient baseline characteristics.

RESULTS

Among 41,836 patients new to oral monotherapy, 876 (2.1%) received sitagliptin. Compared to patients initiating non-sitagliptin monotherapy, patients on sitagliptin monotherapy were older (64 vs. 60 years) and had lower body mass index (33 kg/m(2) vs. 34 kg/m(2)), higher serum creatinine (1.2 vs. 1.0 mg/dL), higher prevalence of chronic renal disease (7.2% vs. 1.9%), greater use of lipid-lowering agents (42% vs. 38%), and higher prevalence of cardiovascular conditions (CVD: 12.7% vs. 8.3%) and microvascular complications (MVD: 13.4% vs. 5.8%) (all p < 0.05). Of 22,683 patients new to dual therapy, 1885 (8.3%) were on sitagliptin regimens. Relative to patients on non-sitagliptin dual therapy regimens, patients prescribed sitagliptin as part of dual therapy regimens were older and had higher serum creatinine, higher prevalence of CVD, MVD, or chronic renal disease, and greater use of lipid-lowering and antihypertensive agents (all p < 0.05). Among 9967 patients new to triple therapy, 2828 (28.4%) were on triple therapy regimens with sitagliptin. Relative to patients on non-sitagliptin triple therapy regimens, patients on sitagliptin as part of triple therapy regimens were older, and had higher serum creatinine and greater use of antihypertensive or lipid-lowering agents (all p < 0.05). Adjusted logistic regression showed that significant predictors of being prescribed sitagliptin monotherapy were older age (OR 1.01, 95% CI 1.00, 1.02), higher HbA(1c) level (OR 1.10, 95% CI 1.04, 1.17), higher serum creatinine level (OR 1.22, 95% CI 1.08, 1.39), presence of MVD (OR 1.50, 95% CI 1.08, 2.09), and presence of chronic renal disease (OR 2.22, 95% CI 1.41, 3.49).

LIMITATIONS

Diabetes care delivered by non-participating physicians is not captured in the GE CDS EMR database and, therefore, the prevalence of the diseases identified based on ICD-9 diagnosis/procedure and CPT codes provided in the Appendix may be underestimated. Duration of diabetes was not consistently recorded and some measures were not available.

CONCLUSION

Patients with type 2 diabetes who were prescribed sitagliptin regimens in clinical practice were older and more likely to have pre-existing co-morbid conditions compared to patients receiving non-sitagliptin regimens with other common oral antihyperglycemic agents. These findings have important implications for observational studies in that estimated clinical and health outcome measures may be biased due to channeling of patients to different therapies based on different baseline characteristics.

Present status of sulfonylurea treatment for type 2 diabetes in Japan: second report of a cross-sectional survey of 15,652 patients

Sulfonylureas are commonly used for the treatment of patients with type 2 diabetes mellitus (T2DM). However, some clinical concerns regarding their use have grown over the past decade. Thus, results of a previous Japan-wide cross-sectional survey of patients with type 2 diabetes mellitus (T2DM) were analyzed to determine the present status and problems associated with the use of sulfonylureas in the treatment of T2DM by general practitioners (GPs) and diabetes specialists. Of 15,652 patients across 721 clinics and hospitals from the previous survey, 15,350 were diagnosed as T2DM (14,312 by GPs and 1,038 by specialists). For each patient, data were collected for HbA1c levels, age, height, body weight, and treatment modality. Of T2DM patients being treated by GPs, 35.4% and 60.0% received sulfonylureas in entire oral drugs or as monotherapy, respectively, compared with 29.2% and 61.2% of patients, respectively, treated by specialists. Of the patients treated with sulfonylurea monotherapy, 1335 patients (35.2%) achieved HbA1c <6.5%, whereas HbA1c was >or=8.0% in 531 patients (14.0%). Patients with HbA1c levels >or=8.0% had a higher body mass index, used glibenclamide more frequently, and used higher doses of sulfonylureas than patients in whom HbA1c levels were <6.5%. In conclusion, the present study shows that sulfonylureas are central in the treatment of T2DM in Japan. However, careful consideration of suitable patients, agents, and doses is necessary to achieve appropriate glycemic control.

Diabetes in Japan: a review of disease burden and approaches to treatment

In recent years there has been rapid growth in diabetes in Japan which now is one of the nations most affected by the worldwide diabetes epidemic. Diabetes has been identified as a healthcare priority by the Ministry of Health, Labour and Welfare (MHLW). Type 1 diabetes is rare in Japan, and type 2 diabetes predominates in both adults and children. The growth in diabetes is due to increases in the number of people with type 2 diabetes associated with increased longevity and lifestyle changes. Approximately 13.5% of the Japanese population now has either type 2 diabetes or impaired glucose tolerance. This high prevalence of type 2 diabetes is associated with a significant economic burden, with diabetes accounting for up to 6% of the total healthcare budget. The costs of diabetes are increased in patients with co-morbidities such as hypertension and hyperlipidaemia and in patients who develop complications, of which retinopathy has the highest cost. Costs increase with increasing number of complications. Current guidelines from the Japan Diabetes Society (JDS) recommend a target HbA(1c) of 6.5% for glycaemic control. This is achieved in approximately one third of patients with type 2 diabetes, and Japanese patients typically have lower HbA(1c) than patients in Western countries (e.g. US, UK). Japanese patients with type 2 diabetes have better adherence with diet and exercise recommendations than their peers in Western countries. Sulfonylureas have been the most widely prescribed first-line treatment for type 2 diabetes, although there is increasing use of combination therapy and of insulin.

Controle glicêmico de pacientes diabéticos tipo 2 nos serviços público e privado de Saúde

OBJETIVO: Comparar o tratamento de pacientes diabéticos tipo 2 provenientes de uma clínica privada aos pacientes atendidos no sistema público de Saúde. MÉTODOS: Foi desenhado um estudo de coorte retrospectivo, incluindo 80 pacientes atendidos no Ambulatório Central da Universidade de Caxias do Sul (AMCE), vinculado ao Sistema Único de Saúde, e 277 pacientes atendidos em uma clínica privada, que foram consultados nestes serviços no período entre maio de 2001 e outubro de 2007. RESULTADOS: Os pacientes atendidos no AMCE mostraram pior controle metabólico, embora somente os valores de A1c e colesterol total tenham alcançado significância estatística. Ambos os grupos apresentaram melhora de quase todos os parâmetros metabólicos. O uso de insulina no final do acompanhamento (B = 4,66; IC95% = 2,18 - 9,89; p < 0,001) e a A1c inicial (B = 1,42; IC95% = 1,16 - 1,74; p = 0,001) foram determinantes de pior controle glicêmico. A frequência de consultas foi determinante de melhor controle (B = 0,72; IC95% = 0,55 - 0,93; p = 0,01). CONCLUSÕES: As variáveis como a A1c inicial e a frequência de consultas, que podem ser consideradas como indicadores do acesso dos pacientes ao sistema de saúde, têm maior impacto no controle do diabetes do que o local no qual os pacientes são tratados.

Cost-effectiveness of pioglitazone in type 2 diabetes patients with a history of macrovascular disease: a German perspective

BACKGROUND

The aim of this study was to project health-economic outcomes relevant to the German setting for the addition of pioglitazone to existing treatment regimens in patients with type 2 diabetes, evidence of macrovascular disease and at high risk of cardiovascular events.

METHODS

Event rates corresponding to macrovascular outcomes from the Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROactive) study of pioglitazone were used with a modified version of the CORE Diabetes Model to simulate outcomes over a 35-year time horizon. Direct medical costs were accounted from a healthcare payer perspective in year 2005 values. Germany specific costs were applied for patient treatment, hospitalization and management. Both costs and clinical benefits were discounted at 5.0% per annum.

RESULTS

Over patient lifetimes pioglitazone treatment improved undiscounted life expectancy by 0.406 years and improved quality-adjusted life expectancy by 0.120 quality-adjusted life years (QALYs) compared to placebo. Direct medical costs (treatment plus complication costs) were marginally higher for pioglitazone treatment and calculation of the incremental cost-effectiveness ratio (ICER) produced a value of euro13,294 per QALY gained with the pioglitazone regimen versus placebo. Acceptability curve analysis showed that there was a 78.2% likelihood that pioglitazone would be considered cost-effective in Germany, using a "good value for money" threshold of euro50,000 per QALY gained. Sensitivity analyses showed that the results were most sensitive to changes in the simulation time horizon. After adjustment for the potential stabilization of pancreatic beta-cell function with pioglitazone treatment, the ICER was euro6,667 per QALY gained for pioglitazone versus placebo.

CONCLUSION

The findings of this modelling analysis indicated that, for patients with a history of macrovascular disease, addition of pioglitazone to existing therapy reduces the long-term cumulative incidence of diabetes-complications at a cost that would be considered to represent good value for money in the German setting.

Insulin therapy in type 2 diabetes is no longer a secondary care activity in the Netherlands

AIM

Because Dutch health care organisations did want to establish well-defined diabetes shared care groups, we investigated the organisation of insulin therapy in general practice in the Netherlands and assessed factors that were associated with providing insulin therapy in type 2 diabetes (DM2) patients.

METHODS

Questionnaire to half of the Dutch general practitioners (GPs) (n=3848). We compared GPs who both start insulin treatment and monitor the dosages with those who always refer patients requiring insulin therapy or only monitor insulin dosages.

RESULTS

Total response was 42% (n=1621). 67% of the GPs start insulin therapy in patients with DM2, especially male GPs and those above the age of 40, as well as GPs working in a health centre and those working together with a practice nurse. GPs working in urban regions less often start insulin. The most often mentioned barriers for starting and/or monitoring insulin therapy are lack of knowledge of insulin therapy, lack of time and insufficient financial incentives.

CONCLUSION

This nation-wide overview shows that insulin therapy is no longer a secondary care based activity. However, there is still need to enlarge the practice staff and to overcome the perceived skills deficit.

Drug evaluation: vildagliptin-metformin single-tablet combination

The single-tablet combination of vildagliptin and metformin addresses key defects of type 2 diabetes for improved glycemic control. By inhibiting the dipeptidyl peptidase-4 (DPP-4) enzyme, vildagliptin raises the levels of the active incretin hormones, glucagon-like peptide 1 and glucose-dependent insulinotropic peptide. This leads to increased synthesis and release of insulin from the pancreatic beta cells and decreased release of glucagon from the pancreatic alpha cells. The combination tablet also contains metformin, which addresses insulin resistance. The complementary mechanisms of action of the two agents in combination have been shown to provide additive and sustained reductions in hemoglobin A(1c) compared with metformin monotherapy. In active-controlled trials, the vildagliptin-metformin combination has been shown to produce equivalent reductions in hemoglobin A(1c) to pioglitazone-metformin and glimepiride-metformin combinations, without significant risk of hypoglycemia and without causing weight gain. In clinical trials, the overall incidence of any adverse event was similar in patients randomized to vildagliptin plus metformin and placebo plus metformin. Available data support the use of vildagliptin in combination with metformin as a promising second-line treatment for the management of type 2 diabetes and this is reflected in the latest UK National Institute for Health and Clinical Excellence draft guideline for consultation on new agents for blood glucose control in type 2 diabetes.

Antiemetic medications in children with presumed infectious gastroenteritis--pharmacoepidemiology in Europe and Northern America

OBJECTIVE

To investigate the prescription pattern of antiemetic medications in 0- to 9-year-old children with infectious gastroenteritis in several industrialized countries during 2005.

STUDY DESIGN

We retrospectively retrieved data from 4 national and international databases (IMS MIDAS, IMS disease analyzer, WIdO databases).

RESULTS

Between 2% and 23% of children with gastroenteritis (International Classification of Diseases code A08.X or A09) received prescriptions for antiemetic medications (United States, 23%; 95% CI, 15-31; Germany, 17%; 95% CI, 15-20; France, 17%; 95% CI, 14-19; Spain, 15%; 95% CI, 10-19; Italy, 11%; 95% CI, 7-16; Canada, 3%; 95% CI, 0-16; United Kingdom, 2%; 95% CI, 1-2). The antihistamines dimenhydrinate and diphenhydramine were most frequently used in Germany and Canada, whereas promethazine was prescribed preferentially in the United States. In France, Spain, and Italy, the dopamine receptor antagonist domperidone was preferred as antiemetic treatment. Ondansetron was used in a minor proportion of antiemetic prescriptions (Germany, Canada, Spain, and Italy, 0%; United States, 3%; United Kingdom, 6%).

CONCLUSION

Antiemetic drugs are frequently used in children with gastroenteritis. In different industrialized countries, prescription of antiemetic medication varies considerably. Ondansetron, the only drug with evidence-based antiemetic efficacy, plays a minor role among antiemetic prescriptions.

Evaluating the cost-effectiveness of therapy conversion to insulin detemir in patients with type 2 diabetes in Germany: a modelling study of long-term clinical and cost outcomes

OBJECTIVES

To evaluate the long-term cost-effectiveness of transferring type 2 diabetes patients to an insulin detemir regimen after failure to achieve adequate control with oral antidiabetic agents (OADs) alone, or in combination with neutral protamine hagedorn (NPH) insulin, or with insulin glargine in Germany.

METHODS

A computer simulation model of diabetes was used to make long-term projections of future clinical outcomes and direct medical costs based on findings from a German subanalysis of the PREDICTIVE trial. The study analysed the impact of converting patients failing their current treatments to an insulin detemir regimen. Therapy conversion to insulin detemir +/- OADs was associated with a significant reduction in glycosylated haemoglobin (HbA(1)c) compared with OADs alone, NPH insulin +/- OADs, and insulin glargine +/- OADs. Across all three groups, hypoglycaemia rates decreased by 80% and patients lost an average of 0.9 kg of body weight during treatment with insulin detemir +/- OADs.

RESULTS

Therapy conversion to insulin detemir +/- OADs was projected to improve life expectancy by 0.28 years compared with OADs alone, and by 0.13 years compared with the NPH and glargine regimens. Transfer to insulin detemir was associated with improvements in quality-adjusted life expectancy of 0.21 quality-adjusted life years (QALYs) over OADs alone, 0.28 QALYs over NPH +/- OADs, and 0.29 QALYs over glargine +/- OADs. Insulin detemir was associated with savings over patient lifetimes due to reduced diabetes-related complications in all three comparisons.

CONCLUSIONS

Therapy conversion to insulin detemir +/- OADs in type 2 diabetes patients failing OADs alone, NPH or insulin glargine regimens was associated with improvements in life expectancy, quality-adjusted life expectancy and cost savings in all three scenarios evaluated.