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Rättö H, Kurko T, Pajunen P, Kastarinen H. Second-line pharmacotherapy intensification after metformin monotherapy in type 2 diabetes: a nationwide register study from Finland during 2011-2022. BMC Health Serv Res 2024; 24:944. [PMID: 39160557 PMCID: PMC11331595 DOI: 10.1186/s12913-024-11325-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/17/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND In this nationwide register study, we examined the initiation of a second-line antidiabetic medicine (ADM) among new patients receiving regular metformin monotherapy in Finland during 2011-2022. We also reflected the second-line treatment patterns on changes in the reimbursement policy, and the national type 2 diabetes (T2D) care guidelines. METHODS Using register data on all reimbursed ADM purchases during 2010-2022, we defined nine annual cohorts of patients initiating regular metformin monotherapy during 2011-2019, each with a three-year follow-up. Descriptive methods were used to study the patterns of metformin monotherapy and second-line intensification over time. Proportional hazards models were used to analyse the take-up of the second-line ADM. RESULTS The share of new patients initiating metformin use (11-13% of all metformin users) and regular metformin use (83-85% of all new metformin users) remained stable. In all cohorts, 16-19% of the patients took up a second-line ADM (median time to intensification 1.5 years). With the 2011 cohort as reference, the highest proportion of new regular metformin users taking up a second ADM (hazard ratio 1.12. 95% confidence interval 1.07 ; 1.16, P < .0001) was in the 2019 cohort. In the 2017 cohort, the proportion of patients initiating sodium-glucose cotransporter 2 inhibitors as second-line treatment surpassed those initiating dipeptidyl peptidase-4 inhibitors. The reimbursement policy restricted the use of GLP-1-analogues. CONCLUSIONS Second-line treatment intensification patterns over time paralleled the changes in the reimbursement system. Thus, our findings suggest that the reimbursement policy may influence the use of ADMs in Finland.
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Affiliation(s)
- Hanna Rättö
- Research Unit, The Social Insurance Institution of Finland, P.O. Box 450, Helsinki, 00056 KELA, Finland.
| | - Terhi Kurko
- Research Unit, The Social Insurance Institution of Finland, P.O. Box 450, Helsinki, 00056 KELA, Finland
| | - Pia Pajunen
- Medical Advisory Unit, The Social Insurance Institution of Finland, Helsinki, Finland
| | - Helena Kastarinen
- Medical Advisory Unit, The Social Insurance Institution of Finland, Kuopio, Finland
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Bidulka P, Lugo-Palacios DG, Carroll O, O'Neill S, Adler AI, Basu A, Silverwood RJ, Bartlett JW, Nitsch D, Charlton P, Briggs AH, Smeeth L, Douglas IJ, Khunti K, Grieve R. Comparative effectiveness of second line oral antidiabetic treatments among people with type 2 diabetes mellitus: emulation of a target trial using routinely collected health data. BMJ 2024; 385:e077097. [PMID: 38719492 PMCID: PMC11077536 DOI: 10.1136/bmj-2023-077097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE To compare the effectiveness of three commonly prescribed oral antidiabetic drugs added to metformin for people with type 2 diabetes mellitus requiring second line treatment in routine clinical practice. DESIGN Cohort study emulating a comparative effectiveness trial (target trial). SETTING Linked primary care, hospital, and death data in England, 2015-21. PARTICIPANTS 75 739 adults with type 2 diabetes mellitus who initiated second line oral antidiabetic treatment with a sulfonylurea, DPP-4 inhibitor, or SGLT-2 inhibitor added to metformin. MAIN OUTCOME MEASURES Primary outcome was absolute change in glycated haemoglobin A1c (HbA1c) between baseline and one year follow-up. Secondary outcomes were change in body mass index (BMI), systolic blood pressure, and estimated glomerular filtration rate (eGFR) at one year and two years, change in HbA1c at two years, and time to ≥40% decline in eGFR, major adverse kidney event, hospital admission for heart failure, major adverse cardiovascular event (MACE), and all cause mortality. Instrumental variable analysis was used to reduce the risk of confounding due to unobserved baseline measures. RESULTS 75 739 people initiated second line oral antidiabetic treatment with sulfonylureas (n=25 693, 33.9%), DPP-4 inhibitors (n=34 464 ,45.5%), or SGLT-2 inhibitors (n=15 582, 20.6%). SGLT-2 inhibitors were more effective than DPP-4 inhibitors or sulfonylureas in reducing mean HbA1c values between baseline and one year. After the instrumental variable analysis, the mean differences in HbA1c change between baseline and one year were -2.5 mmol/mol (95% confidence interval (CI) -3.7 to -1.3) for SGLT-2 inhibitors versus sulfonylureas and -3.2 mmol/mol (-4.6 to -1.8) for SGLT-2 inhibitors versus DPP-4 inhibitors. SGLT-2 inhibitors were more effective than sulfonylureas or DPP-4 inhibitors in reducing BMI and systolic blood pressure. For some secondary endpoints, evidence for SGLT-2 inhibitors being more effective was lacking-the hazard ratio for MACE, for example, was 0.99 (95% CI 0.61 to 1.62) versus sulfonylureas and 0.91 (0.51 to 1.63) versus DPP-4 inhibitors. SGLT-2 inhibitors had reduced hazards of hospital admission for heart failure compared with DPP-4 inhibitors (0.32, 0.12 to 0.90) and sulfonylureas (0.46, 0.20 to 1.05). The hazard ratio for a ≥40% decline in eGFR indicated a protective effect versus sulfonylureas (0.42, 0.22 to 0.82), with high uncertainty in the estimated hazard ratio versus DPP-4 inhibitors (0.64, 0.29 to 1.43). CONCLUSIONS This emulation study of a target trial found that SGLT-2 inhibitors were more effective than sulfonylureas or DPP-4 inhibitors in lowering mean HbA1c, BMI, and systolic blood pressure and in reducing the hazards of hospital admission for heart failure (v DPP-4 inhibitors) and kidney disease progression (v sulfonylureas), with no evidence of differences in other clinical endpoints.
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Affiliation(s)
- Patrick Bidulka
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - David G Lugo-Palacios
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Orlagh Carroll
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen O'Neill
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda I Adler
- Diabetes Trials Unit, The Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Headington, Oxford, UK
| | - Anirban Basu
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle, WA, USA
| | - Richard J Silverwood
- Centre for Longitudinal Studies, UCL Social Research Institute, University College London, London, UK
| | - Jonathan W Bartlett
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Paul Charlton
- Patient author, Patient Research Champion Team, National Institute for Health and Care Research, London, UK
| | - Andrew H Briggs
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Sim R, Chong CW, Loganadan NK, Saidoung P, Adam NL, Hussein Z, Chaiyakunapruk N, Lee SWH. Cost-Effectiveness of Glucose-Lowering Therapies as Add-on to Standard Care for People With Type 2 Diabetes in Malaysia. Value Health Reg Issues 2023; 38:9-17. [PMID: 37419012 DOI: 10.1016/j.vhri.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/21/2023] [Accepted: 05/24/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVES This study aims to evaluate the cost-effectiveness of various glucose-lowering therapies as add-on to standard care for people with type 2 diabetes (T2D) in Malaysia. METHODS A state-transition microsimulation model was developed to compare the clinical and economic outcomes of 4 treatments: standard care, dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter-2 inhibitors (SGLT2is), and glucagon-like peptide-1 receptor agonists. Cost-effectiveness was assessed from a healthcare provider's perspective over a lifetime horizon with 3% discount rate in a hypothetical cohort of people with T2D. Data input were informed from literature and local data when available. Outcome measures include costs, quality-adjusted life-years, incremental cost-effectiveness ratios, and net monetary benefits. Univariate and probabilistic sensitivity analyses were performed to assess uncertainties. RESULTS Over a lifetime horizon, the costs to treat a person with T2D ranged from RM 12 494 to RM 41 250, whereas the QALYs gains ranged from 6.155 to 6.731, depending on the treatment. Based upon a willingness-to-pay threshold of RM 29 080 per QALY, we identified SGLT2i as the most cost-effective glucose-lowering treatment, as add-on to standard care over patient's lifetime, with the net monetary benefit of RM 176 173 and incremental cost-effectiveness ratios of RM 12 279 per QALY gained. The intervention also added 0.577 QALYs and 0.809 LYs compared with standard care. Cost-effectiveness acceptability curve showed that SGLT2i had the highest probability of being cost-effective in Malaysia across varying willingness-to-pay threshold. The results were robust to various sensitivity analyses. CONCLUSIONS SGLT2i was found to be the most cost-effective intervention to mitigate diabetes-related complications.
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Affiliation(s)
- Ruth Sim
- School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
| | - Chun Wie Chong
- School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
| | - Navin Kumar Loganadan
- Department of Pharmacy, Putrajaya Hospital, Ministry of Health Malaysia, Putrajaya, Malaysia
| | - Pantakarn Saidoung
- Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand; Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Noor Lita Adam
- Hospital Tuanku Jaafar, Ministry of Health Malaysia, Seremban Malaysia
| | - Zanariah Hussein
- Department of Medicine, Putrajaya Hospital, Ministry of Health Malaysia, Putrajaya, Malaysia
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA; IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Selangor, Malaysia; School of Pharmacy, Faculty of Health and Medical Sciences, Taylor's University, Selangor, Malaysia; Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Selangor, Malaysia; Center for Global Health, University of Pennsylvania, Philadelphia, PA, USA.
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Mahmoud F, Mullen A, Sainsbury C, Rushworth GF, Yasin H, Abutheraa N, Mueller T, Kurdi A. Meta-analysis of factors associated with antidiabetic drug prescribing for type 2 diabetes mellitus. Eur J Clin Invest 2023; 53:e13997. [PMID: 37002856 DOI: 10.1111/eci.13997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/09/2023] [Accepted: 03/22/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND There is a lack of consensus on prescribing alternatives to initial metformin therapy and intensification therapy for type 2 diabetes mellitus (T2DM) management. This review aimed to identify/quantify factors associated with prescribing of specific antidiabetic drug classes for T2DM. METHODS Five databases (Medline/PubMed, Embase, Scopus, Web of Science) were searched using the synonyms of each concept (patients with T2DM, antidiabetic drugs and factors influencing prescribing) in both free text and Medical Subject Heading (MeSH) forms. Quantitative observational studies evaluating factors associated with antidiabetic prescribing of metformin, sulfonylurea, thiazolidinedione, Dipeptidyl-peptidase 4 inhibitors (DPP4-I), sodium glucose transporter 2 inhibitors (SGLT2-I), Glucagon-Like peptide receptor agonist (GLP1-RA) and insulin in outpatient settings and published from January 2009 to January 2021 were included. Quality assessment was performed using a Newcastle-Ottawa scale. The validation was done for 20% of identified studies. The pooled estimate was measured using a three-level random-effect meta-analysis model based on odds ratio [95% confidence interval]. Age, sex, body mass index (BMI), glycaemic control (HbA1c) and kidney-related problems were quantified. RESULTS Of 2331 identified studies, 40 met the selection criteria. Of which, 36 and 31 studies included sex and age, respectively, while 20 studies examined baseline BMI, HbA1c and kidney-related problems. The majority of studies (77.5%, 31/40) were rated as good and despite that the overall heterogeneity for each studied factor was more than 75%, it is mostly related to within-study variance. Older age was significantly associated with higher sulfonylurea prescription (1.51 [1.29-1.76]), yet lower prescribing of metformin (0.70 [0.60-0.82]), SGLT2-I (0.57 [0.42-0.79]) and GLP1-RA (0.52 [0.40-0.69]); while higher baseline BMI showed opposite significant results (sulfonylurea: 0.76 [0.62-0.93], metformin: 1.22 [1.08-1.37], SGLT2-I: 1.88 [1.33-2.68], and GLP1-RA: 2.35 [1.54-3.59]). Both higher baseline HbA1c and having kidney-related problems were significantly associated with lower metformin prescription (0.74 [0.57-0.97], 0.39 [0.25-0.61]), but more insulin prescriptions (2.41 [1.87-3.10], 1.52 [1.10-2.10]). Also, DPP4-I prescriptions were higher for patients with kidney-related problems (1.37 [1.06-1.79]) yet lower among patients with higher HbA1c (0.82 [0.68-0.99]). Sex was significantly associated with GLP1-RA and thiazolidinedione prescribing (F:M; 1.38 [1.19-1.60] and 0.91 [0.84-0.98]). CONCLUSION Several factors were identified as potential determinants of antidiabetic drug prescribing. The magnitude and significance of each factor differed by antidiabetic class. Patient's age and baseline BMI had the most significant association with the choice of four out of the seven studied antidiabetic drugs followed by the baseline HbA1c and kidney-related problems which had an impact on three studied antidiabetic drugs, whereas sex had the least impact on prescribing decision as it was associated with GLP1-RA and thiazolidinedione only.
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Affiliation(s)
- Fatema Mahmoud
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Alexander Mullen
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Chris Sainsbury
- Department of Diabetes, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Gordon F Rushworth
- Highland Pharmacy Education & Research Centre, NHS Highland, Inverness, UK
| | - Haya Yasin
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Nouf Abutheraa
- The Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Tanja Mueller
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Department of Pharmacology and Toxicology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
- Centre of Research and Strategic Studies, Lebanese French University, Erbil, Iraq
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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Bidulka P, Mathur R, Lugo-Palacios DG, O'Neill S, Basu A, Silverwood RJ, Charlton P, Briggs A, Smeeth L, Adler AI, Douglas IJ, Khunti K, Grieve R. Ethnic and socioeconomic disparities in initiation of second-line antidiabetic treatment for people with type 2 diabetes in England: A cross-sectional study. Diabetes Obes Metab 2023; 25:282-292. [PMID: 36134467 PMCID: PMC10092566 DOI: 10.1111/dom.14874] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/06/2022] [Accepted: 09/18/2022] [Indexed: 12/14/2022]
Abstract
AIMS To assess any disparities in the initiation of second-line antidiabetic treatments prescribed among people with type 2 diabetes mellitus (T2DM) in England according to ethnicity and social deprivation level. MATERIALS AND METHODS This cross-sectional study used linked primary (Clinical Practice Research Datalink) and secondary care data (Hospital Episode Statistics), and the Index of Multiple Deprivation (IMD). We included people aged 18 years or older with T2DM who intensified to second-line oral antidiabetic medication between 2014 and 2020 to investigate disparities in second-line antidiabetic treatment prescribing (one of sulphonylureas [SUs], dipeptidyl peptidase-4 [DPP-4] inhibitors, or sodium-glucose cotransporter-2 [SGLT2] inhibitors, in combination with metformin) by ethnicity (White, South Asian, Black, mixed/other) and deprivation level (IMD quintiles). We report prescriptions of the alternative treatments by ethnicity and deprivation level according to predicted percentages derived from multivariable, multinomial logistic regression. RESULTS Among 36 023 people, 85% were White, 10% South Asian, 4% Black and 1% mixed/other. After adjustment, the predicted percentages for SGLT2 inhibitor prescribing by ethnicity were 21% (95% confidence interval [CI] 19-23%), 20% (95% CI 18-22%), 19% (95% CI 16-22%) and 17% (95% CI 14-21%) among people with White, South Asian, Black, and mixed/other ethnicity, respectively. After adjustment, the predicted percentages for SGLT2 inhibitor prescribing by deprivation were 22% (95% CI 20-25%) and 19% (95% CI 17-21%) for the least deprived and the most deprived quintile, respectively. When stratifying by prevalent cardiovascular disease (CVD) status, we found lower predicted percentages of people with prevalent CVD prescribed SGLT2 inhibitors compared with people without prevalent CVD across all ethnicity groups and all levels of social deprivation. CONCLUSIONS Among people with T2DM, there were no substantial differences by ethnicity or deprivation level in the percentage prescribed either SGLT2 inhibitors, DPP-4 inhibitors or SUs as second-line antidiabetic treatment.
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Affiliation(s)
- Patrick Bidulka
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Rohini Mathur
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - David G Lugo-Palacios
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephen O'Neill
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Anirban Basu
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle, Washington
| | - Richard J Silverwood
- Centre for Longitudinal Studies, UCL Social Research Institute, University College London, London, UK
| | - Paul Charlton
- Patient Research Champion Team, National Institute for Health Research, Twickenham, UK
| | - Andrew Briggs
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Amanda I Adler
- Diabetes Trials Unit, The Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Headington, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Morton JI, Ilomӓki J, Magliano DJ, Shaw JE. Persistent disparities in diabetes medication receipt by socio-economic disadvantage in Australia. Diabet Med 2022; 39:e14898. [PMID: 35694847 PMCID: PMC9545050 DOI: 10.1111/dme.14898] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 06/09/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND It is unknown how use of newer glucose-lowering drugs (GLDs) has changed in Australia following the publication of clinical trials demonstrating definitive clinical advantages for glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose co-transporter 2 inhibitors (SGLT2is), and whether this varies by socio-economic disadvantage. METHODS We included 1,064,645 people with type 2 diabetes registered on the National Diabetes Services Scheme. This cohort was linked to the Pharmaceutical Benefits Scheme database to evaluate trends in diabetes medication receipt and variation by socio-economic disadvantage between 2013 and 2019. RESULTS The proportion of people with type 2 diabetes receiving ≥3 GLDs concurrently increased from 12% in 2013 to 25% in 2019. By 2019, 6% of people with diabetes were receiving a GLP-1 RA and 21% an SGLT2i. Disparities in receipt of GLP-1 RAs and SGLT2is by socio-economic disadvantage decreased over time (ORs for most vs. least disadvantaged quintile were 0.80 [0.77-0.85] and 0.87 [0.82-0.94] in 2014 and 0.95 [0.92-0.98] and 1.07 [1.05-1.09] in 2019 for GLP-1 RAs and SGLT2is, respectively). However, people in more disadvantaged areas were more likely to receive multiple GLDs. After stratifying by number of concurrent GLDs received, people in more disadvantaged areas were less likely to receive GLP-1 RAs and SGLT2is in 2019 (ORs for most vs. least disadvantaged: 0.81 [0.78-0.84] and 0.90 [0.87-0.93] for people receiving ≥3 GLDs, respectively). CONCLUSIONS After controlling for intensity of glucose-lowering therapy, people in more disadvantaged areas were less likely to receive cardioprotective GLDs, although disparities decreased over time.
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Affiliation(s)
- Jedidiah I. Morton
- Baker Heart and Diabetes InstituteMelbourneVictoriaAustralia
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityMelbourneVictoriaAustralia
| | - Jenni Ilomӓki
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityMelbourneVictoriaAustralia
| | - Dianna J. Magliano
- Baker Heart and Diabetes InstituteMelbourneVictoriaAustralia
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Jonathan E. Shaw
- Baker Heart and Diabetes InstituteMelbourneVictoriaAustralia
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
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Falkentoft AC, Andersen J, Malik ME, Selmer C, Gæde PH, Staehr PB, Hlatky MA, Fosbøl E, Køber L, Torp-Pedersen C, Gislason GH, Gerds TA, Schou M, Bruun NE, Ruwald AC. Impact of socioeconomic position on initiation of SGLT-2 inhibitors or GLP-1 receptor agonists in patients with type 2 diabetes – a Danish nationwide observational study. THE LANCET REGIONAL HEALTH. EUROPE 2022; 14:100308. [PMID: 35146474 PMCID: PMC8802041 DOI: 10.1016/j.lanepe.2022.100308] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Low socioeconomic position may affect initiation of sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and glucacon-like-peptide-1 receptor agonists (GLP-1RA) among patients with type 2 diabetes (T2D). We examined the association between socioeconomic position and initiation of SGLT-2i or GLP-1RA in patients with T2D at time of first intensification of antidiabetic treatment. Methods Through nationwide registers, we identified all Danish patients on metformin who initiated second-line add-on therapy between December 10, 2012, and December 31, 2020. For each time period (2012-2014, 2015-2017, and 2018-2020), we used multivariable multinomial logistic regression to associate disposable income, as proxy for socioeconomic position, with the probability of initiating a specific second-line treatment at time of first intensification. We reported probabilities standardised to the distribution of demographics and comorbidities of patients included in the last period (2018-2020). Findings We included 48915 patients (median age 62 years; 61·7% men). In each time period, high-income patients were more often men and had less comorbidities as compared with low income-patients. In each time period, the standardised probability of initiating a SGLT-2i or a GLP-1RA was significantly higher in the highest income group compared with the lowest: 11·4% vs. 9·5% (probability ratio [PR] 1·21, 95 % confidence interval [CI] 1·01-1·44) in 2012-2014; 22·6% vs. 19.6% (PR 1·15, CI 1·05-1·27) in 2015-2017; and 65·8% vs. 54·8% (PR 1·20, CI 1·16-1·24) in 2018-2020. The differences by income were consistent across multiple subgroups. Interpretation Despite a universal healthcare system, low socioeconomic position was consistently associated with a lower probability of initiating a SGLT-2i or a GLP-1RA. These disparities may widen the future socioeconomic gap in cardiovascular outcomes. Funding The work was funded by unrestricted grants from ‘Region Sjaelland Den Sundhedsvidenskabelige Forskningsfond’ and ‘Murermester Lauritz Peter Christensen og hustru Kirsten Sigrid Christensens Fond’.
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Affiliation(s)
- Alexander C. Falkentoft
- Department of Cardiology, Zealand University Hospital, University of Copenhagen, Roskilde, Denmark
- Address for corresponding author: Alexander Christian Falkentoft, Department of Cardiology, Zealand University Hospital, Sygehusvej 10, 4000 Roskilde, Denmark, Tel.: +45 50908969.
| | | | - Mariam Elmegaard Malik
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Christian Selmer
- Department of Endocrinology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark
| | | | | | - Mark A. Hlatky
- Department of Medicine, Stanford University School of Medicine, Stanford California, USA
| | - Emil Fosbøl
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjaellands Hospital, Hillerød, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gunnar H. Gislason
- The Danish Heart Foundation, Copenhagen, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Thomas Alexander Gerds
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Niels E. Bruun
- Department of Cardiology, Zealand University Hospital, University of Copenhagen, Roskilde, Denmark
- Institute of Clinical medicine, Copenhagen University, and Clinical Institute, Aalborg University, Denmark
| | - Anne-Christine Ruwald
- Department of Cardiology, Zealand University Hospital, University of Copenhagen, Roskilde, Denmark
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
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Bidulka P, O'Neill S, Basu A, Wilkinson S, Silverwood RJ, Charlton P, Briggs A, Adler AI, Khunti K, Tomlinson LA, Smeeth L, Douglas IJ, Grieve R. Protocol for an observational cohort study investigating personalised medicine for intensification of treatment in people with type 2 diabetes mellitus: the PERMIT study. BMJ Open 2021; 11:e046912. [PMID: 34580091 PMCID: PMC8477338 DOI: 10.1136/bmjopen-2020-046912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION For people with type 2 diabetes mellitus (T2DM) who require an antidiabetic drug as an add-on to metformin, there is controversy about whether newer drug classes such as dipeptidyl peptidase-4 inhibitors (DPP4i) or sodium-glucose co-transporter-2 inhibitors (SGLT2i) reduce the risk of long-term complications compared with sulfonylureas (SU). There is widespread variation across National Health Service Clinical Commissioning Groups (CCGs) in drug choice for second-line treatment in part because National Institute for Health and Care Excellence guidelines do not specify a single preferred drug class, either overall or within specific patient subgroups. This study will evaluate the relative effectiveness of the three most common second-line treatments in the UK (SU, DPP4i and SGLT2i as add-ons to metformin) and help target treatments according to individual risk profiles. METHODS AND ANALYSIS The study includes people with T2DM prescribed one of the second-line treatments-of-interest between 2014 and 2020 within the UK Clinical Practice Research Datalink linked with Hospital Episode Statistics and Office of National Statistics. We will use an instrumental variable (IV) method to estimate short-term and long-term relative effectiveness of second-line treatments according to individuals' risk profiles. This method minimises bias from unmeasured confounders by exploiting the natural variation in second-line prescribing across CCGs as an IV for the choice of prescribed treatment. The primary outcome to assess short-term effectiveness will be change in haemoglobin A1c (%) 12 months after treatment initiation. Outcome measures to assess longer-term effectiveness (maximum ~6 years) will include microvascular and macrovascular complications, all-cause mortality and hospital admissions during follow-up. ETHICS AND DISSEMINATION This study was approved by the Independent Scientific Advisory Committee (20-064) and the London School of Hygiene & Tropical Medicine Research Ethics Committee (21395). Results, codelists and other analysis code will be made available to patients, clinicians, policy-makers and researchers.
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Affiliation(s)
- Patrick Bidulka
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen O'Neill
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anirban Basu
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle, Washington, USA
| | - Samantha Wilkinson
- Personalized Healthcare Data Science, Roche Products Limited, Welwyn Garden City, UK
| | | | - Paul Charlton
- Patient Research Champion Team, National Institute for Health Research, Twickenham, UK
| | - Andrew Briggs
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda I Adler
- Diabetes Trials Unit, The Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Laurie A Tomlinson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Morton JI, Ilomӓki J, Magliano DJ, Shaw JE. The association of socioeconomic disadvantage and remoteness with receipt of type 2 diabetes medications in Australia: a nationwide registry study. Diabetologia 2021; 64:349-360. [PMID: 33078206 DOI: 10.1007/s00125-020-05304-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/09/2020] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS In recent years, several new medications for the treatment of type 2 diabetes have been released and some evidence indicates sociodemographic disparity in their utilisation. We sought to investigate sociodemographic disparities in receipt of diabetes medications across Australia. METHODS This study included 1,203,317 people with type 2 diabetes registered on the Australian National Diabetes Services Scheme (NDSS) followed from 2007 to 2015. The NDSS was linked to the Australian pharmaceutical claims database. We investigated trends in diabetes medication dispensing and variation in dispensing by sociodemographic strata. RESULTS Compared with individuals in the least disadvantaged areas, those in the most disadvantaged quintile were less likely to receive dipeptidyl peptidase-4 inhibitors (DPP4is), glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is) in the first year of availability (OR [95% CI] for most vs least disadvantaged: 0.78 [0.75, 0.82], 0.65 [0.60, 0.71] and 0.89 [0.84, 0.95], respectively). These disparities dissipated over time for DPP4is and SGLT2is but remained significant for GLP-1RAs. The OR (95% CI) of receiving DPP4is, GLP-1RAs and SGLT2is in the first year of availability for people in remote areas vs major cities was 0.46 (0.39, 0.54), 0.46 (0.35, 0.61) and 0.71 (0.59, 0.84), respectively. These disparities remained significant through to 2015. CONCLUSIONS/INTERPRETATION People with diabetes in more disadvantaged areas are less likely to receive newer diabetes medications, although this effect decreased over time. However, there are considerable and persistent differences in receipt of newer diabetes medications between major cities and remote areas of Australia. Graphical abstract.
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Affiliation(s)
- Jedidiah I Morton
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Jenni Ilomӓki
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Dianna J Magliano
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Dubrofsky L, Srivastava A, Cherney DZ. Sodium-Glucose Cotransporter-2 Inhibitors in Nephrology Practice: A Narrative Review. Can J Kidney Health Dis 2020; 7:2054358120935701. [PMID: 32637144 PMCID: PMC7315675 DOI: 10.1177/2054358120935701] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/10/2020] [Indexed: 12/11/2022] Open
Abstract
Purpose of the review: Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are recommended for eligible patients with type 2 diabetes for the secondary prevention of adverse cardiovascular and kidney disease outcomes. Patients with type 2 diabetes and albuminuric chronic kidney disease, a history of atherosclerotic cardiovascular disease, and/or heart failure with reduced ejection fraction should be assessed for the use of these therapies. Sources of information: The sources include published clinical trials with SGLT2is, with a focus on cardiovascular safety studies and kidney protection trials. Methods: Information was gathered via a review of relevant literature and clinical practice guidelines, incorporated with real-life clinical experience. Key findings: Clinicians prescribing these agents must be familiar with the benefits of SGLT2is on cardiovascular and renal endpoints, and with adverse effects of SGLT2is, including mycotic genital infections and diabetic ketoacidosis. Primary care physicians and specialists should know how to adjust antihypertensive, antiglycemic, and diuretic agents. With the results of completed cardiovascular outcome trials and the Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy trial, nephrologists specifically have a unique opportunity to impact the safe, effective, and equitable implementation of SGLT2is into clinical practice. Limitations: Further work is needed in specific patient subgroups, including patients with chronic kidney disease stages IV and V, patients with kidney disease but lower levels of albuminuria, and in patients without diabetes.
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Affiliation(s)
- Lisa Dubrofsky
- Division of Nephrology, University Health Network, University of Toronto, ON, Canada
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David Z Cherney
- Toronto General Hospital Research Institute, UHN, Toronto, ON, Canada.,Department of Physiology, University of Toronto, ON, Canada.,Department of Medicine, Division of Nephrology, University of Toronto, ON, Canada.,Banting & Best Diabetes Centre, Toronto, ON, Canada
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11
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Wilkinson S, Williamson E, Pokrajac A, Fogarty D, Stirnadel‐Farrant H, Smeeth L, Douglas IJ, Tomlinson LA. Comparative effects of sulphonylureas, dipeptidyl peptidase-4 inhibitors and sodium-glucose co-transporter-2 inhibitors added to metformin monotherapy: a propensity-score matched cohort study in UK primary care. Diabetes Obes Metab 2020; 22:847-856. [PMID: 31957254 PMCID: PMC7187358 DOI: 10.1111/dom.13970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/10/2020] [Accepted: 01/15/2020] [Indexed: 12/13/2022]
Abstract
AIM To assess the comparative effects of sodium-glucose co-transporter-2 (SGLT2) inhibitors, sulphonylureas (SUs) and dipeptidyl peptidase-4 (DPP-4) inhibitors on cardiometabolic risk factors in routine care. MATERIALS AND METHODS Using primary care data on 10 631 new users of SUs, SGLT2 inhibitors or DPP-4 inhibitors added to metformin, obtained from the UK Clinical Practice Research Datalink, we created propensity-score matched cohorts and used linear mixed models to describe changes in glycated haemoglobin (HbA1c), estimated glomerular filtration rate (eGFR), systolic blood pressure (BP) and body mass index (BMI) over 96 weeks. RESULTS HbA1c levels fell substantially after treatment intensification for all drugs: mean change at week 12: SGLT2 inhibitors: -15.2 mmol/mol (95% confidence interval [CI] -16.9, -13.5); SUs: -14.3 mmol/mol (95% CI -15.5, -13.2); and DPP-4 inhibitors: -11.9 mmol/mol (95% CI -13.1, -10.6). Systolic BP fell for SGLT2 inhibitor users throughout follow-up, but not for DPP-4 inhibitor or SU users: mean change at week 12: SGLT2 inhibitors: -2.3 mmHg (95% CI -3.8, -0.8); SUs: -0.8 mmHg (95% CI -1.9, +0.4); and DPP-4 inhibitors: -0.9 mmHg (95% CI -2.1,+0.2). BMI decreased for SGLT2 inhibitor and DPP-4 inhibitor users, but not SU users: mean change at week 12: SGLT2 inhibitors: -0.7 kg/m2 (95% CI -0.9, -0.5); SUs: 0.0 kg/m2 (95% CI -0.3, +0.2); and DPP-4 inhibitors: -0.3 kg/m2 (95% CI -0.5, -0.1). eGFR fell at 12 weeks for SGLT2 inhibitor and DPP-4 inhibitor users. At 60 weeks, the fall in eGFR from baseline was similar for each drug class. CONCLUSIONS In routine care, SGLT2 inhibitors had greater effects on cardiometabolic risk factors than SUs. Routine care data closely replicated the effects of diabetes drugs on physiological variables measured in clinical trials.
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Affiliation(s)
- Samantha Wilkinson
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Elizabeth Williamson
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | - Liam Smeeth
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Ian J. Douglas
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Laurie A. Tomlinson
- Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
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