Prescribing of diabetes medications to people with type 2 diabetes and chronic kidney disease: a national cross-sectional study

Attenuated Risk Association of End-Stage Kidney Disease with Metformin in Type 2 Diabetes with eGFR Categories 1–4

Type 2 diabetes (T2D)-associated end-stage kidney disease (ESKD) is a global burden, while the renoprotective effects of metformin remain controversial. In a population-based cohort (2002–2018) including 96,643 patients with T2D observed for 0.7 million person-years, we estimated the risk association of metformin and its dose-relationship with ESKD in a propensity-score overlap-weighting (PS-OW) cohort by eGFR categories. Amongst 96,643, 83,881 (86.8%) had eGFR-G1/G2 (≥60 mL/min/1.73 m²), 8762 (9.1%) had eGFR-G3a (≥45–60 mL/min/1.73 m²), 3051 (3.2%) had eGFR-G3b (≥30–45 mL/min/1.73 m²), and 949 (1.0%) had eGFR-G4 (≥15–30 mL/min/1.73 m²). The respective proportions of metformin users in these eGFR categories were 95.1%, 81.9%, 53.8%, and 20.8%. In the PS-OW cohort with 88,771 new-metformin and 7872 other oral glucose-lowering-drugs (OGLDs) users, the respective incidence rates of ESKD were 2.8 versus 22.4/1000 person-years. Metformin use associated with reduced risk of ESKD (hazard ratio (HR) = 0.43 [95% CI: 0.35–0.52] in eGFR-G1/G2, 0.64 [0.52–0.79] in eGFR-G3a, 0.67 [0.56–0.80] in eGFR-G3b, and 0.63 [0.48–0.83] in eGFR-G4). Metformin use was associated with reduced or neutral risk of major adverse cardiovascular events (MACE) (7.2 versus 16.0/1000 person-years) and all-cause mortality (14.6 versus 65.1/1000 person-years). Time-weighted mean daily metformin dose was 1000 mg in eGFR-G1/G2, 850 mg in eGFR-G3a, 650 mg in eGFR-G3b, and 500 mg in eGFR-G4. In a subcohort of 14,766 patients observed for 0.1 million person-years, the respective incidence rates of lactic acidosis and HR in metformin users and non-users were 42.5 versus 226.4 events/100,000 person-years (p = 0.03) for eGFR-G1/G2 (HR = 0.57, 0.25–1.30) and 54.5 versus 300.6 events/100,000 person-years (p = 0.01) for eGFR-G3/G4 (HR = 0.49, 0.19–1.30). These real-world data underscore the major benefits and low risk of lactic acidosis with metformin use down to an eGFR of 30 mL/min/1.73 m² and possibly even 15 mL/min/1.73 m², while reinforcing the importance of dose adjustment and frequent monitoring of eGFR.

Diabetes Mellitus Diagnosis and Screening in Australian General Practice: A National Study

Aims

To investigate the epidemiology of diabetes diagnosis and screening in Australian general practice.

Methods

Cross-sectional study using electronic health records of 1,522,622 patients aged 18+ years attending 544 Australian general practices (MedicineInsight database). The prevalence of diagnosed diabetes and diabetes screening was explored using all recorded diagnoses, laboratory results, and prescriptions between 2016 and 2018. Their relationship with patient sociodemographic and clinical characteristics was also investigated.

Results

Overall, 7.5% (95% CI 7.3, 7.8) of adults had diabetes diagnosis, 0.7% (95% CI 0.6, 0.7) prediabetes, and 0.3% (95% CI 0.3, 0.3) unrecorded diabetes/prediabetes (elevated glucose levels without a recorded diagnosis). Patients with unrecorded diabetes/prediabetes had clinical characteristics similar to those with recorded diabetes, except for a lower prevalence of overweight/obesity (55.5% and 69.9%, respectively). Dyslipidaemia was 1.8 times higher (36.2% vs. 19.7%), and hypertension was 15% more likely (38.6% vs. 33.8%) among patients with prediabetes than with diabetes. Diabetes screening (last three years) among people at high risk of diabetes was 55.2% (95% CI 52.7, 57.7), with lower rates among young or elderly males.

Conclusions

Unrecorded diabetes/prediabetes is infrequent in Australian general practice, but prediabetes diagnosis was also lower than expected. Diabetes screening among high-risk individuals can be improved, especially in men, to enhance earlier diabetes diagnosis and management.

Compliance with the DPP-4 inhibitors dose adjustment recommendations based on renal function in a population database

OBJECTIVE

To examine the prescription pattern of the different dipeptidyl peptidase-4 inhibitors (DPP4is), depending on the estimated glomerular filtration rate (eGFR) under real-world clinical practice conditions.

METHOD

This was a descriptive, observational study using a population database (SIDIAP Catalonia). Subjects diagnosed with T2DM with kidney function assessed and on active treatment with DPP4is were enrolled. Patients were included at the time of the measurement of eGFR (CKD-epi) and were monitored for 6 months after enrolment. For each subject, the prescribed daily dose (PDD) of DPP4i, the theoretical dose according to the degree of renal failure established by the recommendations in the summary of product characteristics (DDD-adj), and the PDR ratio (PDD/DDD-adj) were estimated. A subject was considered overtreated if his/her RDR was greater than 1.2 (>20%).

RESULTS

The study sample consisted of 72,135 subjects with a mean age of 69.7 (±11.6) years and 55.9% males. The proportion of patients overtreated varied depending on the type of DPP4i and the renal function stage. Overall, overdosage was recorded in 7.15% of all DPP4i treatments. In advanced stages (IIIb, IV, and V), overdosage was much higher (36.8% for all DPP4is, and 58.7% if linagliptin is excluded).

DISCUSSION

Under real-world clinical practice conditions, more than one third of T2DM patients with advanced renal failure were overdosed with DPP4is because the doses were not adequately adjusted to the glomerular filtration rate of each patient.

Compliance with the DPP-4 inhibitors dose adjustment recommendations based on renal function in a population database

OBJECTIVE

To examine the prescription pattern of the different dipeptidyl peptidase-4 inhibitors (DPP4is), depending on the estimated glomerular filtration rate (eGFR) under real-world clinical practice conditions.

METHOD

This was a descriptive, observational study using a population database (SIDIAP Catalonia). Subjects diagnosed with T2DM with kidney function assessed and on active treatment with DPP4is were enrolled. Patients were included at the time of the measurement of eGFR (CKD-EPI) and were monitored for 6 months after enrolment. For each subject, the prescribed daily dose (PDD) of DPP4i, the theoretical dose according to the degree of renal failure established by the recommendations in the summary of product characteristics (DDD-adj), and the PDR ratio (PDD/DDD-adj) were estimated. A subject was considered overtreated if his/her RDR was greater than 1.2 (>20%).

RESULTS

The study sample consisted of 72,135 subjects with a mean age of 69.7 (±11.6) years and 55.9% males. The proportion of patients overtreated varied depending on the type of DPP4i and the renal function stage. Overall, overdosage was recorded in 7.15% of all DPP4i treatments. In advanced stages (IIIb, IV and V), overdosage was much higher (36.8% for all DPP4is, and 58.7% if linagliptin is excluded).

DISCUSSION

Under real-world clinical practice conditions, more than one third of T2DM patients with advanced renal failure were overdosed with DPP4is because the doses were not adequately adjusted to the glomerular filtration rate of each patient.

Barriers to initiating SGLT2 inhibitors in diabetic kidney disease: a real-world study

Background

Sodium-glucose cotransporter 2 inhibitor (SGLT2i) should be considered for patients with type 2 diabetes (T2D) and chronic kidney disease (CKD) having estimated glomerular filtration rate (eGFR) ≥ 30 mL/min/1.73 m² and urine albumin-to-creatinine ratio (UACR) > 30 mg/g. However, SGLT2i is currently underprescribed among eligible, at-risk patients for CKD progression. We analyzed prescription patterns and barriers to initiating SGLT2i in patients with T2D and CKD in real practice.

Methods

A total of 3,703 consecutive outpatients with T2D from four teaching hospitals during six months (2019 ~ 2020) were reviewed. Five eGFR categories (G1, ≥ 90; G2, 60–89; G3ab, 30–59; G4-5, < 30 mL/min/1.73 m²) and three UACR categories (A1, < 30; A2, 30–300; A3, > 300 mg/g) were used to define CKD status.

Results

Overall, 25.8 % patients received SGLT2i in the following eGFR and albuminuria categories: G1 (A1, 31 %; A2, 48 %; A3, 45 %); G2 (A1, 18 %; A2, 24 %; A3, 30%); and G3 (A1, 9 %; A2, 7 %; A3, 13 %).

Total prevalence estimate of CKD was 33.8 % (n = 1,253), of whom 25.6 % patients received SGLT2i. We defined eGFR ≥ 45 mL/min/1.73 m² and UACR ≥ 30 mg/g as high-risk CKD group eligible for SGLT2i (n = 905), of whom 32.9 % patients were treated with an SGLT2i. In this high-risk group, SGLT2i initiation showed negative correlations with age ≥ 65 years and recent hospitalization. Conversely, HbA1c level, body mass index (BMI), presence of diabetic retinopathy, and previous heart failure events were positively correlated with SGLT2i initiation.

Conclusions

Only 32.9 % of T2D with CKD eligible for SGLT2i is currently treated with SGLT2i in real-world clinical practice. The older patient group and clinical inertia are the main barriers to initiate SGLT2i for eligible patients. Clinicians should change the glucocentric approach and focus on reducing renal events in T2D.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02381-3.

Blood pressure control in Australian general practice: analysis using general practice records of 1.2 million patients from the MedicineInsight database

INTRODUCTION

Hypertension is mostly managed in primary care. This study investigated the prevalence of diagnosed hypertension in Australian general practice and whether hypertension control is influenced by sociodemographic characteristics, duration since diagnosis or prescription of antihypertensive medications.

METHODS

Cross-sectional study using a large national database of electronic medical records of patients attending general practice in 2017 (MedicineInsight).

RESULTS

Of 1.2 million 'regular' patients (one or more consultations per year in every year from 2015 to 2017), 39.8% had a diagnosis of hypertension (95% confidence interval 38.7-40.9). Of these, 85.3% had their blood pressure (BP) recorded in 2017, and 54.9% (95% confidence interval 54.2-55.5) had controlled hypertension (<140/90 mmHg). BP control was lower in females (54.1%) compared with males (55.7%) and in the oldest age group (52.0%), with no differences by socioeconomic status. Hypertension control was lower among 'regular' patients recently diagnosed (6-12 months = 48.6% controlled) relative to those more than 12 months since diagnosis (1-2 years = 53.6%; 3-5 years 55.5%; >5 years = 55.0%). Among recently diagnosed 'regular' patients, 59.2% had no record of being prescribed antihypertensive therapy in the last 6 months of the study, of which 44.3% had controlled hypertension. For those diagnosed more than 5 years ago, 37.4% had no record of being prescribed antihypertensive patients, and 56% had normal BP levels.

CONCLUSION

Although the prevalence of hypertension varied by socidemographics, there were no differences in BP assessment or control by socioeconomic status. Hypertension control remains a challenge in primary care, and electronic medical records provide an opportunity to assess hypertension management.

Associations between multimorbidity and glycaemia (HbA1c) in people with type 2 diabetes: cross-sectional study in Australian general practice

OBJECTIVES

To explore the prevalence of multimorbidity as well as individual and combinations of long-term conditions (LTCs) in people with type 2 diabetes (T2D) attending Australian general practice, using electronic health record (EHR) data. We also examine the association between multimorbidity condition count (total/concordant(T2D related)/discordant(unrelated)) and glycaemia (glycated haemoglobin, HbA1c).

DESIGN

Cross-sectional study.

SETTING

Australian general practice.

PARTICIPANTS

69 718 people with T2D with a general practice encounter between 2013 and 2015 captured in the MedicineInsight database (EHR Data from 557 general practices and >3.8 million Australian patients).

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of multimorbidity, individual and combinations of LTCs. Multivariable linear regression models used to examine associations between multimorbidity counts and HbA1c (%).

RESULTS

Mean (SD) age 66.42 (12.70) years, 46.1% female and mean (SD) HbA1c 7.1 (1.4)%. More than 90% of participants with T2D were living with multimorbidity. Discordant conditions were more prevalent (83.4%) than concordant conditions (69.9 %). The three most prevalent discordant conditions were: painful conditions (55.4%), dyspepsia (31.6%) and depression (22.8%). The three most prevalent concordant conditions were hypertension (61.4%), coronary heart disease (17.1%) and chronic kidney disease (8.5%). The three most common combinations of conditions were: painful conditions and hypertension (38.8%), painful conditions and dyspepsia (23.1%) and hypertension and dyspepsia (22.7%). We found no associations between any multimorbidity counts (total, concordant and discordant) or combinations and HbA1c.

CONCLUSIONS

Multimorbidity was common in our cohort of people with T2D attending Australian general practice, but was not associated with glycaemia. Although we did not explore mortality in this study, our results suggest that the increased mortality in those with multimorbidity and T2D observed in other studies may not be linked to glycaemia. Interestingly, discordant conditions were more prevalent than concordant conditions with painful conditions being the second most common comorbidity. Better understanding of the implications of different patterns of multimorbidity in people with T2D will allow more effective tailored care.

Metformin and Risk of Alzheimer's Disease Among Community-Dwelling People With Diabetes: A National Case-Control Study

CONTEXT

Type 2 diabetes has been linked with an increased risk of Alzheimer's disease (AD). Studies on the association between metformin use and AD have reported conflicting results.

OBJECTIVE

To investigate whether metformin use modifies the association between diabetes and incident, clinically verified AD.

DESIGN

Nested case-control study.

SETTING

All community-dwelling people in Finland.

PARTICIPANTS

Cases were all community-dwelling Finns with AD diagnosed from 2005 to 2011 and with diabetes diagnosed ≥ 3 years before AD (n = 9862). Cases were matched with up to 2 control persons by age, sex, and diabetes duration (n = 19 550).

MAIN OUTCOME MEASURE

Cumulative metformin exposure was determined from reimbursed dispensings over a 10- to 16-year period. Adjusted odds ratios (aORs) were calculated using conditional logistic regression to estimate associations, with adjustment for potential confounders.

RESULTS

A total of 7225 (73.3%) cases and 14528 (74.3%) controls received metformin at least once. Metformin use (ever use) was not associated with incident AD (aOR 0.99; 95% confidence interval [CI], 0.94-1.05). The adjusted odds of AD were lower among people dispensed metformin for ≥ 10 years (aOR 0.85; 95% CI, 0.76-0.95), those dispensed cumulative defined daily doses (DDDs) of < 1825-3650 (aOR 0.91; 95% CI, 0.84-0.98) and > 3650 DDDs (aOR 0.77; 95% CI, 0.67-0.88), and among persons dispensed an average of 2 g metformin daily (aOR 0.89; 95% CI, 0.82-0.96).

CONCLUSION

In this large national sample we found no evidence that metformin use increases the risk of AD. Conversely, long-term and high-dose metformin use was associated with a lower risk of incident AD in older people with diabetes.

Glycemia Lowering Effect of an Aqueous Extract of Hedychium coronarium Leaves in Diabetic Rodent Models

Hedychium coronarium has a long history of use worldwide as a food and in folk medicine. In this study, we aimed to investigate the effect of an aqueous extract of H. coronarium leaves (HC) on type 2 diabetes mellitus (T2DM). Two types of animal models were used in this study: Streptozotocin (STZ)-induced T2DM (Wistar rats; N = 8) and C57BKSdb/db mice (N = 5). After treatment with HC for 28 days, glucose tolerance improved in both of the diabetic animal models. As significant effects were shown after 14 days of treatment in the STZ-induced T2DM model, we carried out the experiments with it. After 28 days of treatment with HC, the levels of cholesterol, triglyceride, high-density lipoprotein, and low-density lipoprotein were significantly improved in the STZ-induced T2DM model. The lesions degree of islet β-cells was decreased after the HC treatment. Although the insulin level increased moderately, the aldosterone level was significantly decreased in the HC-treated groups, suggesting that aldosterone might play an important role in this effect. In summary, HC is a natural product and it is worth exploring its effect on T2DM.