Antihyperglycemic Medications: A Claims-Based Estimate of First-line Therapy Use Prior to Initialization of Second-line Medications

How drug onset rate and duration of action affect drug forgiveness

Medication nonadherence is one of the largest problems in healthcare today, particularly for patients undergoing long-term pharmacotherapy. To combat nonadherence, it is often recommended to prescribe so-called "forgiving" drugs, which maintain their effect despite lapses in patient adherence. Nevertheless, drug forgiveness is difficult to quantify and compare between different drugs. In this paper, we construct and analyze a stochastic pharmacokinetic/pharmacodynamic (PK/PD) model to quantify and understand drug forgiveness. The model parameterizes a medication merely by an effective rate of onset of effect when the medication is taken (on-rate) and an effective rate of loss of effect when a dose is missed (off-rate). Patient dosing is modeled by a stochastic process that allows for correlations in missed doses. We analyze this "on/off" model and derive explicit formulas that show how treatment efficacy depends on drug parameters and patient adherence. As a case study, we compare the effects of nonadherence on the efficacy of various antihypertensive medications. Our analysis shows how different drugs can have identical efficacies under perfect adherence, but vastly different efficacies for adherence patterns typical of actual patients. We further demonstrate that complex PK/PD models can indeed be parameterized in terms of effective on-rates and off-rates. Finally, we have created an online app to allow pharmacometricians to explore the implications of our model and analysis.

Comparative effectiveness of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, and sulfonylureas on risk of major adverse cardiovascular events: emulation of a randomised target trial using electronic health records

BACKGROUND

Randomised clinical trials showed that compared with placebo, SGLT2 inhibitors and GLP-1 receptor agonists reduced risk of adverse cardiovascular events. The evidence base for the older antihyperglycaemic drug classes (DPP-4 inhibitors and sulfonylureas) is generally less well developed. Because most randomised trials evaluated one antihyperglycaemic medication versus placebo, a head-to-head comparative effectiveness analysis of the newer drug classes (SGLT2 inhibitors vs GLP-1 receptor agonists) or newer (SGLT2 inhibitors or GLP-1 receptor agonists) versus older (DPP-4 inhibitors or sulfonylureas) drug classes on risk of major adverse cardiovascular events (MACE) is not available. In this study, we aimed to evaluate the comparative effectiveness of incident use of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, or sulfonylureas on risk of MACE.

METHODS

We first specified the protocol of a four-arm randomised pragmatic clinical trial and then emulated it using the health-care databases of the US Department of Veterans Affairs. We built a cohort of metformin users with incident use of SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, or sulfonylureas between Oct 1, 2016 and Sept 30, 2021, and followed up until Dec 31, 2022. We used the overlap weighting approach to balance the treatment groups using a battery of predefined variables and a set of algorithmically selected variables from high-dimensional data domains. Both intention-to-treat and per-protocol analyses (the latter estimated the effect of maintained use of the antihyperglycaemic throughout follow-up) were conducted to estimate risk of MACE-defined as a composite endpoint of stroke, myocardial infarction, and all-cause mortality.

FINDINGS

The final cohort consisted of 283 998 new users of SGLT2 inhibitors (n=46 516), GLP-1 receptor agonists (n=26 038), DPP-4 inhibitors (n=55 310), or sulfonylureas (n=156 134). In intention-to-treat analyses, compared with sulfonylureas, SGLT2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors were associated with lower risk of MACE (hazard ratio [HR] 0·77 [95% CI 0·74-0.80], 0·78 [0·74-0·81), and 0·90 [0·86-0.93], respectively). Both SGLT2 inhibitors and GLP-1 receptor agonists were associated with a lower risk of MACE when compared with DPP-4 inhibitors (HR 0·86 [0·82-0·89] and 0·86 [0·82-0·90], respectively). The risk of MACE between SGLT2 inhibitors and GLP-1 receptor agonists yielded an HR of 0·99 (0·94-1·04). In per-protocol analyses, compared with sulfonylureas, SGLT2 inhibitors, GLP1 receptor agonists, and DPP-4 inhibitors were associated with reduced risk of MACE (HR 0·77 [95% CI 0·73-0·82], 0·77 [0·72-0·82], and 0·88 [0·83-0·93], respectively). Both SGLT2 inhibitors and GLP-1 receptor agonists were associated with a lower risk of MACE when compared with DPP-4 inhibitors (HR 0·88 [0·83-0·93] and 0·88 [0·82-0·93], respectively). The risk of MACE between SGLT2 inhibitors and GLP-1 receptor agonists yielded an HR of 1·01 (0·94-1·07).

INTERPRETATION

Both SGLT2 inhibitors and GLP-1 receptor agonists were associated with reduced risk of MACE compared with DPP-4 inhibitors or sulfonylureas. DPP-4 inhibitors were associated with reduced risk of MACE compared with sulfonylureas. There was no statistically significant difference in risk of MACE between SGLT2 inhibitors and GLP-1 receptor agonists. The results provide evidence of the real-world comparative effectiveness of the four most commonly used second-line antihyperglycaemics and could guide choice of antihyperglycaemic therapy.

FUNDING

US Department of Veterans Affairs and the American Society of Nephrology.

Comparative Effectiveness of Sodium-Glucose Cotransporter 2 Inhibitors vs Sulfonylureas in Patients With Type 2 Diabetes

Importance

In the treatment of type 2 diabetes, evidence of the comparative effectiveness of sodium-glucose cotransporter 2 (SGLT2) inhibitors vs sulfonylureas-the second most widely used antihyperglycemic class after metformin-is lacking.

Objective

To evaluate the comparative effectiveness of SGLT2 inhibitors and sulfonylureas associated with the risk of all-cause mortality among patients with type 2 diabetes using metformin.

Design, Setting, and Participants

A cohort study used data from the US Department of Veterans Affairs compared the use of SGLT2 inhibitors vs sulfonylureas in individuals receiving metformin for treatment of type 2 diabetes. A total of 23 870 individuals with new use of SGLT2 inhibitors and 104 423 individuals with new use of sulfonylureas were enrolled between October 1, 2016, and February 29, 2020, and followed up until January 31, 2021.

Exposures

New use of SGLT2 inhibitors or sulfonylureas.

Main Outcomes and Measures

This study examined the outcome of all-cause mortality. Predefined variables and covariates identified by a high-dimensional variable selection algorithm were used to build propensity scores. The overlap weighting method based on the propensity scores was used to estimate the intention-to-treat effect sizes of SGLT2 inhibitor compared with sulfonylurea therapy. The inverse probability of the treatment adherence weighting method was used to estimate the per-protocol effect sizes.

Results

Among the 128 293 participants (mean [SD] age, 64.60 [9.84] years; 122 096 [95.17%] men), 23 870 received an SGLT2 inhibitor and 104 423 received a sulfonylurea. Compared with sulfonylureas, SGLT2 inhibitors were associated with reduced risk of all-cause mortality (hazard ratio [HR], 0.81; 95% CI, 0.75-0.87), yielding an event rate difference of -5.15 (95% CI, -7.16 to -3.02) deaths per 1000 person-years. Compared with sulfonylureas, SGLT2 inhibitors were associated with a reduced risk of death, regardless of cardiovascular disease status, in several categories of estimated glomerular filtration rate (including rates from >90 to ≤30 mL/min/1.73 m2) and in participants with no albuminuria (albumin to creatinine ratio [ACR] ≤30 mg/g), microalbuminuria (ACR >30 to ≤300 mg/g), and macroalbuminuria (ACR >300 mg/g). In per-protocol analyses, continued use of SGLT2 inhibitors was associated with a reduced risk of death compared with continued use of sulfonylureas (HR, 0.66; 95% CI, 0.60-0.74; event rate difference, -10.10; 95% CI, -12.97 to -7.24 deaths per 1000 person-years). In additional per-protocol analyses, continued use of SGLT2 inhibitors with metformin was associated with a reduced risk of death compared with SGLT2 inhibitor treatment without metformin (HR, 0.70; 95% CI, 0.50-0.97; event rate difference, -7.62; 95% CI, -17.12 to -0.48 deaths per 1000 person-years).

Conclusions and Relevance

In this comparative effectiveness study analyzing data from the US Department of Veterans Affairs, among patients with type 2 diabetes receiving metformin therapy, SGLT2 inhibitor treatment was associated with a reduced risk of all-cause mortality compared with sulfonylureas. The results provide data from a real-world setting that might help guide the choice of antihyperglycemic therapy.

The medications and health care utilization of patients newly diagnosed with type 2 diabetes mellitus: A nationwide population-based cohort study

BACKGROUND/PURPOSE

The prevalence of young-onset diabetes (YOD) is increasing in Asia, but little is known about the metabolic control, associated complications, or medical behavior in this population. Our aim was to assess the prevalence of young-onset and late-onset type 2 diabetes mellitus (T2DM) and their associated risk factors and medical behaviors in Taiwan.

METHODS

Data were collected from the National Health Insurance Research Database of Taiwan on 11,244 patients from 2008 to 2013. We classified patients with young-onset diabetes if they were diagnosed before 40 years of age and late-onset diabetes (LOD) if diagnosed at 40 years of age or older. We analyzed the prevalence, medication, and medical behaviors between these groups.

RESULTS

We enrolled 2556 newly diagnosed T2DM patients in 2012. Demographics and comorbidities were recorded from YOD (n = 311) and LOD (n = 2245) patients. Most newly diagnosed patients started with monotherapy and almost half of them with sulfonylurea. The prevalence of YOD in Taiwan is up to 12%. In terms of treatment, 42% of T2DM patients are treated in clinics, 58% in hospital, and 25.2% by an endocrinologist.

CONCLUSION

Our study highlights the rising trend of YOD in Taiwan. National endeavors are urgently needed for early diagnosis, effective management, and primary prevention of diabetes.

Use of non-insulin diabetes medicines after insulin initiation: A retrospective cohort study

Background

Clinical guidelines recommend that metformin be continued after insulin is initiated among patients with type 2 diabetes, yet little is known regarding how often metformin or other non-insulin diabetes medications are continued in this setting.

Methods

We conducted a retrospective cohort study to characterize rates and use patterns of six classes of non-insulin diabetes medications: biguanides (metformin), sulfonylureas, thiazolidinediones (TZDs), glucagon-like peptide 1 receptor agonists (GLP1 receptor agonists), dipeptidyl peptidase 4 inhibitors (DPP4 inhibitors), and sodium-glucose co-transporter inhibitors (SGLT2 inhibitors), among patients with type 2 diabetes initiating insulin. We used the 2010–2015 MarketScan Commercial Claims and Encounters data examining 72,971 patients with type 2 diabetes aged 18–65 years old who initiated insulin and had filled a prescription for a non-insulin diabetes medication in the 90 days prior to insulin initiation. Our primary outcome was the proportion of patients refilling the various non-insulin diabetes medications during the first 90 days after insulin initiation. We also used time-to-event analysis to characterize the time to discontinuation of specific medication classes.

Results

Metformin was the most common non-insulin medication used prior to insulin initiation (N = 53,017, 72.7%), followed by sulfonylureas (N = 25,439, 34.9%) and DPP4 inhibitors (N = 8,540, 11.7%). More than four out of five patients (N = 65,902, 84.7%) refilled prescriptions for any non-insulin diabetes medications within 90 days after insulin initiation. Within that period, metformin remained the most common medication with the highest continuation rate of 84.6%, followed by SGLT2 inhibitors (81.9%) and TZDs (79.3%). Sulfonylureas were the least likely medications to be continued (73.6% continuation) though they remained the second most common medication class used after insulin initiation. The median time to discontinuation varied by therapeutic class from the longest time to discontinuation of 26.4 months among metformin users to the shortest (3.0 months) among SGLT2 inhibitor users.

Conclusion

While metformin was commonly continued among commercially insured adults starting insulin, rates of continuation of other non-insulin diabetes medications were also high. Further studies are needed to determine the comparative effectiveness and safety of continuing insulin secretagogues and newer diabetes medications after insulin initiation.

Association of Diabetes Mellitus Status and Glycemic Control With Secondary Prevention Medication Adherence After Acute Myocardial Infarction

Background

Cardioprotective medication adherence can mitigate the risk of recurrent cardiovascular events and mortality after acute myocardial infarction (AMI). We examined the associations of diabetes mellitus status and glycemic control with cardioprotective medication adherence after AMI.

Methods and Results

We performed a retrospective observational cohort study of 14 517 US veterans who were hospitalized for their first AMI between 2011 and 2014 and prescribed a beta‐blocker, 3‐hydroxy‐3‐methyl‐glutaryl‐CoA‐reductase inhibitor, and angiotensin‐converting enzyme inhibitor or angiotensin receptor blocker. The primary exposure was a diagnosis of type 2 diabetes mellitus; in diabetes mellitus patients, hemoglobin A1c (HbA1c) was a secondary exposure. The primary outcome was 1‐year adherence to all 3 medication classes, defined as proportion of days covered ≥0.8, assessed using adjusted risk differences and multivariable Poisson regression. Of 14 517 patients (mean age, 66.3 years; 98% male), 52% had diabetes mellitus; 9%, 31%, 24%, 15%, and 21% had HbA1c <6%, 6% to 6.9%, 7% to 7.9%, 8% to 8.9%, and ≥9%, respectively. Diabetes mellitus patients were more likely to be adherent to all 3 drug classes than those without diabetes mellitus (adjusted difference in adherence, 2.1% [0.5, 3.7]). Relative to those with HbA1c 6% to 6.9%, medication adherence declined with increasing HbA1c (risk ratio of achieving proportion of days covered ≥0.8, 0.99 [0.94, 1.04], 0.93 [0.87, 0.99], 0.82 [0.77, 0.88] for HbA1c 7–7.9%, 8–8.9%, and ≥9%, respectively).

Conclusions

Although diabetes mellitus status had a minor positive impact on cardioprotective medication adherence after AMI, glycemic control at the time of AMI may help identify diabetes mellitus patients at risk of medication nonadherence who may benefit from adherence interventions after AMI.