Persistence Patterns with Oral Hypoglycemic Agents in Type 2 Diabetes
Jennifer StephensBetina T. BlakKaren GoldMarc BottemanChris L. PashosCaroline S. WalkinshawR. Keith Campbell
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Abstract:
• Objectives: To determine persistence with therapy in patients newly starting oral hypoglycemic treatment for management of type 2 diabetes, and to determine differences in persistence according to sex, age, and initial agent. • Design: Retrospective medication claims analysis. • Setting and participants: 46,884 patients from a large U.S. pharmacy benefits manager (PBM) database who were older than 18 years of age and who newly started monotherapy with an oral agent for type 2 diabetes. • Methods: All patients were followed for 10 months for refill persistence patterns with their initial drug. Agents included in the analysis were glimepiride, immediaterelease glipizide, glipizide GITS (gastrointestinal therapeutic system), glyburide, metformin, pioglitazone, repaglinide, and rosiglitazone. • Results: The overall average length of therapy was 167 days out of 300 days of follow-up. Women were significantly less persistent than men (161 days versus 173 days, respectively). Persistence significantly increased with patient age, from a low of 126 days (18‐34 years) to 179 days (50‐64 years), but then fell to 161 days (≥ 65 years). Significant differences were also identified for the oral agents, with persistence ranging from 126 days with repaglinide to 177 days with glipizide GITS. • Conclusions: Overall persistence with the initial oral hypoglycemic drug treatment appears to be low in type 2 diabetes and differs within sex, age, and individual drug categories. Careful selection of the initial oral agent to minimize adverse events and reduce dosing frequency may improve persistence, enhance glycemic control, and reduce the economic burden of type 2 diabetes.Keywords:
Repaglinide
Persistence (discontinuity)
Glipizide
Pioglitazone
Glimepiride
Rosiglitazone
Oral hypoglycemic agents
Gliclazide
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Combination therapy
Fixed-dose combination
Pharmacotherapy
Medication therapy management
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Persistence and adherence to treatment are essential to reach the treatment goals of hypertension. This study was conducted to investigate the antihypertensive drug persistence in hypertensive patients in the routine clinical settings. Patients above 20 years of age with stage 1 hypertension, who have received the first prescription for hypertension, were included in the study. Patients were followed up for one year. During each follow-up, the parameters noted were systolic and diastolic blood pressure, changes in the prescription by the treating physician, the number of days patient missed the medication and the probable reason for missing the dose, and total doses of anti-hypertensive medications received. Based on patient behavior of persistence with first-line single treatment, they were categorized as continuers, combiners, switchers, discontinuers. A total of 77 patients were included in the study, among them 51(66.2%) were males and 26 (33.8%) were females. Among these, 67 (87.1%) showed 100% adherence to medication schedule. Around 10 (12.99%) patients missed their antihypertensive medication for more than a day (2-24 days, mean 9.89±7.24 days). Amlodipine was the most common antihypertensive used, followed by atenolol and then losartan. There were no significant differences among the types of antihypertensives used among males and females as well as among diabetics and nondiabetics. Around 14 (18.2%) patients needed an add-on antihypertensive after 4-11 months. Most commonly used add on drug was atenolol. The target blood pressure goal (<140/90mmHg) was reached in 70 (90.9%) patients at the end of 1 year.
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Longer medication persistence in type 2 diabetes (T2D) is associated with improved glycaemic control. It is not clear which oral therapies have the best persistence. The objective of this study was to compare medication persistence across different oral therapies in people with T2D. We performed a retrospective cohort analysis using a primary-care-based population, the Royal College of General Practitioners Research and Surveillance Centre cohort. We identified new prescriptions for oral diabetes medication in people with type 2 diabetes between January 1, 2004 and July 31, 2015. We compared median persistence across each class. We also compared non-persistence (defined as a prescription gap of ≥ 90 days) between classes, adjusting for confounders, using Cox regression. Confounders included: age, gender, ethnicity, socioeconomic status, alcohol use, smoking status, glycaemic control, diabetes duration, diabetes complications, comorbidities, and number of previous and concurrent diabetes medications. We identified 60,327 adults with T2D. The majority 42,810 (70.9%) of those had one or more oral medications prescribed; we measured persistence in those patients (who were prescribed 55,728 oral medications in total). Metformin had the longest median persistence (3.04 years; 95% CI 2.94–3.12). The adjusted hazard ratios for non-persistence compared with metformin were: sulfonylureas HR 1.20 (1.16–1.24), DPP-4 inhibitors HR 1.43 (1.38–1.49), thiazolidinediones HR 1.71 (95% CI 1.64–1.77), SGLT2 inhibitors HR 1.04 (0.93–1.17), meglitinides HR 2.25 (1.97–2.58), and alpha-glucosidase inhibitors HR 2.45 (1.98–3.02). The analysis of SGLT2 inhibitors was limited by the short duration of follow-up for this new class. Other factors associated with reduced medication persistence were female gender, younger age, and non-white ethnicity. Persistence is strongly influenced by medication class and should be considered when initiating treatments.
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Non-persistence may be a significant barrier to the use of metformin. Our objective was to assess reasons for metformin non-persistence, and whether initial metformin dosing or use of extended release (ER) formulations affect persistence to metformin therapy.Retrospective cohort study.Electronic health record data from a network of urban academic practices.The cohort was restricted to individuals receiving a metformin prescription between 2009/1/1 and 2015/9/31, under care for at least 6 months before the first prescription of metformin. The cohort was further restricted to patients with no evidence of any antihyperglycaemic agent use prior to the index date, an haemoglobin A1c measured within 1 month prior to or 1 week after the index date, at least 6 months of follow-up, and with the initial metformin prescription originating in either a general medicine or endocrinology clinic.The primary outcome measure was early non-persistence, as defined by the absence of further prescriptions for metformin after the first 90 days of follow-up.The final cohort consisted of 1259 eligible individuals. The overall rate of early non-persistence was 20.3%. Initial use of ER and low starting dose metformin were associated with significantly lower rates of reported side effects and non-persistence, but after multivariable analysis, only use of low starting doses was independently associated with improved persistence (adjusted OR 0.54, 95% CI 0.37 to 0.76, for comparison of 500 mg daily dose or less to all higher doses).These data support the routine prescribing of low starting doses of metformin as a tool to improve persistence. In this study setting, many providers routinely used ER metformin as an initial treatment; while this practice may have benefits, it deserves more rigorous study to assess whether increased costs are justified.
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To compare compliance and persistence with statin and oral antihyperglycemic therapies in patients with type 2 diabetes who received concomitant therapy.Retrospective cohort study using a large US commercial claims database.Patients with type 2 diabetes and dispensed prescriptions for both statin and oral antihyperglycemic therapies on the same date in 2006 (index date = first date of such dispensing) were included in the analysis (N = 52,414). Patients were required to have continuous enrollment in the database for 1 year prior to (baseline) and 2 years after (follow-up) index date. The 2-year medication possession ratio (MPR) was compared between statin and oral antihyperglycemic therapy. For the persistence analysis, treatment discontinuation was defined by a gap >30 days between the last date of supply from previous dispensing and subsequent refill. The likelihood of discontinuation of statin versus oral antihyperglycemic therapy was estimated by fitting a robust Cox proportional hazards regression model, adjusted for baseline variables.The 2-year MPR was 70% for statin and 78% for oral antihyperglycemic therapy (P <.0001). The proportion of patients with a 2-year MPR >80% was 52% for statin and 63% for oral antihyperglycemic therapy (P <.0001). The median time to discontinuation of statin was significantly shorter compared with oral antihyperglycemic therapy (284 vs 495 days, P <.001). There was a greater risk to discontinue statin than oral antihyperglycemic therapy (adjusted hazard ratio: 1.47 [95% confidence interval 1.45-1.48]).Compliance and persistence with statin therapy significantly lagged behind oral antihyperglycemic therapy in patients with type 2 diabetes who were treated concomitantly with both therapies.
Discontinuation
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Combination therapy
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Glipizide
Persistence (discontinuity)
Pharmacotherapy
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Introduction: Diabetes mellitus is on alarming rise in India. Drug utilization studies help to identify the adherence to standard guidelines and extent of drug use and to evaluate the rational drug usage.Aims and objectives: To determine the drug utilization pattern and effectiveness of oral hypoglycemic agents among diabetes mellitus patients.Materials and methods: It is a prospective observational study carried out for a period of six months at RIMS kadapa, and two others diabetic centers. The diabetic patients who visited the medicine outpatient department were included. After obtaining approval from institutional ethical committee, a structured data collection form was used to collect demographic data, complete prescription details and other relevant information required for the study. The drug utilization pattern was determined. The drugs were categorized by Anatomical therapeutic classification (ATC) and DDD/1000 inhabitants/day was calculated by using WHO guidelines. Among all oral hypoglycemic agents the most effective drug/combination in this region was identified.RESULTS: 716 prescriptions were assessed out of which,401(56.0%) were females and 315(43.9%) were males, most of the patients were in the age group of 40-60 for males 175(55%) and females 205(51.1%). Hypertension was the most common co-morbid seen. The average number of drugs per prescription was 4.26 and anti-diabetics per prescription was 1.79. DDD/1000 inhabitants/day for metformin (A10BA02) was 10.5, glimiperide (A10BB12) was 9.3, glibenclamide (A10BB01) was 7.91, pioglitazone (A10BG03) was 7.25. Out of 716 patients 311(45.25%) patients were on Monotherapy, and 405 (56.5%) were on Combination therapy.A total of 200 newly diagnosed patients of diabetes mellitus were enrolled in the study out of which only 128 members were followed up successfully. The combinations of Metformin +Sulfonyl Ureas + Others showed a good control of fasting blood sugar when compared with only Metformin, only Sulfonyl Ureas or Metformin +Sulfonyl Ureas, Sulfonyl Ureas + Others.Conclusion: Metformin was the most utilized drug followed by glimiperide. Combination therapy was most frequent when compared to monotherapy in which metformin+glimiperide was commonly prescribed one. so by understanding the current prescribing patterns attempts can be made to improve rational prescribing. The combination of Metformin+Sulfonyl Ureas+Others is more effective combination.
Pioglitazone
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Discontinuation
Persistence (discontinuity)
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Gliclazide
Metabolic control analysis
Combination therapy
Regimen
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OBJECTIVE—Clinical trials provide information regarding the safety and efficacy of medications used to manage type 2 diabetes but do not elucidate drug effectiveness in a typical managed care environment. The aim of this study was to characterize “real-world” drug utilization patterns from both a prescriber and a patient perspective. RESEARCH DESIGN AND METHODS—We conducted a retrospective analysis of a large administrative pharmacy claims database, using data on continuously pharmacy benefit–eligible members prescribed oral hypoglycemic agents (OHAs). RESULTS—The 12-month persistence rate for the OHA cohort was low, ranging from 31% for α-glucosidase inhibitors to 60% for metformin; compliance rates varied between 70 and 80%. During the first 12 months of therapy, 36% of the patients remaining on therapy at 12 months had one or more therapy modifications. The mean number of therapy changes increased with the length of patient follow-up, with more than half of all patients experiencing at least one therapy change over the duration of follow-up. CONCLUSIONS—These findings document the wide variation in utilization patterns associated with pharmacological management of type 2 diabetes, suggesting that opportunity exists to optimize its pharmacological management.
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Persistence (discontinuity)
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