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Mitsuboshi S, Morizumi M, Kotake K, Kaseda R, Narita I. Individual dipeptidyl peptidase-4 inhibitors and acute kidney injury in patients with type 2 diabetes: A systematic review and network meta-analysis. Basic Clin Pharmacol Toxicol 2024; 135:71-80. [PMID: 38698656 DOI: 10.1111/bcpt.14014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/21/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
This network meta-analysis of randomized controlled trials aimed to determine whether any individual dipeptidyl peptidase-4 (DPP-4) inhibitors increase the risk of acute kidney injury (AKI). The Medical Literature Analysis and Retrieval System Online via PubMed, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were systematically searched to identify relevant studies. The primary outcome was AKI. A frequentist network meta-analysis was performed using a random-effects model to account for heterogeneity. Twenty-nine studies involving 56 117 participants were included. There were 918 cases of AKI (1.63%). The risk of bias was generally considered to be low. The only DPP-4 inhibitor that significantly increased the frequency of AKI when compared with placebo was sitagliptin (risk ratio 1.65, 95% confidence interval 1.22-2.23). However, because one study showed significant outliers in the funnel plot, in a highly heterogeneous population composed solely of patients undergoing surgery for coronary artery bypass graft, we conducted a post-hoc sensitivity analysis to exclude this study. The results showed no statistically significant difference in the risk of AKI between sitagliptin and placebo. Individual DPP-4 inhibitors do not appear to increase the risk of AKI. However, sitagliptin may be associated with AKI in patients with underlying severe cardiovascular disease.
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Affiliation(s)
| | - Makoto Morizumi
- Department of Pharmacy, Ohno Memorial Hospital, Osaka, Japan
| | - Kazumasa Kotake
- Department of Pharmacy, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Ryohei Kaseda
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Gonzalez J, Dave CV. Prescribing trends of SGLT2 inhibitors among HFrEF and HFpEF patients with and without T2DM, 2013-2021. BMC Cardiovasc Disord 2024; 24:285. [PMID: 38816795 PMCID: PMC11137883 DOI: 10.1186/s12872-024-03961-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are recommended for treatment of heart failure (HF), regardless of type 2 diabetes (T2DM) status. However, limited data exist on SGLT2i prescribing in HF patients without T2DM or across HF subtypes. METHODS This was a serial, cross-sectional study of US MarketScan commercial and Medicare claims (2013-2021). Prevalence of SGLT2i was calculated by calendar year among HFrEF and HFpEF patients and stratified by T2DM status. RESULTS Among 218,066 HFrEF patients [mean (SD): 54.9 (8.92) years; 66.4% male], the prevalence of SGLT2i use increased from 0.3 to 18.6%, while among 150,437 HFpEF patients [56.5 (7.77) years; 47.6% male], it rose from 0.5 to 9.9%. These increases were driven by the subgroup with comorbid T2DM. SGLT2i prevalence use ratios among patients with T2DM compared to those without decreased from > 100 in 2018 to 3.8 in 2021 among HFrEF patients, and from 83.1 in 2018 to 17.5 in 2021, coinciding with the publication of landmark trials and corresponding changes in clinical guidelines. CONCLUSIONS SGLT2i use rose rapidly following changes in guidelines but remained low among those without T2DM. By the end of the study, approximately 1 in 3 HFrEF and 1 in 5 HFpEF patients with T2DM were using an SGLT2i, compared to only 1 in 11 HFrEF and 1 in 85 HFpEF patients without T2DM. Future work identifying barriers with the uptake of GDMT, including SGLT2i, among HF patients is needed.
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Affiliation(s)
- Jimmy Gonzalez
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA.
- Department of Pharmacy, Jersey Shore University Medical Center, Neptune, NJ, USA.
| | - Chintan V Dave
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
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Gillett AC, Hagenaars SP, Handley D, Casanova F, Young KG, Green H, Lewis CM, Tyrrell J. The impact of major depressive disorder on glycaemic control in type 2 diabetes: a longitudinal cohort study using UK Biobank primary care records. BMC Med 2024; 22:211. [PMID: 38807170 PMCID: PMC11134616 DOI: 10.1186/s12916-024-03425-9] [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: 05/12/2023] [Accepted: 05/15/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND This study evaluates longitudinal associations between glycaemic control, measured by mean and within-patient variability of glycated haemaglobin (HbA1c) levels, and major depressive disorder (MDD) in individuals with type 2 diabetes (T2D), focusing on the timings of these diagnoses. METHODS In UK Biobank, T2D was defined using self-report and linked health outcome data, then validated using polygenic scores. Repeated HbA1c measurements (mmol/mol) over the 10 years following T2D diagnosis were outcomes in mixed effects models, with disease duration included using restricted cubic splines. Four MDD exposures were considered: MDD diagnosis prior to T2D diagnosis (pre-T2D MDD), time between pre-T2D MDD diagnosis and T2D, new MDD diagnosis during follow-up (post-T2D MDD) and time since post-T2D MDD diagnosis. Models with and without covariate adjustment were considered. RESULTS T2D diagnostic criteria were robustly associated with T2D polygenic scores. In 11,837 T2D cases (6.9 years median follow-up), pre-T2D MDD was associated with a 0.92 increase in HbA1c (95% CI: [0.00, 1.84]), but earlier pre-T2D MDD diagnosis correlated with lower HbA1c. These pre-T2D MDD effects became non-significant after covariate adjustment. Post-T2D MDD individuals demonstrated increasing HbA1c with years since MDD diagnosis ( β = 0.51 , 95% CI: [0.17, 0.86]). Retrospectively, across study follow-up, within-patient variability in HbA1c was 1.16 (95% CI: 1.13-1.19) times higher in post-T2D MDD individuals. CONCLUSIONS The timing of MDD diagnosis is important for understanding glycaemic control in T2D. Poorer control was observed in MDD diagnosed post-T2D, highlighting the importance of depression screening in T2D, and closer monitoring for individuals who develop MDD after T2D.
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Affiliation(s)
- Alexandra C Gillett
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Trust, London, UK.
| | - Saskia P Hagenaars
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Trust, London, UK
| | - Dale Handley
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Francesco Casanova
- Clinical and Biomedical Science, Institute of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Katherine G Young
- Clinical and Biomedical Science, Institute of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Harry Green
- Clinical and Biomedical Science, Institute of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Cathryn M Lewis
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Trust, London, UK
- Department of Medical and Molecular Genetics, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jess Tyrrell
- Clinical and Biomedical Science, Institute of Health and Life Sciences, University of Exeter, Exeter, UK
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Scheen AJ. Underuse of GLP-1 receptor agonists in the management of type 2 diabetes despite a favorable benefit-safety profile. Expert Opin Drug Saf 2024:1-14. [PMID: 38738549 DOI: 10.1080/14740338.2024.2354885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 05/09/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Patients with type 2 diabetes (T2DM) are at high risk of atherosclerotic cardiovascular disease (ASCVD) and cardiovascular death. Cardiovascular protection is a key objective in T2DM. AREAS COVERED Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have proven their efficacy in reducing major cardiovascular events in high-risk patients with T2DM in placebo-controlled trials, a finding confirmed in observational studies compared with other glucose-lowering agents. Overall, GLP-1RAs have a good safety profile associated with a favorable benefit/risk ratio for the management of T2DM, even if their cost-effectiveness might be questionable. International guidelines recommend GLP-1RAs as preferred glucose-lowering agents in patients with ASCVD and as a valuable alternative in overweight/obese patients with T2DM. However, real-life studies worldwide revealed that only a minority of patients receive a GLP-1RA, despite a positive trend for increased prescriptions in recent years. Surprisingly, however, fewer patients with established ASCVD are treated with these cardioprotective antihyperglycemic agents versus patients without ASCVD. EXPERT OPINION The reasons for GLP-1RA underuse in clinical practice are multiple. Multifaceted and coordinated interventions targeting all actors of the health-care system must be implemented to stimulate the adoption of GLP-1RAs as part of routine cardiovascular care among patients with T2DM, especially in those with ASCVD.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, CHU Liège, Liège, Belgium
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
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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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Suen M, Manski-Nankervis JA, McBride C, Lumsden N, Hunter B. Implementing a Sodium-Glucose Cotransporter 2 Inhibitor Module With a Software Tool (Future Health Today): Qualitative Study. JMIR Form Res 2024; 8:e50737. [PMID: 38477973 DOI: 10.2196/50737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 12/26/2023] [Accepted: 01/07/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Primary care plays a key role in the management of type 2 diabetes. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been demonstrated to reduce hospitalization and cardiac and renal complications. Tools that optimize management, including appropriate prescribing, are a priority for treating chronic diseases. Future Health Today (FHT) is software that facilitates clinical decision support and quality improvement. FHT applies algorithms to data stored in electronic medical records in general practice to identify patients who are at risk of a chronic disease or who have a chronic disease that may benefit from intensification of management. The platform continues to evolve because of rigorous evaluation, continuous improvement, and expansion of the conditions hosted on the platform. FHT currently displays recommendations for the identification and management of chronic kidney disease, cardiovascular disease, type 2 diabetes, and cancer risk. A new module will be introduced to FHT focusing on SGLT2 inhibitors in patients with type 2 diabetes who have chronic kidney diseases, cardiovascular diseases, or risk factors for cardiovascular disease. OBJECTIVE The study aims to explore the barriers and enablers to the implementation of an SGLT2 inhibitor module within the Future Health Today software. METHODS Clinic staff were recruited to participate in interviews on their experience in their use of a tool to improve prescribing behavior for SGLT2 inhibitors. Thematic analysis was guided by Clinical Performance Feedback Intervention Theory. RESULTS In total, 16 interviews were completed. Identified enablers of use included workflow alignment, clinical appropriateness, and active delivery of the module. Key barriers to use were competing priorities, staff engagement, and knowledge of the clinical topic. CONCLUSIONS There is a recognized benefit to the use of a clinical decision support tool to support type 2 diabetes management, but barriers were identified that impeded the usability and actionability of the module. Successful and effective implementation of this tool could support the optimization of patient management of type 2 diabetes in primary care.
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Affiliation(s)
- Matthew Suen
- Department of General Practice and Primary Care, University of Melbourne, Parkville, Australia
| | | | - Caroline McBride
- Department of General Practice and Primary Care, University of Melbourne, Parkville, Australia
| | - Natalie Lumsden
- Department of General Practice and Primary Care, University of Melbourne, Parkville, Australia
| | - Barbara Hunter
- Department of General Practice and Primary Care, University of Melbourne, Parkville, Australia
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Neuen BL, Jun M, Wick J, Kotwal S, Badve SV, Jardine MJ, Gallagher M, Chalmers J, Nallaiah K, Perkovic V, Peiris D, Rodgers A, Woodward M, Ronksley PE. Estimating the population-level impacts of improved uptake of SGLT2 inhibitors in patients with chronic kidney disease: a cross-sectional observational study using routinely collected Australian primary care data. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 43:100988. [PMID: 38192747 PMCID: PMC10772282 DOI: 10.1016/j.lanwpc.2023.100988] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/27/2023] [Accepted: 11/28/2023] [Indexed: 01/10/2024]
Abstract
Background Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce the risk of kidney failure and death in patients with chronic kidney disease (CKD) but are underused. We evaluated the number of patients with CKD in Australia that would be eligible for treatment and estimated the number of cardiorenal and kidney failure events that could be averted with improved uptake of SGLT2 inhibitors. Methods This cross-sectional observational study leveraged nationally representative primary care data from 392 Australian general practices (MedicineInsight) between 1 January 2020 and 31 December 2021. We identified patients that would have met inclusion criteria of key SGLT2 inhibitor trials and applied these data to age and sex-stratified estimates of CKD prevalence for the Australian population (using national census data), estimating the number of preventable events using trial event rates. Key outcomes included cardiorenal events (CKD progression, kidney failure, or death due to cardiovascular or kidney disease) and kidney failure. Findings In MedicineInsight, 44.2% of adults with CKD would have met CKD eligibility criteria for an SGLT2 inhibitor; baseline use was 4.1%. Applying these data to the Australian population, 230,246 patients with CKD would have been eligible for treatment with an SGLT2 inhibitor. Optimal implementation of SGLT2 inhibitors (75% uptake) could reduce cardiorenal and kidney failure events annually in Australia by 3644 (95% CI 3526-3764) and 1312 (95% CI 1242-1385), respectively. Interpretation Improved uptake of SGLT2 inhibitors for patients with CKD in Australia has the potential to prevent large numbers of patients experiencing CKD progression or dying due to cardiovascular or kidney disease. Identifying strategies to increase the uptake of SGLT2 inhibitors is critical to realising the population-level benefits of this drug class. Funding University of New South Wales Scientia Program and Boehringer IngelheimEli Lilly Alliance.
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Affiliation(s)
- Brendon L. Neuen
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Min Jun
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - James Wick
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sradha Kotwal
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Nephrology, Prince of Wales Hospital, Sydney, Australia
| | - Sunil V. Badve
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Renal Medicine, St George Hospital, Sydney, Australia
| | - Meg J. Jardine
- NHMRC Clinical Trials Centre, University of Sydney, New South Wales, Australia
- Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Martin Gallagher
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Renal Medicine, Liverpool Hospital, Sydney, Australia
| | - John Chalmers
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Kellie Nallaiah
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Vlado Perkovic
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - David Peiris
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Anthony Rodgers
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Mark Woodward
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Paul E. Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Panchal K, Lawson C, Chandramouli C, Lam C, Khunti K, Zaccardi F. Diabetes and risk of heart failure in people with and without cardiovascular disease: systematic review and meta-analysis. Diabetes Res Clin Pract 2024; 207:111054. [PMID: 38104900 DOI: 10.1016/j.diabres.2023.111054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/06/2023] [Accepted: 12/13/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND People with diabetes have an increased risk of heart failure (HF), compared to those without diabetes. However, no comprehensive systematic review and meta-analysis has explored whether these associations could differ in relation to prevalent cardiovascular disease (CVD). AIMS To estimate the association between diabetes and incident heart failure (HF), compared to without diabetes, in individuals with and without CVD. METHODS PubMed, Scopus, and Web of Science were searched for observational cohort studies from the earliest dates to 22nd March 2023. A random-effects model calculated the pooled relative risk (RR). RESULTS Of 11,609 articles, 31 and 6 studies reported data in people with type 2 diabetes (T2D) and type 1 diabetes (T1D) respectively. Individuals with T2D had an increased risk of HF irrespective of CVD prevalence: 1.61 (95% CI: 1.35-1.92) in those with CVD; 1.78 (1.60-1.99) without CVD; and 2.02 (1.75-2.33) with unspecified CVD prevalence. Meta-regression did not identify a significant difference comparing HF risk in T2D individuals with vs. without CVD (p = 0.232). CONCLUSION Peoplewith T2D, compared to those without diabetes, have similar increased risk of HF, regardless of CVD prevalence. Strategiesproven to lower HF risk in T2D individuals should be prioritized for those with and without CVD.
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Affiliation(s)
- Kajal Panchal
- University of Leicester, Leicester Diabetes Centre, UK.
| | - Claire Lawson
- University of Leicester, Department of Cardiovascular Sciences, UK.
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Trueman C, Shin E, Donovan A, McAdam-Marx C, Coan C. Pharmacist impact on evidence-based prescribing of diabetes medications in patients with clinical atherosclerotic cardiovascular disease. J Manag Care Spec Pharm 2023; 29:1275-1283. [PMID: 38058135 PMCID: PMC10776252 DOI: 10.18553/jmcp.2023.29.12.1275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
BACKGROUND Including pharmacists on care teams of patients with type 2 diabetes (T2D) has been shown to promote guideline-based prescribing and improve glycemic control, lowering risks of adverse cardiovascular outcomes. Evidence is lacking regarding whether including pharmacists on the care team is associated with the prescribing of GLP-1 receptor agonists (GLP-1 RA) and SGLT-2 inhibitors (SGLT-2i) recommended for use in patients with T2D and atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE To assess the association between having a pharmacist on the primary care team of patients with T2D and ASCVD and being prescribed a guideline-recommended GLP-1 RA or SGLT-2i. METHODS A cross-sectional analysis of patients with T2D and ASCVD seen by primary care providers at an academic medical center between June 2019 and May 2020 was completed. Patients with prescriptions for GLP-1 RA or SGLT-2i with evidence of cardiovascular benefit were identified and compared between those with pharmacist care vs usual care using multivariable log-binominal regression analyses. RESULTS Of 1,497 included patients, 1,283 (85.7%) were in the usual care group (mean age 68.9 years, hemoglobin A1c 7.6%) and 214 (14.3%) in the pharmacist care group (mean age 64.5 years, A1c 9.0%). Of the pharmacist care group, 50.5% were prescribed a GLP-1 RA or SGLT-2i with cardiovascular benefit vs 17.9% in the usual care group (P < 0.001). In multivariable analyses controlling for A1c and other potential confounders, those in the pharmacist care group were 2.15 times as likely to have been prescribed a GLP-1 RA or SGLT-2i than those in the usual care group (adjusted risk ratio 2.15, 95% CI = 1.83-2.52; P < 0.001). CONCLUSIONS These data provide preliminary evidence that integrating pharmacists into patient care teams is associated with increased prescribing of guideline-recommended treatment with GLP-1 RA and SGLT-2i in patients with T2D and ASCVD, yet there is room for improvement in prescribing these agents to patients with T2D and ASCVD.
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Affiliation(s)
- Caressa Trueman
- Department of Pharmacy and Nutrition Care, Nebraska Medicine, Omaha
| | - Emily Shin
- Department of Pharmacy and Nutrition Care, Nebraska Medicine, Omaha
| | - Anthony Donovan
- Department of Pharmacy and Nutrition Care, Nebraska Medicine, Omaha
| | - Carrie McAdam-Marx
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha
| | - Canice Coan
- Department of Pharmacy and Nutrition Care, Nebraska Medicine, Omaha
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Lin J, Pearson SA, Greenfield JR, Park KH, Havard A, Brieger D, Day RO, Falster MO, de Oliveira Costa J. Trends in use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) in Australia in the era of increased evidence of their cardiovascular benefits (2014-2022). Eur J Clin Pharmacol 2023; 79:1239-1248. [PMID: 37449993 PMCID: PMC10427543 DOI: 10.1007/s00228-023-03539-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE To investigate trends in SGLT2i and GLP-1RA use in Australia in the era of increased evidence of their cardiovascular benefits. METHODS We used national dispensing claims for a 10% random sample of Australians to estimate the number of prevalent and new users (no dispensing in the prior year) of SGLT2i or GLP-1RA per month from January 2014 to July 2022. We assessed prescriber specialty and prior use of other antidiabetic and cardiovascular medicines as a proxy for evidence of type 2 diabetes (T2D) and cardiovascular conditions, respectively. RESULTS We found a large increase in the number of prevalent users (216-fold for SGLT2i; 11-fold for GLP-1RA); in July 2022 approximately 250,000 Australians were dispensed SGLT2i and 120,000 GLP-1RA. Most new users of SGLT2i or GLP-1RA had evidence of both T2D and cardiovascular conditions, although from 2022 onwards, approximately one in five new users of SGLT2i did not have T2D. The proportion of new users initiating SGLT2i by cardiologists increased after 2021, reaching 10.0% of initiations in July 2022. Among new users with evidence of cardiovascular conditions, empagliflozin was the most commonly prescribed SGLT2i, while dulaglutide or semaglutide was the most common GLP-1RA. CONCLUSION SGLT2i and GLP-1RA use is increasing in Australia, particularly in populations with higher cardiovascular risk. The increased use of SGLT2i among people without evidence of T2D suggests that best-evidence medicines are adopted in Australia across specialties, aligning with new evidence and expanding indications.
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Affiliation(s)
- Jialing Lin
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Darlinghurst, Australia
- St Vincent's Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Clinical Diabetes, Appetite and Metabolism, Garvan Institute of Medical Research, Darlinghurst, Australia
| | - Kyeong Hye Park
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Endocrinology and Metabolism, National Health Insurance Ilsan Hospital, Goyang-shi, Gyeonggi-do, South Korea
| | - Alys Havard
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Richard O Day
- St Vincent's Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Michael O Falster
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Juliana de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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Winkley K, Sorsa T, Tian Q, Reece I, Fitzgerald C, Chamley M, Ismail K, Forbes A, Upsher R. The diabetes insulin self-management education (DIME) intervention for people with type 2 diabetes starting insulin: a pilot feasibility randomised controlled trial. Pilot Feasibility Stud 2023; 9:89. [PMID: 37237318 DOI: 10.1186/s40814-023-01318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 05/03/2023] [Indexed: 05/28/2023] Open
Abstract
OBJECTIVE To determine the feasibility and acceptability of a diabetes insulin self-management education (DIME) group intervention for people with type 2 diabetes starting insulin. DESIGN Single-centre parallel randomised pilot trial. SETTING Primary care, South London, UK. SUBJECTS Adults with type 2 diabetes, requiring insulin treatment, on maximum tolerated dose of 2 or more oral antidiabetic drugs with HbA1c > / = 7.5% (58 mmol/mol) on 2 occasions. We excluded people who were non-fluent in English; morbid obesity (BMI > / = 35 kg/m2); in employment that contraindicates insulin treatment; and those with severe depression, anxiety disorders, psychotic disorders, personality disorders, or cognitive impairment. METHODS Participants were randomised using blocks of 2 or 4 to 3, 2-h group, face-to-face, DIME sessions or standard insulin group education sessions (control). We assessed feasibility according to consent to randomisation and attendance at intervention (DIME) and standard group insulin education sessions. Acceptability of the interventions was determined using exit interviews. We additionally measured change in self-reported insulin beliefs, diabetes distress and depressive symptoms between baseline and 6-month post-randomisation. RESULTS There were 28 potentially eligible participants, of which 17 consented to randomisation, 9 were allocated to the DIME group intervention and 8 were allocated to the standard group insulin education. Three people withdrew from the study (1 from DIME and 2 from standard insulin education) before the start of the first session and did not complete baseline questionnaires. Of the remaining participants (n = 14), all DIME participants (n = 8) completed all 3 sessions, and all standard insulin education participants (n = 6) completed at least 1 standard insulin education session. The median group size was 2, the mean age of participants was 57.57 (SD 6.45) years, and 64% were female (n = 9). Exit interviews demonstrated that all participants (n = 7) found the group sessions acceptable, and thematic analysis of interview transcripts indicated social support, the content of group sessions and post-group experiences were positive, especially amongst DIME participants. There was improvement on self-report questionnaires. CONCLUSIONS The DIME intervention was acceptable and feasible to deliver to participants with type 2 diabetes starting insulin in South London, UK. TRIAL REGISTRATION International Study Registration Clinical Trial Network (ISRCTN registration number 13339678).
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Affiliation(s)
- Kirsty Winkley
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, SE1 8WA, London, UK.
| | - Taru Sorsa
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Qingxiu Tian
- Department of Endocrinology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Ilse Reece
- Lambeth Diabetes Intermediate Care Team, London, UK
| | | | - Mark Chamley
- Lambeth Diabetes Intermediate Care Team, London, UK
| | - Khalida Ismail
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Angus Forbes
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, SE1 8WA, London, UK
| | - Rebecca Upsher
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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12
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Summers SP, Rastogi V, Yadavalli SD, Wang SX, Schaller MS, Jones DW, Ochoa Chaar CI, de Bruin JL, Verhagen HJM, Schermerhorn ML. The Association between Diabetes Mellitus and its Management with Outcomes following Endovascular Repair for Descending Thoracic Aortic Aneurysm. J Vasc Surg 2023:S0741-5214(23)00545-1. [PMID: 36966848 DOI: 10.1016/j.jvs.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/17/2023] [Accepted: 02/24/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Prior literature is conflicted regarding the effect of diabetes mellitus (DM) on outcomes following endovascular repair of aortic aneurysms. In this study, we aimed to examine the association between DM and outcomes following TEVAR for TAA. METHODS We identified patients who underwent TEVAR for TAA of the descending thoracic aorta in the VQI between 2014-2022. We created two cohorts, DM and non-DM, based on the patient's preoperative DM status, and secondarily sub-stratified DM patients by management strategy: dietary management, non-insulin medications, and insulin therapy cohorts. Outcomes included perioperative and 5-year mortality, in-hospital complications, indications for repair, and one-year sac dynamics, which were analyzed with multivariable cox regression, multivariable logistic regression, and chi-square tests, respectively. RESULTS We identified 2,637 patients, of which 473 (18%) had DM preoperatively. Among DM patients, 25% were diet controlled, 54% non-insulin medications, and 21% insulin therapy. Within patients who underwent TEVAR for TAA, the proportions of ruptured presentation were higher in the dietary (11.1%) and insulin (14.3%) managed cohorts relative to non-insulin therapy (6.6%) and non-DM (6.9%). Following multivariable regression analysis, we found that DM was associated with similar perioperative mortality (OR: 1.14 [95% CI: 0.70-1.81]) and 5-year mortality compared with non-DM patients (HR: 1.15 [95% CI: 0.91-1.48]). Furthermore, all in-hospital complications were comparable between DM patients and non-DM patients. Compared with non-DM patients, dietary management of DM was significantly associated with higher adjusted perioperative mortality (OR: 2.16 [95% CI: 1.03-4.19]) and higher 5-year mortality (HR: 1.50 [95% CI: 1.03-2.20]), though this was not the case for other DM subgroups. All cohorts displayed similar one-year sac dynamics, with sac regression occurring in 47% of non-DM patients vs 46% of DM patients (P= 0.27). CONCLUSION Preoperatively, DM patients that underwent TEVAR had a higher proportion of ruptured presentation when treated with diet or insulin medications than when treated with non-insulin medications. Following TEVAR for descending TAA, DM was associated with a similar risk of perioperative and 5-year mortality to non-DM. In contrast, dietary therapy for DM was associated with significantly higher perioperative mortality and 5-year mortality.
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Affiliation(s)
- Steven P Summers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sophie X Wang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Melinda S Schaller
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Cassius I Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Taylor DM, Nimmo AM, Caskey FJ, Johnson R, Pippias M, Melendez-Torres G. Complex Interventions Across Primary and Secondary Care to Optimize Population Kidney Health: A Systematic Review and Realist Synthesis to Understand Contexts, Mechanisms, and Outcomes. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00097. [PMID: 36888919 PMCID: PMC10278806 DOI: 10.2215/cjn.0000000000000136] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/22/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND CKD affects 850 million people worldwide and is associated with high risk of kidney failure and death. Existing, evidence-based treatments are not implemented in at least a third of eligible patients, and there is socioeconomic inequity in access to care. While interventions aiming to improve delivery of evidence-based care exist, these are often complex, with intervention mechanisms acting and interacting in specific contexts to achieve desired outcomes. METHODS We undertook realist synthesis to develop a model of these context-mechanism-outcome interactions. We included references from two existing systematic reviews and from database searches. Six reviewers produced a long list of study context-mechanism-outcome configurations based on review of individual studies. During group sessions, these were synthesized to produce an integrated model of intervention mechanisms, how they act and interact to deliver desired outcomes, and in which contexts these mechanisms work. RESULTS Searches identified 3371 relevant studies, of which 60 were included, most from North America and Europe. Key intervention components included automated detection of higher-risk cases in primary care with management advice to general practitioners, educational support, and non-patient-facing nephrologist review. Where successful, these components promote clinician learning during the process of managing patients with CKD, promote clinician motivation to take steps toward evidence-based CKD management, and integrate dynamically with existing workflows. These mechanisms have the potential to result in improved population kidney disease outcomes and cardiovascular outcomes in supportive contexts (organizational buy-in, compatibility of interventions, geographical considerations). However, patient perspectives were unavailable and therefore did not contribute to our findings. CONCLUSIONS This systematic review and realist synthesis describes how complex interventions work to improve delivery of CKD care, providing a framework within which future interventions can be developed. Included studies provided insight into the functioning of these interventions, but patient perspectives were lacking in available literature.
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Affiliation(s)
- Dominic M. Taylor
- Renal Service, North Bristol NHS Trust, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Ailish M. Nimmo
- Renal Service, North Bristol NHS Trust, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Fergus J. Caskey
- Renal Service, North Bristol NHS Trust, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Rachel Johnson
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Maria Pippias
- Renal Service, North Bristol NHS Trust, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
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McEwan P, Foos V, Martin B, Chen J, Evans M. Estimating the value of sodium-glucose cotransporter-2 inhibitors within the context of contemporary guidelines and the totality of evidence. Diabetes Obes Metab 2023. [PMID: 36864575 DOI: 10.1111/dom.15040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/04/2023]
Abstract
AIMS To comprehensively estimate the cost-effectiveness of sodium glucose cotransporter-2 (SGLT2) inhibitor usage in the management of type 2 diabetes mellitus (T2DM) at established clinical review points, incorporating the totality of proven health benefits. MATERIALS AND METHODS This study considered the cardio- and reno-protective effects of SGLT2 inhibitors using the Cardiff type 2 diabetes model. Conventional cost-effectiveness evaluations were undertaken for eligible populations at relevant intensification points reflecting the 2022 guidelines versus the 2015 National Institute of Health and Care Excellence (NICE) guidelines; incremental cost-effectiveness ratio lifetime trajectories and timepoints for complete cost-offset were estimated for each pathway. Treatment effects, utility decrements and costs (applied additively and discounted at 3.5%) were sourced from the published literature. RESULTS For all subpopulations on treatment pathways reflecting the NG28-2022 guidelines, SGLT2 inhibitor introduction was cost-effective, becoming cost-saving between 2 and 16 years post-initiation. Despite increases in pharmacy costs, predicted lifetime costs were lower than for pathways reflecting the NG28-2015 guidelines, driven by a reduction in heart failure hospitalization and chronic kidney disease costs. Incremental gains in quality-adjusted life years (ranging from 0.58-1.12) resulted in dominance for the updated NG28-2022 guidance in all scenarios. CONCLUSIONS Our results show that SGLT2 inhibitors have the potential to lower healthcare costs while improving health outcomes in eligible patient subpopulations.
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Affiliation(s)
- Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Volker Foos
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | | | - Jieling Chen
- AstraZeneca R&D Pharmaceuticals, Gaithersburg, Maryland, USA
| | - Marc Evans
- Diabetes Resource Centre, University Hospital Llandough, Cardiff, UK
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15
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Nagy DK, Bresee LC, Eurich DT, Simpson SH. Rural Residence Is Associated With a Delayed Trend Away From Sulfonylurea Use for Treatment Intensification of Type 2 Diabetes. Diabetes Care 2023; 46:613-619. [PMID: 36637880 DOI: 10.2337/dc22-1223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/17/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To examine the intersection between location of residence along the rural-urban continuum (metropolitan, urban, and rural) and sulfonylurea dispensation records for the management of type 2 diabetes. RESEARCH DESIGN AND METHODS This retrospective cohort study used administrative health records of adult new metformin users between April 2008 and March 2019 in Alberta, Canada. Multivariable logistic regression was performed to examine the association between sulfonylurea-based treatment intensification and location of residence. RESULTS Treatment was intensified in 66,084 (38%) of 171,759 new metformin users after a mean of 1.5 years. At treatment intensification, mean age was 55 years, 62% of users were male, and 27% were rural residents. The most common antihyperglycemic drug, given to 30,297 people (46%) for treatment intensification, was a sulfonylurea. At the beginning of our observation period, the proportion of people dispensed a sulfonylurea at first treatment intensification was highest in rural (57%), compared with urban (54%) and metropolitan (52%) areas (P = 0.009). Although proportions decreased over time across the province, rural residents continued to constitute the highest proportion of sulfonylurea users (45%), compared with urban (35%) and metropolitan (37%) residents (P < 0.001), and the trend away from sulfonylurea use was delayed by ∼4 years for rural residents. Adjusting for potential sources of confounding, rural residence was associated with a significantly higher likelihood of using a sulfonylurea compared with metropolitan residence (adjusted odds ratio 1.34; 95% CI 1.29-1.39). CONCLUSIONS Variation in sulfonylurea dispensation across the rural-urban continuum provides a basis for continued research in the differences in process of care by location.
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Affiliation(s)
- Danielle K Nagy
- 1Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Lauren C Bresee
- 2Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dean T Eurich
- 3School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Scot H Simpson
- 1Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
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Barth SD, Kostev K, Krensel M, Mathey E, Rathmann W. Do Glucagonlike Peptide-1 Receptor Agonist and Sodium-glucose Co-transporter 2 Inhibitor Prescriptions in Germany Reflect Recommendations for Type 2 Diabetes with Cardiovascular Disease of the ADA/EASD Consensus Report? Exp Clin Endocrinol Diabetes 2023; 131:153-161. [PMID: 35981560 DOI: 10.1055/a-1927-4454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To analyze whether prescription use of GLP-1RA and SGLT2i in individuals with type 2 diabetes with cardiovascular disease (CVD) has increased after the ADA/EASD consensus guidelines (2018) in a German Real-World setting and which clinical characteristics are associated with prescription use of these drugs. METHODS The Disease Analyzer database (IQVIA) comprises a representative panel of 1,373 general practitioners, diabetologists, and cardiologists throughout Germany (01/2015-12/2020: 12.6 million patients). Newly diagnosed type 2 diabetes (n=45,531) was identified by ICD-10 codes (E11). Matching (1:1) on practice specialty, sex, age, and year of diabetes diagnosis was performed for CVD. Logistic regression models were fitted to obtain adjusted odds ratios (OR) for characteristics associated with prescription use (median follow-up: 1.9 years). RESULTS Overall, 35% of patients (n=16,006) were treated with glucose-lowering drugs during the first year after type 2 diabetes diagnosis (HbA1c≥7.0%: 80%). GLP-1RA (2.4%) and SGLT2i (8.5%) were rarely prescribed. After the consensus, use of GLP-1RA and SGLT2i increased, however, almost independently of pre-existing CVD (12/2019-11/2020 vs. 12/2017-11/2018: yes, no): GLP-1RA: from 5.7 to 9.2%, 5.2 to 7.6%; SGLT2i: from 13.9 to 20.4%, 12.1 to 16.6%. Among cardiovascular risk factors, the largest OR for GLP-1RA was for obesity (4.5; 95%CI: 3.2-6.3). CVD was moderately related with SGLT2i (1.45; 1.32-1.60) and GLP-1RA (1.35; 1.08-1.69) prescriptions. A weak association was observed between SGLT2i and heart failure (1.18; 95%CI: 1.05-1.32). CONCLUSION National prescription use of GLP-1RA and SGLT2i did not come close to the recommendation in subjects with CVD issued by the 2018 ADA/EASD consensus.
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Affiliation(s)
| | | | | | | | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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The Growing Challenge of Chronic Kidney Disease: An Overview of Current Knowledge. Int J Nephrol 2023; 2023:9609266. [PMID: 36908289 PMCID: PMC9995188 DOI: 10.1155/2023/9609266] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/02/2023] [Accepted: 02/17/2023] [Indexed: 03/05/2023] Open
Abstract
Chronic kidney disease (CKD) is becoming one of the world's most prevalent noncommunicable chronic diseases. The World Health Organization projects CKD to become the 5th most common chronic disease in 2040. Causes of CKD are multifactorial and diverse, but early-stage symptoms are often few and silent. Progression rates are highly variable, but patients encounter both an increased risk for end-stage kidney disease (ESKD) as well as increased cardiovascular risk. End-stage kidney disease incidence is generally low, but every single case carries a significant burden of illness and healthcare costs, making prevention by early intervention both desirable and worthwhile. This review focuses on the prevalence, diagnosis, and causes of CKD. In addition, we discuss the developments in the general treatment of CKD, with particular attention to what can be initiated in general practice. With the addition of recent landmark findings and the expansion of the indication for using sodium-glucose cotransporter 2 inhibitors, there are now new effective treatments to add to standard therapy. This will also be relevant for primary care physicians as many patients with CKD have their family physician as their primary health care professional handling kidney function preservation. In the future, more precise and less invasive diagnostic methods may not only improve the determination of the underlying cause of CKD but may also carry information regarding which treatment to use (i.e. personalized medicine). This could lead to a reduced number of preventive treatments per individual, while at the same time improving the prognosis. This review summarizes ongoing efforts in this area.
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18
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Iketani R, Imai S. Prescription Trends for the Antidiabetic Agents Used to Treat Type 2 Diabetes Mellitus in Japan from 2012-2020: a Time-Series Analysis. Biol Pharm Bull 2023; 46:592-598. [PMID: 37005303 DOI: 10.1248/bpb.b22-00710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
In April 2014, sodium-glucose cotransporter 2 inhibitor (SGLT-2i) was introduced in Japan. In May 2015, the prescription limitation for SGLT-2i was lifted. Subsequently, SGLT-2i was shown to reduce cardiovascular events in patients with type 2 diabetes mellitus (T2DM). SGLT-2i prescription is expected to increase and consequently affect the prescription trends for other antidiabetic agents. Therefore, we evaluated the trends for antidiabetic agent prescriptions in Japan from April 2012 to March 2020. In this study, a dynamic cohort consisting of patients with T2DM derived from the Japan Medical Data Center health insurance database and with at least one antidiabetic agent prescription was investigated. The prescription rates were calculated monthly (/1000 person-months) for each class of antidiabetic agent. The eligible cohort comprised 34333 patients. The prescription rate for dipeptidyl peptidase-4 inhibitor increased from 424.0 in April 2012 to 656.3 in May 2015, and slightly decreased to 635.4 in March 2020. The prescription rate for biguanide consistently increased from 347.2 in April 2012 to 500.1 in March 2020. The prescription rate for sulfonylurea consistently decreased from 393.8 in April 2012 to 172.5 in March 2020. The prescription rate for SGLT-2i consistently increased from 4.1 in April 2014 to 363.1 in March 2020. SGLT-2i prescription increased and may affect the prescription trends for dipeptidyl peptidase-4 inhibitor and sulfonylurea after May 2015, when the prescription limitation for SGLT-2i was lifted. Biguanide prescriptions increased regardless of the introduction of SGLT-2i. The treatment of T2DM in Japan is clearly changing, with a focus on SGLT-2i and biguanide.
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Affiliation(s)
- Ryo Iketani
- Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health
| | - Shinobu Imai
- Division of Pharmacoepidemiology, Department of Healthcare and Regulatory Sciences, School of Pharmacy, Showa University
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Ng NM, Ng YS, Chu TK, Lau P. Factors affecting prescription of sodium-glucose co-transporter 2 inhibitors in patients with type 2 diabetes mellitus with established cardiovascular disease/ chronic kidney disease in Hong Kong: a qualitative study. BMC PRIMARY CARE 2022; 23:317. [PMID: 36476327 PMCID: PMC9730654 DOI: 10.1186/s12875-022-01928-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sodium-glucose co-transporter 2 inhibitors (SGLT2 I) has cardiorenal protective properties and are recommended for patients with diabetes and established atherosclerotic cardiovascular disease (ASCVD) and/or chronic kidney disease (CKD). Although cardiorenal complications are high in diabetes and pose a significant financial burden on the Hong Kong health care system, the use of SGLT2 I in these populations remains low. And yet this issue has not been explored in Hong Kong primary care. This study aimed to explore factors affecting primary care doctors' prescribing of SGLT2 I in patients with diabetes and established ASCVD/CKD in Hong Kong. METHODS A phenomenological qualitative research using semi-structured interviews was conducted between January and May 2021 in one Hospital Authority cluster in Hong Kong. Purposive sampling was employed to recruit primary care doctors in the cluster. The Theoretical Domains Framework (TDF) underpinned the study and guided the development of the interview questions. Data was analysed using both inductive and deductive approaches. The Consolidated criteria for reporting qualitative research (COREQ) checklist was used to guide the reporting. RESULTS Interviews were conducted with 17 primary care doctors. Four overarching themes were inductively identified: knowledge and previous practice patterns influence prescription, balancing risks and benefits, doctors' professional responsibilities, and system barriers. The four themes were then deductively mapped to the nine specific domains of the TDF: knowledge; intention; memory; beliefs about capabilities; beliefs about consequences; goals; role and identity; emotion; and environmental constraints. Most interviewees, to varying extent, were aware of the cardio-renal advantages and safety profile of SGLT2 I but are reluctant to prescribe or change their patients to SGLT2 I because of their knowledge gap that the cardio-renal benefits of SGLT2 I was independent of glyacemic efficacy. Other barriers included their considerations of patients' age and renal impairment, and patients' perceptions and preferences. CONCLUSIONS Despite evidence-based recommendations of the utilisation of SGLT2 I in patients with established ASCVD/CKD, the prescription behaviour among primary care doctors was affected by various factors, most of which were amendable. Our findings will inform the development of structured interventions to address these factors to improve patients' cardio-renal outcomes.
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Affiliation(s)
- Ngai Mui Ng
- grid.417336.40000 0004 1771 3971Department of Family Medicine and Primary Health Care, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong SAR, China
| | - Yeung Shing Ng
- grid.417336.40000 0004 1771 3971Department of Family Medicine and Primary Health Care, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong SAR, China
| | - Tsun Kit Chu
- grid.417336.40000 0004 1771 3971Department of Family Medicine and Primary Health Care, Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong SAR, China
| | - Phyllis Lau
- grid.1008.90000 0001 2179 088XDepartment of General Practice, University of Melbourne, 780, Elizabeth Street, Melbourne, VIC 3010 Australia ,grid.1029.a0000 0000 9939 5719School of Medicine, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
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Aslam AA, Baksh RA, Pape SE, Strydom A, Gulliford MC, Chan LF. Diabetes and Obesity in Down Syndrome Across the Lifespan: A Retrospective Cohort Study Using U.K. Electronic Health Records. Diabetes Care 2022; 45:dc220482. [PMID: 36178378 PMCID: PMC7613880 DOI: 10.2337/dc22-0482] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/12/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Down syndrome (DS) is the most common form of chromosomal trisomy. Genetic factors in DS may increase the risk for diabetes. This study aimed to determine whether DS is associated with an increased incidence of diabetes and the relationship with obesity across the life span compared with control patients. RESEARCH DESIGN AND METHODS This matched population-based cohort study analyzed UK Clinical Practice Research Datalink data from 1990 to 2020. RESULTS A total of 9,917 patients with DS and 38,266 control patients were analyzed. Diabetes rates were higher in patients with DS (incidence rate ratio 3.67; 95% CI 2.43-5.55; P < 0.0001) and peaked at a younger age (median age at diagnosis 38 [interquartile range 28-49] years vs. 53 [43-61] years in control patients). Incidence rates (per 1,000 person-years) for type 1 diabetes mellitus were 0.44 (95% CI 0.31-0.61) in patients with DS vs. 0.13 (0.09-0.17) in control patients. Type 2 diabetes mellitus (T2DM) rates were higher in patients with DS versus control patients in age-groups from 5 years up to 34 years. In patients with DS, peak mean BMI was higher and at a younger age (males 31.2 kg/m2 at age 31 years; females 32.1 kg/m2 at 43 years) versus control patients (males 29.5 kg/m2 at 54 years; females 29.2 kg/m2 at 51 years). Obesity was associated with an increased incidence of T2DM. CONCLUSIONS At younger ages, the incidence of diabetes in patients with DS is up to four times that of control patients. Peak mean BMI is higher and established earlier in DS, contributing to T2DM risk. Further investigation into the relationship between obesity and diabetes in DS is required to inform treatment and prevention measures.
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Affiliation(s)
- Aisha A Aslam
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, U.K
| | - R Asaad Baksh
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
- The LonDowns Consortium, London, U.K
| | - Sarah E Pape
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
- The LonDowns Consortium, London, U.K
- South London and Maudsley NHS Foundation Trust, London, U.K
| | - Andre Strydom
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
- The LonDowns Consortium, London, U.K
- South London and Maudsley NHS Foundation Trust, London, U.K
| | - Martin C Gulliford
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
- School of Life Course & Population Sciences, King's College London, London, U.K
| | - Li F Chan
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, U.K
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21
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Iketani R, Imai S. Impact of breakthrough trials on prescription trends of sodium-glucose cotransporter-2 inhibitors in Japan: An interrupted time-series analysis. J Clin Pharm Ther 2022; 47:1796-1804. [PMID: 36068684 DOI: 10.1111/jcpt.13768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/20/2022] [Accepted: 08/24/2022] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) have been increasingly prescribed for the treatment of type 2 diabetes mellitus (T2DM). We aimed to investigate the impact of clinical trials presenting remarkable results on the prescription of SGLT-2is and the relationship between the impact and generalisability of the breakthrough trials on SGLT-2is. METHODS This retrospective cohort study involved 32,949 patients with T2DM who were prescribed at least one antidiabetic agent in the Japan Medical Data Center health insurance database. Prescription rates of SGLT-2is were calculated monthly from April 2014 to March 2020. We evaluated the impact of the EMPA-REG OUTCOME study for an Asian subgroup on the prescription rate of empagliflozin and the impact of the CANVAS/CANVAS-R study on the prescription rate of canagliflozin. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were estimated using the quasi-Poisson regression model in the overall population, subgroup with a history of cardiovascular disease (high-risk group), and subgroup without a history and risk factors of cardiovascular disease (low-risk group). RESULTS AND DISCUSSION The EMPA-REG OUTCOME study for the Asian subgroup led to increased prescription rates of empagliflozin 3 months after its publication in the overall population and high-risk group but not in low-risk group (IRR [95% CI]: 1.40 [1.17-1.66], 1.39 [1.05-1.84], and 1.00 [0.79-1.27], respectively). The increase in high-risk group may be appropriate because this study included patients with a history of cardiovascular disease only. The CANVAS/CANVAS-R study led to increased prescription rates of canagliflozin 3 months after its publication in the overall population, high-risk group, and low-risk group (IRR [95% CI]: 1.52 [1.06-2.19], 1.39 [1.06-1.83], and 1.81 [1.20-2.75], respectively). The increase in low-risk group may not be appropriate because this study did not include patients without a history or risk factors of cardiovascular disease. WHAT IS NEW AND CONCLUSION The breakthrough trials increased prescription rates not only for patients to whom the trial results could be extrapolated but also for those in whom trial benefits were not certain. Our findings suggest that information about breakthrough trials may need to be provided along with data on trial result generalisability.
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Affiliation(s)
- Ryo Iketani
- Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, Wako, Saitama, Japan
| | - Shinobu Imai
- Department of Drug Safety and Risk Management, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
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22
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Triggle CR, Mohammed I, Bshesh K, Marei I, Ye K, Ding H, MacDonald R, Hollenberg MD, Hill MA. Metformin: Is it a drug for all reasons and diseases? Metabolism 2022; 133:155223. [PMID: 35640743 DOI: 10.1016/j.metabol.2022.155223] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/22/2022] [Accepted: 05/25/2022] [Indexed: 12/15/2022]
Abstract
Metformin was first used to treat type 2 diabetes in the late 1950s and in 2022 remains the first-choice drug used daily by approximately 150 million people. An accumulation of positive pre-clinical and clinical data has stimulated interest in re-purposing metformin to treat a variety of diseases including COVID-19. In polycystic ovary syndrome metformin improves insulin sensitivity. In type 1 diabetes metformin may help reduce the insulin dose. Meta-analysis and data from pre-clinical and clinical studies link metformin to a reduction in the incidence of cancer. Clinical trials, including MILES (Metformin In Longevity Study), and TAME (Targeting Aging with Metformin), have been designed to determine if metformin can offset aging and extend lifespan. Pre-clinical and clinical data suggest that metformin, via suppression of pro-inflammatory pathways, protection of mitochondria and vascular function, and direct actions on neuronal stem cells, may protect against neurodegenerative diseases. Metformin has also been studied for its anti-bacterial, -viral, -malaria efficacy. Collectively, these data raise the question: Is metformin a drug for all diseases? It remains unclear as to whether all of these putative beneficial effects are secondary to its actions as an anti-hyperglycemic and insulin-sensitizing drug, or result from other cellular actions, including inhibition of mTOR (mammalian target for rapamycin), or direct anti-viral actions. Clarification is also sought as to whether data from ex vivo studies based on the use of high concentrations of metformin can be translated into clinical benefits, or whether they reflect a 'Paracelsus' effect. The environmental impact of metformin, a drug with no known metabolites, is another emerging issue that has been linked to endocrine disruption in fish, and extensive use in T2D has also raised concerns over effects on human reproduction. The objectives for this review are to: 1) evaluate the putative mechanism(s) of action of metformin; 2) analyze the controversial evidence for metformin's effectiveness in the treatment of diseases other than type 2 diabetes; 3) assess the reproducibility of the data, and finally 4) reach an informed conclusion as to whether metformin is a drug for all diseases and reasons. We conclude that the primary clinical benefits of metformin result from its insulin-sensitizing and antihyperglycaemic effects that secondarily contribute to a reduced risk of a number of diseases and thereby enhancing healthspan. However, benefits like improving vascular endothelial function that are independent of effects on glucose homeostasis add to metformin's therapeutic actions.
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Affiliation(s)
- Chris R Triggle
- Department of Pharmacology, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar; Department of Medical Education, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar.
| | - Ibrahim Mohammed
- Department of Medical Education, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar
| | - Khalifa Bshesh
- Department of Medical Education, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar
| | - Isra Marei
- Department of Pharmacology, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar
| | - Kevin Ye
- Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, British Columbia V5A 1S6, Canada
| | - Hong Ding
- Department of Pharmacology, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar; Department of Medical Education, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar
| | - Ross MacDonald
- Distribution eLibrary, Weill Cornell Medicine in Qatar, P.O. Box 24144, Education City, Doha, Qatar
| | - Morley D Hollenberg
- Department of Physiology & Pharmacology, a Cumming School of Medicine, University of Calgary, T2N 4N1, Canada
| | - Michael A Hill
- Dalton Cardiovascular Research Center, Department of Medical Pharmacology & Physiology, School of Medicine, University of Missouri, Columbia 65211, MO, USA
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Khunti K, Jabbour S, Cos X, Mudaliar S, Mende C, Bonaca M, Fioretto P. Sodium-glucose co-transporter-2 inhibitors in patients with type 2 diabetes: Barriers and solutions for improving uptake in routine clinical practice. Diabetes Obes Metab 2022; 24:1187-1196. [PMID: 35238129 PMCID: PMC9313799 DOI: 10.1111/dom.14684] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/22/2022] [Accepted: 02/28/2022] [Indexed: 02/06/2023]
Abstract
Recent advances in type 2 diabetes (T2D) research have highlighted the benefits of sodium-glucose co-transporter-2 (SGLT-2) inhibitors, including cardiovascular and renal protection. However, uptake rates of these drugs remain low in patients with T2D, particularly in subpopulations most likely to benefit from them. This review considers the potential barriers to prescribing SGLT-2 inhibitors in T2D in clinical practice and outlines potential multidisciplinary recommendations to overcome these barriers. Safety concerns and a lack of clarity in and divergence of guidelines around the introduction of SGLT-2 inhibitors into treatment regimens may represent a barrier to uptake from the clinicians' perspective, including a general lack of understanding of the benefits associated with SGLT-2 inhibitors. Patient characteristics, such as socioeconomic status, may influence uptake because of the cost of SGLT-2 inhibitors, especially in the United States, where health insurance coverage could be a concern. SGLT-2 inhibitor prescription rates vary between clinical specialty (endocrinology, primary care, cardiology, and nephrology) and country, with cardiologists the lowest prescribers, and endocrinologists the highest. Primary care practitioners may experience more challenges in following SGLT-2 inhibitor-related guidelines than diabetes specialists as there may be fewer opportunities for education on how this drug class improves cardiovascular and renal outcomes in patients with T2D. Uptake rates appear to vary between countries because of differences in guidelines and health insurance systems. The amendment of SGLT-2 inhibitor-related guidelines for more multidisciplinary use and the implementation of patient and clinician education may encourage uptake of these drugs, potentially improving long-term health outcomes among patients with T2D.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, College of Medicine, Biological Sciences and PsychologyUniversity of LeicesterLeicesterUK
- NIHR Applied Research Collaboration ‐ East MidlandsLeicesterUK
| | - Serge Jabbour
- Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Xavier Cos
- Sant Marti de Provençals Primary Care CentresBarcelonaSpain
- Institut Català de la Salut. IDIAP Jordi Gol. DAP_Cat Study Group CIBERDEMUniversitat Autonoma de BarcelonaBarcelonaSpain
| | - Sunder Mudaliar
- Department of MedicineUniversity of California, San Diego School of MedicineSan DiegoCaliforniaUSA
- Veterans Affairs Medical CenterSan DiegoCaliforniaUSA
| | - Christian Mende
- Department of MedicineUniversity of California San DiegoLa JollaCaliforniaUSA
| | - Marc Bonaca
- Department of Medicine, Division of CardiologyUniversity of Colorado School of Medicine, Aurora CO; CPC Clinical ResearchAuroraColoradoUSA
| | - Paola Fioretto
- Department of MedicineUniversity of Padua, Unite of Medical Clinic 3, Hospital of PaduaPaduaItaly
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24
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Limonte CP, Hall YN, Trikudanathan S, Tuttle KR, Hirsch IB, de Boer IH, Zelnick LR. Prevalence of SGLT2i and GLP1RA use among US adults with type 2 diabetes. J Diabetes Complications 2022; 36:108204. [PMID: 35537891 DOI: 10.1016/j.jdiacomp.2022.108204] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/26/2022]
Abstract
AIMS To determine national prevalence of sodium-glucose contransporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP1RA) use among adults with type 2 diabetes mellitus (T2DM). METHODS We studied adults with T2DM and eGFR ≥ 30 mL/min/1.73 m2 who participated in the cross-sectional National Health and Nutrition Examination Survey (NHANES), focusing on the 2017-2020 examination cycle, a key time period prior to widespread dissemination of pivotal trial results and corresponding clinical practice guidelines. We tested prevalence of SGLT2i and GLP1RA use among subgroups based on demographic variables and relevant comorbidities, including chronic kidney disease (CKD), congestive heart failure (CHF), and atherosclerotic cardiovascular disease (ASCVD). We compared use of SGLT2i and GLP1RA to other glucose-lowering medications and assessed trends from prior NHANES cycles. RESULTS Among 1375 participants studied in 2017-2020, mean age was 60 years, 46% were women, 13% self-identified as non-Hispanic Black, 10% self-identified as Mexican American, 37% had CKD, 8.5% had CHF, and 23% had ASCVD. The prevalence of SGLT2i and GLP1RA use was 5.8% and 4.4%, respectively. Among adults with CKD, CHF, or ASCVD, SGLT2i were used by 7.7% and GLP1RA were used by 3.5%. Differences in SGLT2i or GLP1RA use were observed by age, race, ethnicity, health insurance status, body mass index, and by whether a single healthcare provider was identified as responsible for diabetes management. Biguanides, sulfonylureas, DPP-4 inhibitors, and insulin were used more frequently than SGLT2i or GLP1RA. Prevalence of SGLT2i but not GLP1RA use increased significantly from 2013-2014 to 2017-2020. CONCLUSIONS SGLT2i and GLP1RA use is low among adults with T2DM, including among those with strong indications. Enhanced implementation of these agents is crucial to improving kidney and cardiovascular outcomes and mitigating health disparities in T2DM.
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Affiliation(s)
- Christine P Limonte
- Kidney Research Institute and Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Yoshio N Hall
- Kidney Research Institute and Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Subbulaxmi Trikudanathan
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Katherine R Tuttle
- Providence Health Care, Spokane, WA, United States of America; Kidney Research Institute, Division of Nephrology and Institute of Translational Health Sciences, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Irl B Hirsch
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Ian H de Boer
- Kidney Research Institute and Division of Nephrology, Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Leila R Zelnick
- Kidney Research Institute and Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America.
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25
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Milder TY, Stocker SL, Baysari M, Day RO, Greenfield JR. Prescribing of SGLT2 inhibitors in primary care: A qualitative study of General Practitioners and Endocrinologists. Diabetes Res Clin Pract 2021; 180:109036. [PMID: 34481911 DOI: 10.1016/j.diabres.2021.109036] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/21/2021] [Accepted: 08/31/2021] [Indexed: 01/08/2023]
Abstract
AIMS To explore: 1) General Practitioners' (GPs') perspectives regarding initiating SGLT2 inhibitors and the resources that inform their pharmacotherapy choices; and 2) The support provided to GPs by Endocrinologists in relation to the prescription of type 2 diabetes medications. METHODS Semi-structured interviews with 15 GPs and 12 Endocrinologists working in diverse areas in New South Wales, Australia. Interviews were recorded, transcribed, and emergent themes were identified using a general inductive approach. RESULTS Under-appreciation of the cardio-renal benefits of SGLT2 inhibitors, a preference for an Endocrinologist to initiate therapy, and patients' experiences with adverse effects were identified as reasons for low rates of initiating SGLT2 inhibitors by some GPs. GPs reported that they would like to receive education about this topic from Endocrinologists, ideally via case-based discussions. A perceived challenge faced by Endocrinologists in providing GP education included potential constraints on talk content imposed by industry at sponsored events. Endocrinologists indicated that interactive sessions were most useful to GPs. CONCLUSIONS Despite the evidence for the cardio-renal benefits of SGLT2 inhibitors, there are barriers to GPs prescribing these agents. Case-based discussions between GPs and Endocrinologists about type 2 diabetes treatment including the role of SGLT2 inhibitors could overcome some of these barriers.
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Affiliation(s)
- Tamara Y Milder
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; Diabetes and Metabolism, Garvan Institute of Medical Research, Victoria St, Darlinghurst, Sydney 2010, Australia; St. Vincent's Clinical School, Faculty of Medicine and Health, University of NSW, Victoria St, Darlinghurst, Sydney, Australia.
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; University of Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, 2006, Australia
| | - Melissa Baysari
- Discipline of Biomedical Informatics and Digital Health, Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, 2006, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; St. Vincent's Clinical School, Faculty of Medicine and Health, University of NSW, Victoria St, Darlinghurst, Sydney, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; Diabetes and Metabolism, Garvan Institute of Medical Research, Victoria St, Darlinghurst, Sydney 2010, Australia; St. Vincent's Clinical School, Faculty of Medicine and Health, University of NSW, Victoria St, Darlinghurst, Sydney, Australia
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26
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Fernando K, Bain SC, Holmes P, Jones PN, Patel DC. Glucagon-Like Peptide 1 Receptor Agonist Usage in Type 2 Diabetes in Primary Care for the UK and Beyond: A Narrative Review. Diabetes Ther 2021; 12:2267-2288. [PMID: 34309808 PMCID: PMC8312211 DOI: 10.1007/s13300-021-01116-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/07/2021] [Indexed: 11/23/2022] Open
Abstract
The scientific landscape of treatments for type 2 diabetes (T2D) has changed rapidly in the last decade with newer treatments becoming available. However, a large proportion of people with T2D are not able to achieve glycaemic goals because of clinical inertia. The majority of T2D management is in primary care, where clinicians (medical, nursing and pharmacist staff) play an important role in addressing patient needs and achieving treatment goals. However, management of T2D is challenging because of the heterogeneity of T2D and complexity of comorbidity, time constraints, guidance overload and the evolving treatments. Additionally, the current coronavirus disease pandemic poses additional challenges to the management of chronic diseases such as T2D, including routine access to patients for monitoring and communication. Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are a class of agents that have evolved rapidly in recent years. These agents act in a glucose-dependent manner to promote insulin secretion and inhibit glucagon secretion, as well as enhancing satiety and reducing hunger. As a result, they are effective treatment options for people with T2D, achieving glycated haemoglobin reductions, weight loss and potential cardiovascular benefit, as monotherapy or as add-on to other glucose-lowering therapies. However, given the complexity of managing T2D, it is important to equip primary care clinicians with clear information regarding efficacy, safety and appropriate positioning of GLP-1 RA therapies in clinical practice. This review provides a summary of clinical and real-world evidence along with practical guidance, with the aim of aiding primary care clinicians in the initiation and monitoring of GLP-1 RAs to help ensure that desired outcomes are realised. Furthermore, a benefit/risk tool has been developed on the basis of current available evidence and guidelines to support primary care clinicians in selecting individuals who are most likely to benefit from GLP-1 RA therapies, in addition to indicating clinical situations where caution is needed.
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Affiliation(s)
- Kevin Fernando
- North Berwick Health Centre, North Berwick Group Practice, 54 St. Baldred's Road, North Berwick, EH39 4PU, UK.
| | | | | | | | - Dipesh C Patel
- University College London, Royal Free Campus, London, UK
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