First-line pharmacotherapy for incident type 2 diabetes: Prescription patterns, adherence and associated costs

Patterns of metformin use and glycated haemoglobin trends among patients with newly diagnosed type 2 diabetes in Alberta, Canada

AIM

Canadian guidelines recommend metformin as first-line therapy for incident uncomplicated type 2 diabetes and the vast majority of patients are treated accordingly. However, only 54% 65% remain on treatment after 1 year, with the highest discontinuation rates within the first 3 months. The purpose of this study was: (a) to identify individual and clinical factors associated with metformin discontinuation among patients with newly diagnosed uncomplicated type 2 diabetes in Alberta, Canada, and (b) describe glycated haemoglobin (HbA1c) trajectories in the first 12 months after initiation of pharmacotherapy, stratified by metformin usage pattern.

MATERIALS AND METHODS

We conducted a retrospective cohort study using linked administrative datasets from 2012 to 2017 to define a cohort of individuals with uncomplicated incident type 2 diabetes. Using logistic regression, we determined individual and clinical characteristics associated with metformin discontinuation. We categorized individuals based on patterns of metformin use and then used mean HbA1c measurements over a 12-month follow-up period to determine glycaemic trajectories for each pattern.

RESULTS

Characteristics associated with metformin discontinuation were younger age, lower baseline HbA1c and having fewer comorbidities. Sex, income and location (urban/rural) were not significantly associated with metformin discontinuation. Individuals who continued metformin with higher adherence and individuals who discontinued metformin entirely had lowest HbA1c values at 12 months from treatment initiation. Those who changed therapy or had additional therapies added had higher HbA1c values at 12 months.

CONCLUSION

Identifying characteristics associated with discontinuation of metformin and individuals' medication usage patterns provide an opportunity for targeted interventions to support patients' glycaemic management.

Socioeconomic factors associated with poor medication adherence in patients with type 2 diabetes

PURPOSE

This study aims to determine initiation and persistence for patients with type 2 diabetes receiving their first prescription of an antidiabetic agent and the associations with socioeconomic factors.

METHODS

A cohort study including 8515 patients with type 2 diabetes who were prescribed their first antidiabetic medication between 2012 and 2019 in Uppsala, Sweden, was followed during 2 years. Medical records were linked to national registers on dispensed drugs and socioeconomic data. Adherence was assessed based on patients' medication claims within 30 days of prescription (initiation) and continued claims after 24 months (persistence). Multivariable logistic regression was used to determine the associations with the socioeconomic factors age, sex, living status, country of birth, education, occupation, and income.

RESULTS

Within 30 days, 92.4% of the patients claimed their first prescription, and 64.0% were still being dispensed the initially prescribed medication after 24 months. Unemployed patients had lower initiation rates, and women had lower persistence rates. Factors associated with both low initiation and persistence were low income, young or old age, birth outside Europe, and being prescribed other diabetes drugs than metformin monotherapy.

CONCLUSION

Socioeconomic factors have different impact on the initiation of a new medication and the persistence to treatment in type 2 diabetes. It is important to acknowledge these differences to develop appropriate interventions to improve medication nonadherence.

Behaviour Change to Promote Diabetes Outcomes: Getting More From What We Have Through Dissemination and Scalability

The potential benefits of advanced medical treatments (pharmacotherapies) and technologies (diagnostics, devices and apps) are unrealized due to lack of sustained behaviour change in individuals living with type 2 diabetes. The lack of scale-up of effective health behaviour change interventions limits health improvement. Identification of mediators of behaviour change (adherence, self-efficacy, intrinsic motivation) can address this limitation by shifting the focus of behaviour change from input (which behaviour change strategy to choose) to output (what can the person adhere to and sustain). Technology and accessing the workplace environment to promote change offer scalable opportunities for facilitating health behaviour change in populations.

Lessons on Drug Development: A Literature Review of Challenges Faced in Nonalcoholic Fatty Liver Disease (NAFLD) Clinical Trials

NAFLD is the most common chronic liver disease worldwide, occurring in both obese and lean patients. It can lead to life-threatening liver diseases and nonhepatic complications, such as cirrhosis and cardiovascular diseases, that burden public health and the health care system. Current care is weight loss through diet and exercise, which is a challenging goal to achieve. However, there are no FDA-approved pharmacotherapies for NAFLD. This review thoroughly examines the clinical trial findings from 22 drugs (Phase 2 and above) and evaluates the future direction that trials should take for further drug development. These trialed drugs can broadly be categorized into five groups-hypoglycemic, lipid-lowering, bile-pathway, anti-inflammatory, and others, which include nutraceuticals. The multitude of challenges faced in these yet-to-be-approved NAFLD drug trials provided insight into a few areas of improvement worth considering. These include drug repurposing, combinations, noninvasive outcomes, standardization, adverse event alleviation, and the need for precision medicine with more extensive consideration of NAFLD heterogenicity in drug trials. Understandably, every evolution of the drug development landscape lies with its own set of challenges. However, this paper believes in the importance of always learning from lessons of the past, with each potential improvement pushing clinical trials an additional step forward toward discovering appropriate drugs for effective NAFLD management.

Metformin: Is it a drug for all reasons and diseases?

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.

Metformin therapy in pediatric type 2 diabetes mellitus and its comorbidities: A review

Type 2 diabetes (T2D) rates in children and adolescents are rising globally. T2D is a complex and aggressive disease in children with several comorbidities, high treatment failure rates, and insulin needs within a few years from diagnosis. While myriads of pharmacotherapies are licensed to treat adults with T2D, treatments accessible to children and adolescents have been limited until recently. Metformin is an old drug with multiple beneficial metabolic health effects beyond glycemic control. This review discusses Metformin's origins, its mechanisms of action, and evidence for its use in the pediatric population to treat and prevent T2D. We also explore the evidence for its use as an obesity therapy, which is the primary driver of T2D, and T2D-driven comorbidities. While emerging therapies create new horizons for managing pediatric T2D, Metformin remains an inexpensive and safe part of the treatment plans of many T2D children globally for its beneficial metabolic effects.

Prescribing patterns of antidiabetics in type 2 diabetes and factors affecting them

Introduction

There are limited studies that address the use of newer antidiabetics by prescribers in Saudi Arabia and their adoption of the newer diabetes guidelines. The primary aim of our study was to explore the prescribing patterns of first- and second-line agents for the management of type 2 diabetes and the factors affecting them.

Methods

A cross-sectional self-administered survey was designed to collect responses from the prescribers in the Makkah Region of Saudi Arabia from 16 February through 16 June 2021. The questionnaire was developed in the English language, piloted, and tested for validity. Participants were recruited on a convenience sampling basis, and the data were collected by visiting them in-person.

Results

A total of 103 prescribers responded to the survey. The majority of the respondents were male (69%), Saudi nationals (54%), practicing in Makkah city (62%), working in the government sector (62%), and had the prescribing experience of 1–5 years (37%). Metformin (95%) was the respondents' most preferred first-line drug of choice, followed by sulfonylureas (5%). When the first-line was contraindicated, sulfonylureas (30%) were considered the most preferred drug of choice, followed by DPP4 inhibitors (25%) and SGLT2 inhibitors (16%), respectively. When the first-line was not sufficient to control diabetes, sulfonylureas (32%) and DPP4 inhibitors (31%) were considered the most preferred drugs of choice as an add-on therapy. SGLT2 inhibitors (31%) and metformin (24%) were considered the preferred first-line choices if the patient had an established cardiovascular disease.

Conclusion

Sulfonylureas were found to be the most considered choice as second-line therapy. There is a need to provide targeted education to the prescribers related to the newer diabetes guidelines in order to promote the use of more evidence-based and safer antidiabetics.