Timing of GLP-1 Receptor Agonist Initiation for Treatment of Type 2 Diabetes in the UK

Introduction

Patients with type 2 diabetes mellitus (T2DM) who fail to meet glycaemic control are at increased risk of diabetes complications. For patients who cannot maintain glycaemic control with oral medication, one recommended option is to add an injectable glucagon-like peptide-1 receptor agonist (GLP-1 RA) to their treatment regimen. The purpose of this study was to examine time to treatment intensification with GLP-1 RAs, including the duration of time that patients did not maintain glycaemic control with oral medication.

Methods

This was a medical record review conducted in the UK via a physician survey. Patients eligible to have their records reviewed were required to be ≥ 18 years of age, have a confirmed T2DM diagnosis, and have initiated GLP-1 RA treatment for T2DM in the past 6 months. All glycated haemoglobin (HbA1c) values within 5 years prior to GLP-1 RA initiation were collected.

Results

A total of 113 physicians contributed data for 1096 patients (mean age at the time of GLP-1 RA initiation was 54.9 years, 55.4% were male, and 71.4% were White). Median time from T2DM diagnosis to GLP-1 RA initiation was 6.1 years. Median consecutive time patients taking oral regimens were not under glycaemic control (HbA1c > 7.0%) prior to GLP-1 RA initiation was 13.5 months. Patients treated by general practitioners (GPs) had a significantly longer duration of time with insufficient glycaemic control prior to GLP-1 RA initiation compared with patients treated by diabetes specialists (median time for specialists was 11.0 months vs. 17.0 months for GPs; p = 0.038).

Conclusions

Results suggest that treatment intensification is often delayed despite consistently poor glycaemic control for more than 12 months, contrary to treatment guideline recommendations. Findings from this study highlight that some T2DM patients may benefit from more rapid treatment intensification, which could improve glycaemic control and reduce the risk for many short- and long-term health complications.

Associated factors that influenced persistence with basal analog insulin therapy among people with type 2 diabetes: An exploratory analysis from a UK real-world sample

AIM

Real-world effectiveness of insulin therapy is affected by poor treatment persistence, often occurring soon after initiation. An international cross-sectional survey of people with type 2 diabetes mellitus (T2DM) has been conducted to describe reasons for non-persistence with insulin therapy.

METHODS

Responders to an online survey in 7 countries were classified as continuers (no gap of ≥7days), interrupters (interrupted therapy for ≥7days within first 6 months, then restarted), and discontinuers (terminated therapy for ≥7days within first 6 months, no restart before survey). We present the results from the United Kingdom (UK) cohort.

RESULTS

Of 942 global respondents, 131 were from the UK, having a mean age of 37years and a mean of 7years since first T2DM diagnosis. Reasons contributing to insulin continuation (n=50) were improved physical feeling (52.0%) and improved glycemic control (48.0%). Common reasons for interruption (n=50) or discontinuation (n=31), respectively were weight gain (50.0%, 48.4%) and hypoglycemia (38.0%, 25.8%). Most important reason for possible re-initiation for interrupters and discontinuers, respectively was persuasion by physician/healthcare professional (74.0%, 64.5%).

CONCLUSION

The benefits of basal insulin therapy motivated continuers to persist with the treatment; experienced or anticipated side effects contributed to interruption and discontinuation.

Demographic and Clinical Characteristics of Patients With Type 2 Diabetes Mellitus Initiating Dipeptidyl Peptidase 4 Inhibitors: A Retrospective Study of UK General Practice

PURPOSE

The majority of people with type 2 diabetes mellitus (T2DM) will develop chronic kidney disease in their lifetime. Because most dipeptidyl peptidase (DPP)-4 inhibitors require dose adjustment in patients with T2DM and renal impairment, we aimed to understand how these treatments are prescribed in UK clinical practice, and to determine whether recommended dose adjustments are being made at initial prescription.

METHODS

This retrospective, descriptive cohort study analyzed data from the Clinical Practice Research Datalink (CPRD). Patients of interest were those with T2DM and renal impairment initiated on a DPP-4 inhibitor between 2014 and 2015. Patients under 40 years of age and with type 1 diabetes were excluded. Descriptive statistics were calculated for baseline demographic and clinical characteristics, and the study protocol was approved by the Independent Scientific Advisory Committee for Medicines and Healthcare products Regulatory Agency database research.

FINDINGS

A total of 3425 patients diagnosed with T2DM and renal impairment and initiated on a DPP-4 inhibitor were identified. The percentages of patients prescribed the high dose of saxagliptin, alogliptin,sitagliptin, and vildagliptin were 48%, 43%, 41%, and 27%, respectively, which is not recommended given their renal dysfunction. These are conservative estimates, as they do not include patients with severe renal impairment on sitagliptin and alogliptin, whose doses should be further reduced. No patients were prescribed an inappropriately high dose of linagliptin, as there is no requirement for dose adjustment in patients with renal impairment.

IMPLICATIONS

In this study, a considerable number of patients with T2DM and renal impairment were prescribed an inappropriately high dose of saxagliptin, alogliptin, sitagliptin, or vildagliptin for their level of renal impairment at treatment initiation. This prescribing could have been due to the complexity of different dosing requirements, or a lack of awareness of the need for dose adjustment of most DPP-4 inhibitors in patients with renal impairment. Linagliptin may be used in patients with moderate or severe renal impairment without dose adjustment.

Comparisons of DNA marker-based genetic diversity with phenotypic estimates in maize grown in Pakistan

We compared DNA-based genetic diversity estimates with conventional estimates by investigating agronomically important traits in maize grown in the northwestern region of Pakistan. RAPD markers were used to characterize 10 commonly cultivated maize genotypes. The same material was tested for phenotypic variation of quantitative traits using replicated field trials. The genetic distances between pairs of genotypes using RAPD data were used to generate a similarity matrix and to construct a phenogram. Statistical analyses were carried out on the data obtained from field trials of all maize genotypes for days to 50% tasseling, days to 50% silking, plant height, ear height, grain yield, grain weight per cob, and ear length. Analysis of variance and single degree of freedom contrasts were performed on morphological data to examine the relationship between molecular-based clusters and agronomic traits. A molecular marker-based phenogram led to the grouping of all genotypes into four major clusters, some of which were distantly related. These clusters contained one to four genotypes. Analysis of variance showed significant variations among all genotypes for agronomic traits. The single degree of freedom contrasts between groups of genotypes indicated significant differences for most traits. Pair-wise comparisons between clusters were also significant. The two types of data correlated well, providing an opportunity for better choices for selection.

Phytochemical and toxicological studies of aqueous leaves extracts of Erythrophleum africanum

The leaves of Erythrophleum africanum is known in the arid land of tropical Africa to posses toxicological properties. Phytochemical, acute and sub-acute evaluation of the possible toxicity risk of E. africanum aqueous leaves extracts were investigated in this study. Phytochemical constituents detected in the leaves extracts were saponins (1.16% w/v), cardiac glycosides, tannins (0.17 true tannins and 0.23% w/v pseudotannins), flavonoid glycosides, free flavonoids and alkaloids (4.34% w/v). The Lethal Dose (LD50) of the aqueous leaves extracts was greater than 3000 mg kg(-1) per os (orally) in albino rats. Sub-acute administration of the extract for 28 days resulted in significant (p<0.05) changes in some renal and liver indices at 3000 and 2000-3000 mg kg(-1) body weight, respectively. Histopathological lesions of the kidney and liver in form of moderate and marked infiltration with necrosis and perivascular lymphocytic cuff were observed. The observed lesions could be due to roles played by liver and kidneys in metabolism of xenobiotics and their elimination from the body. These investigations thus seem to indicate the toxic effects of the aqueous leaves extracts of E. africanum at 2000-3000 mg kg(-1). These could be attributed to the combined toxicity of the phytochemical constituents such as tannins, saponins, glycosides and alkaloids.

Interactive electronic whiteboards in the medical classroom

Most research on computer-assisted instruction has concentrated on developing systems to be used outside the teaching environment to supplement or complement in-class teaching. We believe that interactive large-screen computers can be used effectively in the classroom as electronic whiteboards to more effectively teach select medical school courses. We describe our experience with one such device, the Xerox LiveBoard, to teach a course on computer-assisted clinical decision analysis to a group of first-year medical students.

Information retrieval using a "digital book shelf"

WALT (Washington University's Approach to Lots of Text), is a prototype interface designed to support information retrieval research. The WALT interface serves as a "front end" to a wide array of retrieval engines including those based on Boolean retrieval, latent semantic indexing, term frequency--inverse document frequency, and Bayesian inference techniques. The WALT interface is composed of seven distinct components: a document examination component known as the Document Browsing Area; four navigation components called the Book Shelf, the Book Spine, the Table of Contents, and the Path Clipboard; a term-based information retrieval component called Control Panel; and a relevance feedback component known as the Reader Feedback Panel. WALT's most unique feature may be it's use of "book shelf" and "book spine" metaphors both to facilitate navigation and to provide a histogram-based display showing documents deemed appropriate for answering user queries.