Association of Weight Loss and Medication Adherence Among Adults With Type 2 Diabetes Mellitus: SHIELD (Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes)

Factors associated with adherence or nonadherence to insulin therapy among adults with type 2 diabetes mellitus: A scoping review

BACKGROUND AND AIM

One of the greatest barriers to the treatment of T2DM is nonadherence which particularly applies to insulin therapy. There is a need for a comprehensive overview of all factors associated with nonadherence to insulin therapy. The aim of this study was to identify factors associated with adherence or nonadherence to insulin therapy among adults with T2DM.

METHODS

A scoping review was conducted in accordance with the PRISMA 2020 statement. A systematic search was performed in PubMed, Cinahl, and Web of Science (January 2013 to March 2023).

RESULTS

A final sample of 48 studies was included in the scoping review. The synthesis revealed 30 factors associated with adherence or nonadherence. The factors were grouped into 6 themes: demographics, attitude and perceptions, management of diabetes, impact on daily living, disease and medication, and healthcare system.

CONCLUSION

The most prominent factors identified were age, cost of healthcare, personal beliefs towards insulin therapy, social stigma, patient education, complexity of diabetes treatment, impact of insulin therapy on daily life, and fear of side effects. The results indicate a need for further research to determine threshold values for the factors associated with adherence or nonadherence.

Effect of Pharmacist-Led Interventions on Medication Adherence and Glycemic Control in Type 2 Diabetic Patients: A Study from the Chinese Population

PURPOSE

Medication adherence plays an important role in glycemic control in type 2 diabetes mellitus (T2DM) self-management. To analyze the factors influencing medication adherence in T2DM patients and the effect of pharmacist-led interventions, we conducted a study in Beijing, China.

PATIENTS AND METHODS

T2DM patients with hypoglycemic drugs for at least 6 months were enrolled. A pharmacist-led survey was conducted followed by individualized interventions for those non-adherent patients monthly within 3 months. FPG, HbA1c, and 2hPG were measured as the comprehensive glycemic control. Medication adherence was determined according to the patient's self-reported compliance with prescribed medication during the last 3 months.

RESULTS

A total of 763 T2DM patients were included. The average age was 63.26±11.89 years, with 363 males. After pharmacist intervention, the patients with good adherence increased from 34.21% to 39.06%, while poor adherence decreased from 32.5% to 24.5% (p < 0.001). The average adherence score was a significant increase (p < 0.001) from 27.846±4.185 to 29.831±7.065. Furthermore, our study demonstrated that pharmacist-led interventions significantly increased glycemic control (FPG from 42.33% to 53.60%, p < 0.001; 2hPG from 41.68% to 48.75%, p = 0.005; HbA1c from 24.12% to 29.23%, p = 0.024). The results found that body mass index (OR 0.643, 95% CI 0.437-0.945), use of medications empirically (occasionally (OR=3.066, 95% CI 2.069-4.543); often (OR=2.984, 95% CI 1.107-8.044)), following the doctor's advice to visit (OR 2.129, 95% CI 1.079-4.202) and lifestyle compliance (OR 2.835, 95% CI 1.094-7.346) were the independent risk factors of non-adherence (p < 0.05), the area under the ROC curve was 0.716.

CONCLUSION

Self-reported medication adherence and glycemic control in T2DM patients were poor which can be improved by pharmacist-led interventions. Interventions should focus on empirical medication behavior, non-adherence to lifestyle, and failure to follow the doctor's advice. The recall bias with self-reported results needs further objective data to verify.

Treatment-Related Attributes of Diabetes Therapies and How People with Type 2 Diabetes Report Their Impact on Indicators of Medication-Taking Behaviors

Purpose

Understanding the treatment-related attributes influencing medication-taking behaviors in people with type 2 diabetes (T2D) is important for delivery of patient-centered care. This review aimed to identify and summarize studies in which people with T2D (PwD) directly indicated the treatment-related attributes associated with medication-taking behaviors or intentions.

Materials and Methods

EMBASE and PubMed were searched for studies (Jan 2005-May 2021) reporting the link between PwD-expressed diabetes treatment-related attributes and the decision to initiate, adhere to, or discontinue a T2D medication. Eligible studies reported attributes associated with oral antidiabetes drugs or injectables (not insulin). Studies not explicitly exploring the link between attributes and indicators of behaviors (eg most discrete-choice experiments [DCE] and those interrogating electronic medical records or claims databases) were excluded, as were studies where the link between attribute and behavior came from anyone but the PwD.

Results

Of the 6464 studies identified, 16 were included. Studies were conducted across multiple countries; the USA was most represented (n = 8 studies). The impact of treatment attributes was described on indicators of initiation (n = 3), adherence (n = 12), and discontinuation (n = 4). Some studies evaluated multiple behaviors. PwD perspectives were solicited by structured questionnaires (n = 10), qualitative approaches (n = 4), or DCE explicitly exploring the link to medication-taking behaviors (n = 2). Closed- (n = 9) and open-ended questions (n = 7) were employed. Across studies, several factors including glycemic efficacy (n = 9), weight change (n = 9), dosing frequency (n = 9), hypoglycemia (n = 8), gastrointestinal adverse events (n = 8), regimen complexity (n = 6), route of administration (n = 3), and cardiovascular risk (n = 1) were reported as influencing behaviors, being motivators or barriers to initiation, adherence, or discontinuation.

Conclusion

Several attributes influence how PwD take their medications. Insights gained directly from PwD have the potential to assist stakeholders in making more informed, patient-centered, treatment decisions, thus choosing and managing medications that PwD are comfortable initiating and persisting with over the longer term.

Weight Change and the Association with Adherence and Persistence to Diabetes Therapy: A Narrative Review

PURPOSE

Type 2 diabetes (T2D) medication adherence is poor and is impacted by individual drug characteristics. Treatment-associated weight change can affect medication-taking behavior. This review aimed to explore weight change on T2D therapy and consider its impact on adherence and discontinuation.

METHODS

Searches were conducted in MEDLINE and EMBASE (2005 to September 2020), and among recent congress abstract books for studies providing data on medication adherence or discontinuation and weight change in people with T2D (PwD).

RESULTS

Nine studies meeting the inclusion criteria were identified from 9188 bibliographic records. All three studies exploring weight change and discontinuation reported weight loss to be associated with higher persistence. Seven studies of varying design explored weight change and adherence. Four reported absolute weight change (kg) and adherence: one pooled data from different diabetes medications and demonstrated that self-reported adherence was significantly associated with weight loss; however, three studies found that weight change in adherent PwD was in the direction of the known weight profile (loss/gain) of the evaluated drug. Categorical weight loss (≥3%) and adherence were reported in two studies: one reported that numerically more adherent versus non-adherent PwD lost ≥3% weight regardless of the drug's weight profile, the other showed that early weight loss with a glucagon-like peptide-1 agonist was significantly associated with better adherence. One study reported adherence by categorical weight change; as weight loss increased, adherence scores improved, regardless of drug type.

CONCLUSION

Findings suggest that discontinuation rates may be lower in PwD who lose as compared to those who gain weight on T2D treatment. The evidence base on adherence and weight change is more challenging to interpret due to the range of study designs. Given the importance of weight control in T2D, further research exploring the individual's treatment, weight journey, and behaviors over time should be undertaken.

Barriers to Completing Therapy for Hepatitis C with Direct-Acting Antivirals: A Real-Life Experience from a Single Treatment Center in Egypt

Introduction

Interferon-based therapies against the hepatitis C virus had a poor adherence profile. On the other hand, new direct-acting antivirals (DAAs) are orally administered medications, show high efficacy against the hepatitis C virus in addition to a high safety profile. Therefore, adherence to this treatment is expected to improve. Assessment for treatment adherence is mandatory to assess the feasibility of achieving viral hepatitis elimination.

Aim

The study aims to assess the adherence rate and causes of non-adherence in Egyptian hepatitis C patients who received interferon-free treatment regimens.

Methods

Retrospective data analysis for 668 hepatitis C patient’s records from August 2014 to October 2019 was done. Assessment of treatment adherence was done by revising the records and phone calls. However, 172 patients were excluded due to the absence of contact data. Rest of patients (n = 496) was categorized into 2 groups: Adherent (n = 432) and non-adherent (n = 64). For whom comparative analysis was done.

Results

The adherent group (87%) achieved 100 % sustained virological response after 12 weeks (SVR 12). Non-adherence was reported in 12.9% of patients. Low awareness was the main cause of non-adherence (43.75%). BMI was the only significant risk factor for poor adherence (P = .04). Other Patient demographics, clinical, and laboratory data didn’t show any significant differences between both groups.

Conclusion

Interferon-free regimens are tolerable. Raising awareness is mandatory for proper treatment adherence and, subsequently, good clinical outcomes.

Adherence to Medication, Diet and Physical Activity and the Associated Factors Amongst Patients with Type 2 Diabetes

INTRODUCTION

The prevalence of type 2 diabetes mellitus (T2D) has increased considerably while the outcome of diabetic management is suboptimal. In order to promote diabetic management, associated factors for adherence to medications, diet, and physical activity (PA) need to be more clearly identified amongst patients with T2D.

METHODS

This cross-sectional study was conducted on 206 men and 294 women amongst patients with diabetes who were registered in ten special diabetic clinics in Shiraz, Iran from November 2018 to April 2019. Levels of adherence to medication, Mediterranean diet (MD), and physical activity were measured with validated and appropriate questionnaires.

RESULTS

Mean age (± SD) was 56.92 ± 0.52 years and 294 (58.8%) were female. Data showed that reduced adherence to medication, MD, and PA increased glycated hemoblobin (HbA1c). Adherence to medication among low, moderate, and high levels was 27.2%, 59.2%, and 13.6%, respectively. Associated factors such as 50-64 years of age, at least 65 years of age, overweight, obese, divorced widow, smoker, and ex-smoker had a significant influence on adherence to medication, P = 0.017, P = 0.018, P = 0.008. P = 0.045, P = 0.026, P < 0.004, and P = 0.001, respectively. In addition, adherence to MD among low, moderate, and high levels was 5.4%, 77.2%, and 17.4%, respectively. Associated factors such as 50-64 years of age, at least 65 years of age, overweight, obese, and smoker had a significant influence on adherence to MD, P = 0.011, P = 0.046, P = 0.002, P < 0.001, and P = 0.032, respectively. Furthermore, adherence to PA among low, moderate, and high levels was 21%, 68.6%, and 10.4%, respectively. Only the non-smoker factor played a significant role in PA adherence, P = 0.010.

CONCLUSION

Levels of adherence to medications, diet, and PA amongst patients with T2D are not within the acceptable range. Recognized associated factors that contribute to adherence might improve diabetes management and allow one to tailor the appropriate message to improve glycemic indices.

Effect of Weight Change on Economic Outcomes Among Persons with Type 2 Diabetes Mellitus in the United States: Beyond Glycemic Control

BACKGROUND

Previous studies report weight loss to be associated with significantly lower total health care costs among patients with type 2 diabetes mellitus (T2DM). The effect of weight change on health care costs, independent of glycemic control and after controlling for time-varying covariates among T2DM patients, remains unknown.

OBJECTIVE

To evaluate the effect of weight change, independent of glycemic control, on all-cause and T2DM-related health care resource utilization (HCRU) and costs among T2DM patients in the United States.

METHODS

A retrospective cohort study was conducted using a linked data extract composed of IQVIA's RWI Data Adjudicated Claims-US and Ambulatory Electronic Medical Record data. Adults (aged ≥ 18 years) with T2DM receiving ≥ 1 oral antidiabetic drug (OAD) medication, glucagon-like peptide-1 receptor agonist (GLP-1RA), and/or short- or long-acting insulin between January 1, 2010, and December 31, 2014 were included (the date of the first observed medical claim with a diagnosis code or medication prescription claim was the index date). Baseline characteristics were evaluated in the 6-month pre-index period. Weight loss (3%, 5%, or 7% from baseline) was evaluated over two 6-month periods (months 1-6 and 7-12) following the index date. Covariates included time-varying weight, hemoglobin A1c (A1c), costs, and HCRU within each 6-month period. Outcomes of interest (all-cause and T2DM-related HCRU and costs) were evaluated in the 6-month (months 13-18) and 12-month (months 13-24) periods following the initial 1- to 6-month and 7- to 12-month post-index periods. Structural nested mean models were used to evaluate the effect of weight change on these outcomes, independent of glycemic control.

RESULTS

1,407 patients were included (mean age = 55 years; 55% male), with a mean baseline weight of 102.2 kg (median = 99.7 kg) and a mean baseline A1c of 7.4% (median = 6.9%). In adjusted analysis, weight loss was associated with significantly lower all-cause and T2DM-related annual total health care costs. Compared with those showing no weight change, a 3%, 5%, and 7% weight loss resulted in approximately $500, $800, and $1,100 in savings, respectively, in all-cause annual total health care costs per patient in the year following the weight loss. Similarly, compared with those with no weight change, a 3%, 5%, and 7% weight loss resulted in approximately $200, $300, and $400 in savings, respectively, in T2DM-related annual total health care costs per patient in the following year. Even greater savings (up to ~$2,000 and ~$800 in all-cause and T2DM-related annual costs per patient, respectively) were experienced by those who lost weight compared with those who gained weight.

CONCLUSIONS

After accounting for glycemic control, this study found that weight loss was associated with additional significant reductions in all-cause and T2DM-related annual total health care costs. Understanding the role of weight loss in T2DM may provide useful evidence for decision makers as they evaluate therapy options for T2DM.

DISCLOSURES

This study was funded by Novo Nordisk. Dang-Tan, Smolarz, and Iyer are employees of Novo Nordisk. Karkare and DeKoven (employees of IQVIA) and Fridman (employed by AMF Consulting) were contracted by Novo Nordisk to conduct this study. Fridman also reports personal fees from Shire, GSK, and CSL Behring, outside of the submitted work. Lu, an employee of IQVIA, accessed the database and conducted the statistical analysis for this study.

The Effect of Early Response to GLP-1 RA Therapy on Long-Term Adherence and Persistence Among Type 2 Diabetes Patients in the United States

BACKGROUND

Treatment adherence and persistence are crucial to achieve glycemic control in patients with type 2 diabetes (T2D). Early response to a new therapy may lead to improved treatment adherence and associated outcomes.

OBJECTIVE

To assess the effect of early response to glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapy, as indicated by reduced hemoglobin A1c (A1c) and body weight, on long-term adherence and persistence.

METHODS

Adults aged ≥ 18 years with T2D initiated with GLP-1 RA therapy after January 1, 2010, were identified from the IBM Explorys Therapeutic Dataset. Patients were required to have health care utilization ≥ 6 months before and ≥ 18 months after the index prescription. Changes in A1c and body weight from baseline through 6 months were assessed for all patients; early response was defined by > 1% reduction in A1c and > 3% reduction in body weight within 3-6 months. Adherence (assessed as the proportion of days covered [PDC] ≥ 80%) and nonpersistence/discontinuation (indicated by a gap in therapy ≥ 60 days) over 18 months were evaluated among early responders versus nonresponders. Multivariable logistic regression was used to assess the effect of early response to GLP-1 RA therapy on adherence and discontinuation over 18 months.

RESULTS

Among 8,329 identified patients, 33.3% and 31.2% experienced early response as indicated by reductions in A1c > 1% point and in body weight > 3% from baseline, respectively. Significantly higher proportions (P < 0.001) of early responders in both reduced A1c and body weight were adherent over 18 months compared with patients without an early response (A1c: 45.0% vs. 37.1%; body weight: 43.3% vs. 38.0%). Significantly lower proportions (P < 0.001) of early responders discontinued over 18 months compared with patients without an early response (A1c: 61.4% vs. 67.9%; body weight: 61.9% vs. 67.5%). After controlling for baseline demographic and clinical characteristics including baseline weight, baseline A1c, oral antidiabetes drug use, insulin use, and the presence of comorbidity of diabetes, patients were more likely to be adherent over 18 months if they had reductions in A1c > 1% (OR = 1.59, 95% CI = 1.36-1.85) or body weight reduction > 3% (OR = 1.18, 95% CI = 1.02-1.36) at 3-6 months compared with those without an early response. Similarly, the early responders had significantly lower likelihood of discontinuation compared with those without early response (A1c > 1%; OR = 0.62, 95% CI = 0.53-0.72; body weight > 3%; OR = 0.81, 95% CI = 0.70-0.94).

CONCLUSIONS

Early response to GLP-1 RA therapy was associated with significantly increased adherence and reduced likelihood of discontinuation.

DISCLOSURES

Funding to conduct this study was provided to IBM Watson Health by Novo Nordisk A/S. The analysis was conducted independently by IBM Watson Health. Novo Nordisk A/S and IBM Watson Health collaborated on study design and interpretation of results. At the time of this study, Durden and Laing were employed by IBM Watson Health and received funding from Novo Nordisk to conduct this study. Fowler is employed by IBM Watson Health. Panton and Mocevic were employed by Novo Nordisk while this study was conducted. A portion of these results were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2018; April 23-26, 2018; Boston, MA, where it was awarded with a bronze ribbon.

Cost of achieving HbA1c and weight loss treatment targets with IDegLira vs insulin glargine U100 plus insulin aspart in the USA

Background

Compared with basal-bolus insulin therapy (insulin glargine U100 plus insulin aspart), IDegLira has been shown to be associated with similar improvements in HbA1c, with superior weight loss and reduced hypoglycemia in patients with type 2 diabetes. The present analysis evaluated the cost per patient with type 2 diabetes achieving HbA1c-focused and composite treatment targets with IDegLira and insulin glargine U100 plus insulin aspart (≤4 times daily).

Methods

The proportions of patients achieving treatment targets were obtained from the treat-to-target, non-inferiority DUAL VII study (NCT02420262). The annual cost per patient achieving target (cost of control) was analyzed from a US healthcare payer perspective. The annual cost of control was assessed for eight prespecified endpoints and four post-hoc endpoints.

Results

The number needed to treat to bring one patient to targets of HbA1c <7.0% and HbA1c ≤6.5% was similar with IDegLira and insulin glargine U100 plus insulin aspart. However, when weight gain and/or hypoglycemia were included, the number needed to treat was lower with IDegLira. IDegLira and insulin glargine U100 plus insulin aspart had similar costs of control for HbA1c <7.0%. However, cost of control values were substantially lower with IDegLira when the more stringent target of HbA1c ≤6.5% was used, and when patient-centered outcomes of hypoglycemia risk and impact on weight were included.

Conclusion

IDegLira was shown to be a cost-effective treatment vs insulin glargine U100 plus insulin aspart for patients with type 2 diabetes not achieving glycemic targets on basal insulin in the USA.

Adherence to oral glucose lowering drugs, quality of life, treatment satisfaction and illness perception: A cross-sectional study in patients with type 2 diabetes

OBJECTIVE

To evaluate treatment adherence to oral glucose lowering drugs (OGLD) and health related quality of life in Lebanese diabetics. Secondary objectives were to examine associations between treatment adherence, quality of life (QOL), treatment satisfaction and illness perception.

METHODS

This cross-sectional study, conducted in all districts of Lebanon between August 2016 and April 2017, enrolled 207 adult patients, taking any OGLD.

RESULTS

The effectiveness score (Beta = 0.55), female gender (Beta = 7.04), and the quality of life score (Beta = 0.28) would significantly increase the adherence score respectively. On another hand, the body mass index (Beta = -1.216) would significantly decrease the adherence score. Adherence was negatively and significantly associated to IPQ score (r = -0.181), effectiveness score (r = -0.504), side effects (r = -0.583), convenience (r = -0.317), global satisfaction (r = -0.428), physical health (r = -0.477), psychological health (r = -0.521), social relationships (r = -0.405) and environment (r = -0.429).

CONCLUSION

Perceived effectiveness and patient's quality of life seem to be important parameters enhancing adherence. Based on this study, planning interventions to enhance treatment adherence and improve the quality of life is crucial for all diabetic patients. Additional efforts are suggested to be made by concerned authorities to set up awareness campaigns to increase alertness on the importance of adherence to medications in diabetics.

Ideglira is Associated With Improved Short-Term Clinical Outcomes and Cost Savings Compared with Insulin Glargine U100 Plus Insulin Aspart in the U.S

OBJECTIVE

In the DUAL (Dual Action of Liraglutide and Insulin Degludec in Type 2 Diabetes) VII trial, IDegLira (a combination of insulin degludec and liraglutide) was compared with insulin glargine U100 plus insulin aspart. Both treatment approaches achieved similar glycemic control, but there were differences in hypoglycemia, changes in body weight, and injection frequency. The aim of the present analysis was to assess the short-term cost effectiveness of IDegLira versus insulin glargine U100 plus insulin aspart for treatment of patients with type 2 diabetes mellitus not meeting glycemic targets on basal insulin in the U.S.

SETTING

METHODS

A cost-utility model was developed to evaluate the clinical and economic outcomes associated with the 2 treatments over a 1-year time horizon, capturing the impact on quality of life of hypoglycemic events, body mass index, and injection frequency. Costs were captured from a healthcare payer perspective in 2017 U.S. dollars ($).

RESULTS

IDegLira was associated with improved quality of life by 0.12 quality-adjusted life years compared with insulin glargine U100 plus insulin aspart. The key drivers of this difference were reduced injection frequency and hypoglycemic events avoided. IDegLira was associated with increased annual drug costs, but this was entirely offset by reduced needle costs and reduced costs of self-monitoring of blood glucose testing. IDegLira was associated with total annual cost savings of $743 per patient.

CONCLUSION

IDegLira was found to improve quality-adjusted life expectancy and reduce costs when compared with insulin glargine U100 plus insulin aspart for treatment of patients with type 2 diabetes not achieving glycemic control on basal insulin in the U.S.

SETTING

ABBREVIATIONS

ADA = American Diabetes Association; BMI = body mass index; CI = confidence interval; DUAL = Dual Action of Liraglutide and Insulin Degludec in Type 2 Diabetes; GLP-1 = glucagon-like peptide-1; HbA1c = glycated hemoglobin; ICER = incremental cost-effectiveness ratio; IU = international units; QALY = quality-adjusted life year; SMBG = self-monitoring of blood glucose.

Back to basics with active lifestyles: exercise is more effective than metformin to reduce cardiovascular risk in older adults with type 2 diabetes

To establish the effect of three types of treatment - multicomponent exercise (MEX); the oral hypoglycaemic drug metformin (MET); combined therapy comprising exercise plus metformin (MEXMET) - on cardiovascular risk in older adults with type 2 diabetes (T2D) and with comorbidities in an early stage of the disease (HbA1c < 7.5%). A sample of 284 participants was evaluated for multifactorial cardiovascular risk at baseline and at 24-month intervention according to anthropometric and hemodynamic components, lipid profile, glycaemia and cardiorespiratory fitness (CRF). Participants underwent one of three conditions: MEX (n = 59), training in three sessions per week; MET (n = 30), using metformin 850 mg twice daily; MEXMET (n = 195), combining exercise and metformin. After the 24-month intervention MEX and MEXMET showed more positive results than MET therapy. MEX decreased body mass (BM; 4%), waist circumference (WC; 4%), body mass index (BMI; 3%), systolic blood pressure (SBP; 11%), diastolic blood pressure (DBP; 11%), triglycerides (21%), and glycaemia (12%), and increased cardiorespiratory fitness (CRF; 18%). Conversely, the MET group showed increased WC (2%), waist-to-hip ratio (WHR) (3%), and SBP (5%). Differences between MEX and MET groups presented large effect sizes for BM, WC, WHR, SBP, DBP and CRF, and moderate effect sizes for BMI and glycaemia. MEX was the most effective therapy in decreasing cardiovascular risk in the early stage of T2D in older adults with multimorbidity and attenuated the adverse effects of pharmacological therapy in MEXMET treatment.

Empagliflozin compared with glimepiride in metformin-treated patients with type 2 diabetes: 208-week data from a masked randomized controlled trial

AIM

To report results at week 208, including a 104-week masked extension, of the EMPA-REG H2H-SU trial in patients with type 2 diabetes with inadequate glycaemic control on metformin, in which empagliflozin 25 mg given for 104 weeks provided a sustained reduction in glycated haemoglobin (HbA1c) with a small but statistically significant benefit vs glimepiride, sustained reductions in weight and blood pressure, and low risk of hypoglycaemia.

RESEARCH DESIGN AND METHODS

Patients with type 2 diabetes and HbA1c 53-86 mmol/mol (7% to 10%) were randomized to empagliflozin 25 mg or glimepiride 1 to 4 mg for 104 weeks as add-on to metformin. Patients who completed the randomized treatment period could participate in a 104-week extension in which they continued the double-blind treatment allocated at randomization.

RESULTS

Of 765 and 780 patients treated with empagliflozin and glimepiride, 576 and 549 patients, respectively, entered the extension period of the study. At week 208, the adjusted mean difference in change from baseline in HbA1c with empagliflozin vs glimepiride was -1.96 mmol/mol, 95% CI -3.57, -0.35 (-0.18%, 95% CI -0.33, -0.03); P = 0.0172. Rescue therapy was given to 23% of patients on empagliflozin and 34% on glimepiride (odds ratio 0.56 [95% CI 0.45, 0.71]; P < 0.0001). Confirmed hypoglycaemic adverse events (plasma glucose ≤3.9 mmol/L and/or requiring assistance) occurred in 3% of patients on empagliflozin and 28% on glimepiride (odds ratio 0.08 [95% CI 0.05, 0.13]; P < 0.0001).

CONCLUSIONS

In patients with type 2 diabetes, empagliflozin 25 mg as add-on to metformin for 208 weeks reduced HbA1c with a significantly lower risk of hypoglycaemia and a significantly smaller proportion of patients receiving rescue therapy compared with glimepiride.

The management of type 2 diabetes with fixed-ratio combination insulin degludec/liraglutide (IDegLira) versus basal-bolus therapy (insulin glargine U100 plus insulin aspart): A short-term cost-effectiveness analysis in the UK setting

AIM

To evaluate the cost-effectiveness of IDegLira versus basal-bolus therapy (BBT) with insulin glargine U100 plus up to 4 times daily insulin aspart for the management of type 2 diabetes in the UK.

METHODS

A Microsoft Excel model was used to evaluate the cost-utility of IDegLira versus BBT over a 1-year time horizon. Clinical input data were taken from the treat-to-target DUAL VII trial, conducted in patients unable to achieve adequate glycaemic control (HbA1c <7.0%) with basal insulin, with IDegLira associated with lower rates of hypoglycaemia and reduced body mass index (BMI) in comparison with BBT, with similar HbA1c reductions. Costs (expressed in GBP) and event-related disutilities were taken from published sources. Extensive sensitivity analyses were performed.

RESULTS

IDegLira was associated with an improvement of 0.05 quality-adjusted life years (QALYs) versus BBT, due to reductions in non-severe hypoglycaemic episodes and BMI with IDegLira. Costs were higher with IDegLira by GBP 303 per patient, leading to an incremental cost-effectiveness ratio (ICER) of GBP 5924 per QALY gained for IDegLira versus BBT. ICERs remained below GBP 20 000 per QALY gained across a range of sensitivity analyses.

CONCLUSIONS

IDegLira is a cost-effective alternative to BBT with insulin glargine U100 plus insulin aspart, providing equivalent glycaemic control with a simpler treatment regimen for patients with type 2 diabetes inadequately controlled on basal insulin in the UK.

Treatment choice, medication adherence and glycemic efficacy in people with type 2 diabetes: a UK clinical practice database study

OBJECTIVE

Using primary care data obtained from the UK Clinical Practice Research Datalink, this retrospective cohort study examined the relationships between medication adherence and clinical outcomes in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data were extracted for patients treated between 2008 and 2016, and stratified by oral antihyperglycemic agent (OHA) line of therapy (mono, dual or triple therapy). Patients were monitored for up to 365 days; associations between medication possession ratio (MPR) and outcomes at 1 year (glycated hemoglobin A1c (HbA1c), weight and hypoglycemia incidence) were assessed using linear regression modeling and descriptive analyses.

RESULTS

In total, 33 849 patients were included in the study (n=23 925 OHA monotherapy; n=8406 OHA dual therapy; n=1518 OHA triple therapy). One-year change in HbA1c was greater among adherent (-0.90 to -1.14%; -9.8 to -12.5 mmol/mol) compared with non-adherent patients (-0.49 to -0.69%; -5.4 to -7.5 mmol/mol). On average, adherent patients had higher hypoglycemia event rates than non-adherent patients (rate ratios of 1.24, 1.10 and 2.06 for OHA mono, dual and triple therapy cohorts, respectively) and experienced greater weight change from baseline. A 10% improvement in MPR was associated with -0.09% (-1.0 mmol/mol), -0.09% (-1.0 mmol/mol) and -0.21% (-2.3 mmol/mol) changes in HbA1c for OHA mono, dual and triple therapy cohorts, respectively.

CONCLUSIONS

For patients with type 2 diabetes, increasing medication adherence can bring about meaningful improvements in HbA1c control as the requirement for treatment escalation increases. Regimens associated with weight loss and the avoidance of hypoglycemia were generally associated with better medication adherence and improved glycemic control.

Factors Associated With Medication Engagement Among Older Adults With Diabetes: Systematic Review and Meta-Analysis

Purpose

The purpose of this systematic review and meta-analysis is to explore the factors associated with medication engagement among older adults (≥60 years) with diabetes.

Methods

Five databases (PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Scopus) were systematically searched to identify studies examining the association between factors and medication engagement among older diabetes patients. A study met inclusion for meta-analysis if the prevalence of medication engagement or factor was reported in ≥2 studies and the frequency or strength of association was either reported or able to be computed. Quality appraisal was performed with the Downs and Black tool.

Results

Of 538 retrieved studies, 33 (20 cohort and 13 cross-sectional) were included for systematic review; of these, 22 met criteria for meta-analysis. Findings from meta-analysis show that women (odds ratio [OR], 0.92; 95% CI, 0.86-0.97), those with depression (OR, 0.73; 95% CI, 0.62-0.87), and those with higher out-of-pocket spending for prescription drugs (OR, 0.87; 95% CI, 0.80-0.94) were less likely to take diabetes medication when compared with men, those without depression, and those with lower out-of-pocket costs, respectively. Older age (OR, 1.13; 95% CI, 1.00-1.27) was associated with better engagement to diabetes medication.

Conclusions

Of 4 identified factors, 2 are modifiable. Recent policy efforts to decrease the cost burden of prescribed medication for older adults, such as Medicare Part D, may remove this barrier to medication engagement. Routine screening for depression among older adults with diabetes should be included as part of usual care to facilitate an integrated treatment approach.

Real-world weight change among patients treated with glucagon-like peptide-1 receptor agonist, dipeptidyl peptidase-4 inhibitor and sulfonylureas for type 2 diabetes and the influence of medication adherence

AIMS

The study aims to examine real-world weight change and the role of medication adherence among patients with type 2 diabetes who initiated one of three drug classes: glucagon-like peptide-1 receptor agonist (GLP-1RA), dipeptidyl peptidase-4 inhibitor (DPP4) and sulfonylureas (SUs).

MATERIALS AND METHODS

A cohort of patients initiating one of the three drug classes was selected from a large US database of integrated electronic medical record and administrative claims. Adherence was defined as per cent of days covered ≥80% during the year following drug initiation. Weight change was calculated from drug initiation (-180, +30 d) to 1 year (±90 d) later. Multivariate regression controlled for baseline differences between adherent and poorly adherent patients and the addition of another drug class during follow-up.

RESULTS

The study included 833 GLP-1RA, 2,272 DPP4 and 2,713 SU patients who contributed 2,279, 6,602 and 7,429 observations respectively. Patients initiating a GLP-1RA achieved the largest weight change (-2.46 kg of GLP-1RA, -1.26 kg of DPP4 and 0.18 kg of SU, P < 0.01). Adherent GLP-1 patients lost 1.73 kg more than poorly adherent patients, and adherent SU patients gained 1.11 kg more than poorly adherent patients (all P < 0.01). Adherent and poorly adherent DPP4 patients experienced approximately the same amount of weight loss.

CONCLUSIONS

Medication adherence can mediate observed weight loss in patients treated with a GLP1-RA or weight gain in those treated with an SU. Medication adherence was low in a real-world population, particularly for GLP-1RA, which displayed the strongest weight loss benefit. Because recent American Diabetes Association guidelines recommend selecting drug therapies that have a weight loss or weight neutral effect for the management of type 2 diabetes patients, patients should be encouraged to enhance their adherence to benefit the most from therapies that have weight loss properties.

Relevance of weight in the management of patients with type 2 diabetes mellitus: towards an adipocentric approach to diabetes

In recent decades, there has been a worldwide parallel increase in the prevalence of obesity and type 2 diabetes mellitus (T2DM), which is not surprising, given that increased visceral fat is the main risk factor for the development of T2DM in genetically predisposed individuals. An intervention focused on intensive blood glucose control in T2DM with classic drugs increases the risk of weight gain and the rate of hypoglycaemia. In contrast, weight loss through lifestyle changes, drugs and/or surgery simultaneously improves most cardiovascular (CV) risk factors, including hyperglycemia. Intensive intervention on lifestyle induces an overall benefit in patients with T2DM, but long-term weight loss is modest and has not been shown to reduce CV morbidity and mortality. The emergence of new therapeutic classes for T2DM and obesity, which simultaneously improve HbA1c, weight and other CV risk factors without inducing hypoglycaemia, represents a major change in the management of patients with diabesity. A sodium-glucose cotransporter-2 inhibitor and a GLP-1 receptor agonist have recently been shown to decrease CV and total mortality in type 2 diabetic patients with CV disease. Furthermore, bariatric surgery rapidly induces remission or improvement of T2DM in a large percentage of patients and reduces diabetes-related mortality. The emergence of new therapies raises the possibility of changing the current glucose-centred therapeutic strategy for a weight-centred approach.

A Systematic Review of Insulin Adherence Measures in Patients with Diabetes

BACKGROUND

Diabetes care is associated with a considerable burden to the health care system in the United States, and measuring the quality of health care is an important development goal of the Department of Health and Human Services and the Centers for Medicare & Medicaid Services. Diabetes is a priority disease within the National Quality Strategy and should therefore remain a focus in the measurement of health care quality. Despite the importance of measuring quality in diabetes care management, no quality measure is currently associated with adherence to insulin treatment, and measuring adherence to insulin is known to be complicated.

OBJECTIVES

To (a) identify methods to measure insulin adherence in patients with diabetes and (b) evaluate whether identified methods could be considered for testing as a quality measure.

METHODS

Systematic searches were conducted in the online electronic databases Embase, MEDLINE, and the Cochrane Library, supplemented with additional manual searches to identify publications on insulin adherence from the year 2000 onward. Identified citations were screened for relevance against predefined eligibility criteria, and methods to measure adherence to insulin were extracted from relevant studies into data extraction tables. Methods were critiqued on the feasibility for consideration as a quality measure.

RESULTS

Seventy-eight publications met the inclusion criteria and were reviewed. Included studies reported various indirect methods to measure adherence to insulin, using prescription claims or self-report questionnaires. Commonly reported methods included the (adjusted) medication possession ratio, proportion of days covered, persistence, daily average consumption, and the Morisky Medication Adherence Scale. All types of identified methods were associated with measuring challenges varying from accuracy of estimated adherence, complexity of data collection, absence of validated threshold for good adherence, and reliability of adherence outcomes.

CONCLUSIONS

Without additional research, none of the identified methods are appropriate for use as a quality measure for insulin adherence. We suggest patient involvement in future research and additional quality measure development.

DISCLOSURES

Novo Nordisk paid DRG Abacus to complete the systematic review and manuscript and was involved in the study design, interpretation of data, and decision to publish the findings of the systematic review. Kroes and Webb report personal fees from Novo Nordisk during the conduct of the study and personal fees from DRG Abacus, outside of the submitted work. Webb is employed by DRG Abacus, and Kroes was employed by DRG Abacus at the time of this study. Wisniewski is an employee of Novo Nordisk, which funded the systematic review reported in this article, and also owns stocks in Novo Nordisk. Stolpe has nothing to disclose. Study concept and design were contributed by Kroes, Webb, and Wisniewski, with assistance from Stolpe. Webb took the lead in data collection, along with Kroes, and data interpretation was performed by all the authors. The manuscript was written by Kroes, Webb, and Wisniewski, with assistance from Stolpe, and revised by Kroes, Stolpe, Wisniewski, and Webb.

The impact of duration on effectiveness of exercise, the implication for periodization of training and goal setting for individuals who are overfat, a meta-analysis

Given the assumption that all methods of exercise, e.g., endurance (ET), resistance (RT), or combination of both (E+R), can induce a beneficial effect size (ES) for changes in body composition and health status of individuals who are overfat. Thus the aim and purpose of this study is to evaluate the current body of knowledge to address the question as to the impact that the duration of exercise has on its relative effectiveness for inducing health and body compositional changes in individuals who are overfat to assist with developing periodized exercise protocols and establishing short and long term goals. A tiered meta-analysis of 92-studies and 200-exercise groupings were used for establishing pooled ES within and between groupings based on the increments of 4-week of duration and study designs of ≤8, 9-16, 17-23, 24-36, and ≥36 weeks. Analysis based on random-effect of response indicates a continuum of effectiveness within and between ET, RT and E+R based on duration. Where beneficial effectiveness is not indicated for any measures until after 8-weeks of continuous training with progressive effectiveness being noted in changes to cardiorespiratory fitness, inflammatory cytokines, and alteration of metabolic status from 12-weeks through 32-weeks of continuous training. Results indicate a greater ES for RT and E+R versus ET early in intervention that equalizes with longer durations. Supporting the use of RT and E+R within a periodized program. And secondarily, goals should be established first on performance gains and second body composition or health status modifications for the individual who is overfat.

Antipsychotic-associated weight gain: management strategies and impact on treatment adherence

Antipsychotic-induced weight gain is a major management problem for clinicians. It has been shown that weight gain and obesity lead to increased cardiovascular and cerebrovascular morbidity and mortality, reduced quality of life and poor drug compliance. This narrative review discusses the propensity of various antipsychotics to cause weight gain, the pharmacologic and nonpharmacologic interventions available to counteract this effect and its impact on adherence. Most antipsychotics cause weight gain. The risk appears to be highest with olanzapine and clozapine. Weight increases rapidly in the initial period after starting antipsychotics. Patients continue to gain weight in the long term. Children appear to be particularly vulnerable to antipsychotic-induced weight gain. Tailoring antipsychotics according to the needs of the individual and close monitoring of weight and other metabolic parameters are the best preventive strategies at the outset. Switching to an agent with lesser tendency to cause weight gain is an option, but carries the risk of relapse of the illness. Nonpharmacologic interventions of dietary counseling, exercise programs and cognitive and behavioral strategies appear to be equally effective in individual and group therapy formats. Both nonpharmacologic prevention and intervention strategies have shown modest effects on weight. Multiple compounds have been investigated as add-on medications to cause weight loss. Metformin has the best evidence in this respect. Burden of side effects needs to be considered when prescribing weight loss medications. There is no strong evidence to recommend routine prescription of add-on medication for weight reduction. Heterogeneity of study methodologies and other confounders such as lifestyle, genetic and illness factors make interpretation of data difficult.

A post-hoc analysis of the comparative efficacy of canagliflozin and glimepiride in the attainment of type 2 diabetes-related quality measures

BACKGROUND

The randomized, double-blind CANTATA-SU (CANagliflozin Treatment And Trial Analysis Sulfonyl Urea) clinical trial compared the use of canagliflozin (100 mg or 300 mg) and maximally tolerated glimepiride (6-8 mg) over 104 weeks as add-on therapy for patients with type 2 diabetes mellitus (T2DM) inadequately controlled with metformin. Compared with glimepiride, canagliflozin use was associated with durable reductions in glycated hemoglobin (A1C), blood pressure (BP), and body weight. The aim of this post-hoc analysis of the CANTATA-SU trial was to assess the comparative efficacy of canagliflozin and glimepiride in the attainment of recently updated diabetes-related quality measures (QMs) for up to 104 weeks of treatment.

METHODS

This post-hoc analysis evaluated the proportions of patients achieving individual diabetes-related QMs using data from the randomized, double-blind, Phase 3 CANTATA-SU trial. Change in A1C from baseline, and proportions of the study population achieving QMs: A1C <7.0 %, <8.0 %, and >9.0 % were assessed. Secondary endpoints included change in BP from baseline, and the proportions of the study population achieving QMs related to BP and body weight.

RESULTS

The proportions of patients in the canagliflozin 100 mg, canagliflozin 300 mg, and glimepiride groups meeting criteria for all QMs were similar at baseline. At 52 and 104 weeks of treatment, canagliflozin 100 mg and canagliflozin 300 mg provided better or similar reductions in A1C from baseline and achievement of glycemic control QMs compared with glimepiride. At 52 and 104 weeks of treatment, the attainment of QMs related to reductions in body weight and BP all favored canagliflozin compared with glimepiride. Canagliflozin was associated with lower incidence of documented hypoglycemia and severe hypoglycemia compared with glimepiride.

CONCLUSIONS

Using the recently adjusted and currently accepted diabetes-related QMs, this analysis observed superior glycemic control with canagliflozin compared with maximally tolerated glimepiride in patients with T2DM who were previously poorly controlled on metformin monotherapy. Compared with maximally tolerated glimepiride, canagliflozin resulted in better achievement of diabetes-related QMs related to weight loss and BP, and was associated with lower incidences of hypoglycemic events.

TRIAL REGISTRATION

Clinical trial registry name: CANagliflozin Treatment And Trial Analysis-Sulfonylurea (CANTATA-SU) SGLT2 Add-on to Metformin Versus Glimepiride.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00968812 , registered August 28, 2009.

Optimizing management of glycaemia

The global epidemic of type 2 diabetes (T2DM) continues largely unabated due to an increasingly sedentary lifestyle and obesogenic environment. A cost-effective patient-centred approach, incorporating glucose-lowering therapy and modification of cardiovascular risk factors, could help prevent the inevitable development and progression of macrovascular and microvascular complications. Glycaemic optimization requires patient structured education, self-management and empowerment, and psychological support along with early and proactive use of glucose lowering therapies, which should be delivered in a system of care as shown by the Chronic Care Model. From diagnosis, intensive glycaemic control and individualised care is aimed at reducing complications. In older people, the goal is maintaining quality of life and minimizing morbidity, especially as overtreatment increases hypoglycaemia risk. Maintaining durable glycaemic control is challenging and complex to achieve without hypoglycaemia, weight gain and other significant adverse effects. Overcoming patient and physician barriers can help ensure adequate treatment initiation and intensification. Cardiovascular safety studies with newer glucose-lowering agents are now mandatory, with a sodium glucose co-transporter-2 inhibitor (empagliflozin), and two glucagon like peptide-1 receptor agonists (liraglutide and semaglutide) being the first to demonstrate superior CV outcomes compared with placebo.

Advances in the treatment of type 2 diabetes: impact of dulaglutide

The purpose of this review is to provide a review of current data of the most recently approved glucagon-like peptide (GLP)-1-receptor agonist, dulaglutide, in the treatment of type 2 diabetes. To complete this, a PubMed search was performed to identify manuscripts published from 1947 to July 2015. The search terms "Trulicity", "dulaglutide", and "LY2189265" were utilized, and publications were included if they evaluated the pharmacology, pharmacokinetics, efficacy, safety, or patient-reported outcomes of dulaglutide. Dulaglutide is a GLP-1 receptor agonist that mimics endogenous GLP-1, the hormone produced in response to food intake. Modifications have been made to the molecule to delay breakdown and allow for once-weekly dosing. Dulaglutide has been studied as monotherapy and in combination with several agents, including metformin, glimepiride, pioglitazone, and insulin lispro. Dulaglutide has demonstrated superior efficacy compared to placebo, metformin, insulin glargine, sitagliptin, and twice-daily exenatide. It was found to be noninferior to liraglutide. The most common adverse effects in clinical studies were gastrointestinal-related adverse events, and patient satisfaction was high with the use of dulaglutide. Dulaglutide is an appealing option for the treatment of type 2 diabetes, based on its once-weekly dosing, A1c lowering comparable to liraglutide, weight reduction comparable to exenatide, and a similar adverse-effect profile to other GLP-1 receptor agonists.

Changes in Body Weight Among People With Type 2 Diabetes Mellitus in the United States, NHANES 2005-2012

Purpose

To understand weight loss strategies, weight changes, goals, and behaviors in people with type 2 diabetes mellitus (T2DM) and whether these differ by ethnicity.

Methods

T2DM was identified by self-reported diagnosis using the NHANES 2005-2012 data, which also included measured and self-reported current body weight and height, self-reported weight the prior year, and self-reported aspired weight. Nineteen weight loss strategies were evaluated for association with ≥5% weight loss or weight gain versus <5% weight change.

Results

Among people with T2DM, 88.0% were overweight/obese (body mass index [BMI] ≥25 kg/m2) in the prior year and 86.1% the current year. About 60% of the overweight/obese took weight loss actions, mostly using diet-related methods with average weight lost <5%. Two most “effective” methods reported (smoking, taking laxatives/vomiting) are also potentially most harmful. Similar BMI distributions but different goals and behaviors about weight and weight loss were observed across ethnicity. Only physical activity meeting the recommended level and changing eating habits were consistently associated with favorable and statistically significant weight change.

Conclusions

Weight management in T2DM is an ongoing challenge, regardless of ethnicity/race. Among overweight/obese T2DM subjects, recommended level of physical activity and changing eating habits were associated with statistically significant favorable weight change.

Obesity and glycemic control in patients with diabetes mellitus: Analysis of physician electronic health records in the US from 2009-2011

AIMS

Examine the association between obesity and glycemic control among patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM).

METHODS

Data from US physician electronic health records (Humedica®) from 2009-2011 were utilized. Patients were defined as having above-target glycemic control if they had an HbA1c ≥7% at any time during the study period. Multinomial logistic regressions were conducted separately for T1DM and T2DM patients, and examined associations between BMI categories and probability of having above-target glycemic control (≥7% and <8%, ≥8% and <9%, or ≥9%) while controlling for patient demographics, general health, comorbid conditions, and antihyperglycemic medication use.

RESULTS

There were 14,028 T1DM and 248,567 T2DM patients; 47.8% of T1DM and 63.4% of T2DM were obese (BMI ≥30kg/m(2)). For T1DM, being overweight (BMI 25-<30), obese class I (30-<35), II (35-<40), or III (≥40) was associated with a significantly higher probability of having HbA1c≥8% and <9% or ≥9%, while being overweight was associated with a significantly higher probability of having HbA1c ≥7% and <8% compared to normal BMI (BMI≥18.5 and<25). For T2DM patients, being overweight, obese class I, II, or III was associated with a significantly higher probability of having HbA1c ≥7% and <8%, ≥8% and <9%, or ≥9%.

CONCLUSIONS

For both T1DM and T2DM patients, there were positive and statistically significant associations between being overweight or obese and having suboptimal glycemic control. These findings quantify the associations between obesity and glycemic control, and highlight the potential importance of individual characteristics on glycemic control.

Patient considerations in type 2 diabetes - role of combination dapagliflozin-metformin XR

PURPOSE

The purpose of this review article is to provide guidance to health care providers regarding the use of dapagliflozin-metformin XR (extended release) as a therapeutic option for the treatment of patients with type 2 diabetes mellitus (T2DM).

METHODS

The PubMed database was searched through August 2015 to identify clinical trials and meta-analyses evaluating the use of the sodium-glucose cotransporter type 2 inhibitor dapagliflozin administered as monotherapy or in combination with metformin.

RESULTS

Fourteen studies were included for this review, six of which evaluated dapagliflozin in combination with metformin, one of which evaluated dapagliflozin monotherapy, and four of which evaluated dapagliflozin as an add-on therapy to other antidiabetic agents. The combination of dapagliflozin and metformin resulted in an A1C decrease of up to 2%, weight loss of 2-3 kg, and modest systolic blood pressure decrease of 3-5 mmHg. However, long-term effects on cancer and cardiovascular health are still being investigated. Providing patients with a fixed-dose combination therapy such as dapagliflozin-metformin XR can increase medication adherence and patient satisfaction, and improve glycemic control. Dapagliflozin-metformin XR is ideal because it can be administered orally once a day, is associated with a low risk of hypoglycemia, and provides the added benefit of weight reduction and modest blood pressure lowering.

CONCLUSION

The unique combined mechanism of action and favorable efficacy and safety profile of dapagliflozin-metformin XR support consideration of this fixed-dose combination as a treatment option for patients with T2DM.

Type 2 diabetes: cost-effectiveness of medication adherence and lifestyle interventions

INTRODUCTION

Type 2 diabetes is a major burden for the payer, however, with proper medication adherence, diet and exercise regime, complication occurrence rates, and consequently costs can be altered.

AIMS

The aim of this study was to conduct a cost-effectiveness analysis on real patient data and evaluate which medication adherence or lifestyle intervention is less cost demanding for the payer.

METHODS

Medline was searched systematically for published type 2 diabetes interventions regarding medication adherence and lifestyle in order to determine their efficacies, that were then used in the cost-effectiveness analysis. For cost-effectiveness analysis-required disease progression simulation, United Kingdom Prospective Diabetes Study Outcomes model 2.0 and Slovenian type 2 diabetes patient cohort were used. The intervention duration was set to 1, 2, 5, and 10 years. Complications and drug costs in euro (EUR) were based on previously published type 2 diabetes costs from the Health Care payer perspective in Slovenia.

RESULTS

Literature search proved the following interventions to be effective in type 2 diabetes patients: medication adherence, the Mediterranean diet, aerobic, resistance, and combined exercise. The long-term simulation resulted in no payer net savings. The model predicted following quality-adjusted life-years (QALY) gained and incremental costs for QALY gained (EUR/QALYg) after 10 years of intervention: high-efficacy medication adherence (0.245 QALY; 9,984 EUR/QALYg), combined exercise (0.119 QALY; 46,411 EUR/QALYg), low-efficacy medication adherence (0.075 QALY; 30,967 EUR/QALYg), aerobic exercise (0.069 QALY; 80,798 EUR/QALYg), the Mediterranean diet (0.057 QALY; 27,246 EUR/QALYg), and resistance exercise (0.050 QALY; 111,847 EUR/QALYg).

CONCLUSION

The results suggest that medication adherence intervention is, regarding cost-effectiveness, superior to diet and exercise interventions from the payer perspective. However, the latter could also be utilized by patients without additional costs, but medication adherence intervention requires trained personnel because of its complex structure. Interventions should be performed for >2 years to produce noticeable health/cost results.

Dapagliflozin combination therapy in type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is a progressive disease, and most patients ultimately require two or more antidiabetes drugs in addition to lifestyle changes to achieve and maintain glycemic control. Current consensus statements and guidelines recommend metformin as first-line pharmacotherapy for the treatment of T2DM in most patients. When glycemic control cannot be maintained with metformin alone, the sequential, stepwise addition of other agents is recommended. Agents such as thiazolidinediones or sulfonylureas have typically been added to metformin therapy. Although effective in reducing glycated hemoglobin, these drugs are often associated with adverse effects, most notably weight gain, and in the case of sulfonylureas, hypoglycemia. Sodium-glucose cotransporter 2 inhibitors, such as dapagliflozin, are the newest class of antidiabetes drugs approved for the treatment of T2DM. Dapagliflozin effectively improves glycemic control by increasing the renal excretion of excess glucose. In clinical trials, dapagliflozin has been well tolerated and has additional benefits of weight loss, low risk of hypoglycemia and reduction in blood pressure. This review discusses the clinical evidence and rationale for the use of dapagliflozin as add-on therapy in T2DM. The results suggest that dapagliflozin add-on therapy is a promising new treatment option for a wide range of patients with T2DM. Results from an ongoing cardiovascular outcomes trial are needed to establish the long-term safety of dapagliflozin.

Characteristics and outcomes of patients with type 2 diabetes mellitus treated with canagliflozin: a real-world analysis

BACKGROUND

Canagliflozin, an oral agent that inhibits sodium glucose co-transporter 2, improves glycemic control, body weight, and blood pressure and is generally well tolerated in patients with type 2 diabetes mellitus (T2DM). This study extends the scope of previous analyses by evaluating outcomes associated with the use of canagliflozin over a 6-month period in a real-world setting.

METHODS

This retrospective cohort study used data obtained from a large health plan database for patients (≥18 years) with a diagnosis of T2DM who filled at least one canagliflozin prescription between April 1, 2013 and October 30, 2013 (first 7 months canagliflozin was commercially available in the USA) and were continuously enrolled in the health plan for 6 months prior to (baseline) and 6 months following the first canagliflozin prescription claim (follow-up). Changes in glycemic control were evaluated, along with characteristics of enrolled patients and changes in treatment patterns.

RESULTS

4017 patients (mean age 56 years, 43 % female) met the study inclusion criteria. Of these, at the time of first canagliflozin claim, 21 % used canagliflozin concomitantly with three or more other antihyperglycemic agents (AHAs), 29 % with two other AHAs, 30 % with one other AHA, and 20 % without other AHAs. During follow-up, patients received 3.4 (average) canagliflozin prescription fills and a mean of 148 total days of supply; median adherence (interquartile range [IQR]) was 86 % (66-98 %) for patients with ≥2 fills. Among patients with available glycated hemoglobin (A1C) measurements at baseline and follow-up (n = 826, baseline A1C 8.59 %), mean A1C reduction was 0.81 % (P < 0.001). Mean A1C reduction during the follow-up period was greatest in patients with the highest baseline A1C levels. Of the patients who used canagliflozin concomitantly with other AHAs, 20 % were observed to discontinue one or more other AHAs during follow-up. The most commonly discontinued baseline AHAs were: glucagon-like peptide-1 receptor agonists (16 %), dipeptidyl peptidase-4 inhibitors (15 %), insulin (13 %), sulfonylureas (13 %), and metformin (11 %).

CONCLUSIONS

This real-world study on canagliflozin use in a range of patients with T2DM demonstrated significant improvements in mean A1C from baseline following the first canagliflozin prescription. In patients concomitantly using one or more additional AHAs at baseline, there appears to be a trend toward lower other AHA use after canagliflozin initiation.

Minimizing Hypoglycemia and Weight Gain with Intensive Glucose Control: Potential Benefits of a New Combination Therapy (IDegLira)

Due to the progressive nature of type 2 diabetes (T2D), the majority of patients require increasing levels of therapy to achieve and maintain good glycemic control. At present, once patients become uncontrolled on oral antidiabetic therapies, the two primary treatment options are glucagon-like peptide-1 receptor agonists (GLP-1RAs) or basal insulin, although earlier use of GLP-1RAs has also been advocated. While both of these drug classes have proven efficacy in treating T2D, there can be limitations to their use in some patients, and resistance to further treatment intensification among both patients and physicians. More recently, treatment incorporating both a GLP-1RA and a basal insulin has been used successfully in the clinic and the first such combination product, IDegLira (insulin degludec + liraglutide), has recently been approved for use in Europe. IDegLira combines insulin degludec and the GLP-1RA liraglutide in a single injection. In both insulin-naïve and basal insulin-treated individuals with T2D, IDegLira has demonstrated greater reductions in glycated hemoglobin (HbA_1c) than either of the individual components, with a low rate of hypoglycemia and weight loss. IDegLira may provide a new option for patients requiring treatment intensification but for whom increased weight or a higher risk of hypoglycemia are barriers. This article discusses the rationale behind combining these two drug classes and reviews the available clinical evidence for the efficacy and safety of IDegLira.

Effects of selected antidiabetics on weight loss--a retrospective database analysis

AIMS

In published studies metformin was often associated with weight loss in type 2 diabetes patients. Until now, no epidemiological studies have directly compared the effects of DPP-4 and GLP-1 versus metformin on weight loss. Our study is a comparison of sulfonylurea, DPP-4 and GLP-1 with metformin regarding body weight in type 2 diabetes patients.

METHODS

Data from 2641 patients initiated therapy with either metformin, sulfonylurea, DPP-inhibitors or GLP-1 with baseline BMI >30 were retrospectively analyzed (Disease Analyzer Germany: 11/2008-10/2012). Comparison was performed for the weight change after 1 year of therapy compared with the last value prior to therapy. Differences between SU, DPP-4, GLP-1 versus metformin were estimated using regression model adjusted for age, gender, health insurance status, defined co-diagnoses and body weight at baseline.

RESULTS

In absolute values, metformin patients lost an average of 2.6 kg, subjects treated with SU gained 0.3 kg, body weight in the DPP-4 group decreased by 1.8 kg and GLP-1 patients lost 3.3 kg in body weight after 1 year. After adjustment for other variables, comparisons with metformin revealed the following results: SU +3.4 kg (p < 0.001), DPP-4 +1.0 kg (p = 0.003) and GLP-1 -0.4 kg (p = 0.589).

CONCLUSION

Our study showed that GLP-1 treatment was comparable to metformin regarding the weight reduction, while sulfonylurea and DPP-4 are inferior in this regard.

New and emerging drugs and targets for type 2 diabetes: reviewing the evidence

BACKGROUND

Diabetes is a deadly and costly disease. The number of adults in the United States with newly diagnosed diabetes has nearly tripled from 1980 to 2011. At the current pace, 1 in 3 US adults will have diabetes in their lifetime. Currently, 14 classes of drugs are available to treat type 2 diabetes mellitus, but only 36% of patients with type 2 diabetes achieve glycemic control with the currently available therapies. Therefore, new treatment options are desperately needed.

DISCUSSION

Despite the availability of many pharmacotherapies, in 2011 an estimated 3.1 million (14.9%) patients with type 2 diabetes still reported not taking medications to treat their diabetes. Patient compliance is a major obstacle facing practicing clinicians on a daily basis. New treatment options are desperately needed, but efficacy and tolerability are no longer the only criteria contributing to the success of a drug. Ease of administration, convenient dosing frequency, being weight control friendly, and having a low risk for hypoglycemia are important factors for the survival of a new drug in the US healthcare system. The present review is focused on important new drugs and drug classes in the pipeline, as well as on recently approved drugs, including sodium glucose cotransporter-2 inhibitors, glucagon-like peptide-1 agents, and new insulin therapies, as well as on the technologic improvements in the delivery and dosing frequency of some of the currently available drugs.

CONCLUSIONS

In the United States, diabetes can be expected to continue to wreak significant human and financial tolls. The associated complications will continue to climb if they are not controlled and stopped. New therapies for diabetes are clearly needed that will better address these unmet needs. The common threads among the emerging therapies are their convenience of administration and dosing frequency, which are important to the improvement of patient adherence.