Reasons for non-intensification of treatment in people with type 2 diabetes receiving oral monotherapy: Outcomes from the prospective DIAttitude study

Objectives

To describe the management of glucose-lowering agents in people with type 2 diabetes initially on oral monotherapy, cared for by French general practitioners, and to identify reasons underlying treatment non-intensification.

Methods

People with type 2 diabetes on oral monotherapy were recruited by general practitioners and followed-up over 12 months. Patient characteristics, HbA1c, and glucose-lowering treatments were recorded electronically. Management objectives and reasons for treatment non-intensification were solicited from the general practitioners.

Results

A total of 1212 patients were enrolled by 198 general practitioners; 937 patients (mean age 68 years) were treated with oral monotherapy, and 916 patients had at least two successive HbA1c values recorded. Of these, 390 patients (43%) had HbA1c ≥ 6.5% on both occasions, and 164/390 (42%) had their treatment intensified. The 226 patients whose treatment was not intensified were older (69 ± 11 years vs. 66 ± 12 years, P = 0.02) and had better glycaemic control at study inclusion (6.9% ± 0.6 vs. 7.3% ± 0.8, P < 0.0001) than treatment intensified patients. Among uncontrolled patients, there were no differences in general practitioner treatment objectives at inclusion for treatment intensified and non-intensified patients; the main reason given by general practitioners for non-intensification was that the patient had an adequate HbA1c (66%). HbA1c did exceed the 6.5% target, but was less than 7.0% in 69% of cases.

Conclusions

General practitioners showed a patient-centred approach to treatment, but clinical inertia was apparent for 31% of the uncontrolled patients.     

The incremental costs of recommended therapy versus real world therapy in type 2 diabetes patients

ABSTRACT

Background: The goals of diabetes management have evolved over the past decade to become the attainment of near-normal glucose and cardiovascular risk factor levels. Improved metabolic control is achieved through optimized medication regimens, but costs specifically associated with such optimization have not been examined.

Objective: To estimate the incremental medication cost of providing optimal therapy to reach recommended goals versus actual therapy in patients with type 2 diabetes.

Methods: We randomly selected the charts of 601 type 2 diabetes patients receiving care from the outpatient clinics of Massachusetts General Hospital March 1, 1996–August 31, 1997 and abstracted clinical and medication data. We applied treatment algorithms based on 2004 clinical practice guidelines for hyperglycemia, hyperlipidemia, and hypertension to patients’ current medication therapy to determine how current medication regimens could be improved to attain recommended treatment goals. Four clinicians and three pharmacists independently applied the algorithms and reached consensus on recommended therapies. Mean incremental medication costs, the cost differences between current and recommended therapies, per patient (expressed in 2004 dollars) were calculated with 95% bootstrap confidence intervals (CIs).

Results: Mean patient age was 65 years old, mean duration of diabetes was 7.7 years, 32% had ideal glucose control, 25% had ideal systolic blood pressure, and 24% had ideal low-density lipoprotein cholesterol. Care for these diabetes patients was similar to that observed in recent national studies. If treatment algorithm recommendations were applied, the average annual medication cost/patient would increase from $1525 to $2164. Annual incremental costs/patient increased by $168 (95% CI $133–$206) for antihyperglycemic medications, $75 ($57–$93) for antihypertensive medications, $392 ($354–$434) for antihyperlipidemic medications, and $3 ($3–$4) for aspirin prophylaxis. Yearly incremental cost of recommended laboratory testing ranged from $77–$189/patient.

Limitations: Although baseline data come from the clinics of a single academic institution, collected in 1997, the care of these diabetes patients was remarkably similar to care recently observed nationally. In addition, the data are dependent on the medical record and may not accurately reflect patients’ actual experiences.

Conclusion: Average yearly incremental cost of optimizing drug regimens to achieve recommended treatment goals for type 2 diabetes was approximately $600/patient. These results provide valuable input for assessing the cost-effectiveness of improving comprehensive diabetes care.     

Use of Drugs that Act on the Cytochrome P450 System in the Elderly

OBJECTIVES:

The objective of this study was to analyze medications that act on the cytochrome P450 (CYP450) enzymatic system and are used daily by non-institutionalized elderly individuals.

METHODS:

A cross-sectional population-based study of elderly individuals (≥ 60 years old) was conducted. All continuously used medications with hepatic metabolism via CYP450 that are classified as substrates, inducers or inhibitors were considered. For the analysis, elderly individuals were stratified according to age groups, and hepatic metabolism activity due to daily alcohol consumption and smoking were considered.

RESULTS:

Elderly individuals (396 in total: 222 women and 174 men) between 60 and 95 years of age (mean: 72.1) were assessed. Use of drugs that act on CYP450 was identified in 61.6% of the subjects. Drug use was observed among 16.2% of the subjects: three drugs among 9.8% and four or more among 6.3% of the subjects. The metabolic activities of the drugs used were classified as substrates (58.8%), inhibitors (14.9%), and inducers (4.3%). The main drugs used were beta-blockers and statins (as substrates), proton pump inhibitors and fluoxetine (as inhibitors), and prednisone and carbamazepine (as inducers).

CONCLUSIONS:

The results demonstrate that the elderly use high levels of medications that act on CYP450, thereby increasing the risk of drug interactions in a group that is already vulnerable to adverse drug effects.     

Measuring drug exposure: concordance between defined daily dose and days' supply depended on drug class

ObjectivesTo determine the concordance between two methods to measure drug exposure duration from pharmacy claim data.Study Design and SettingWe conducted a cohort study using 2002–2007 US Medicaid data. Initiators of eight drug groups were identified: statins, metformin, atypical antipsychotics, warfarin, proton pump inhibitors (PPIs), angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (ns-NSAIDs), and coxibs. For each patient, we calculated two measures of exposure duration using (1) observed days' supply available in US pharmacy claims and (2) the World Health Organisation's Defined Daily Dose (DDD) methodology. We used Wilcoxon signed rank tests to compare medians and Spearman correlations to assess correlation between the two measures.ResultsCohort sizes ranged from 143,885 warfarin users to >3,000,000 ns-NSAID users. Similar median exposure durations were observed for ACE inhibitors (70 days vs.75 days), PPIs (44 days vs. 45 days), and coxibs (44 days vs. 45 days). The DDD method overestimated exposure duration for ns-NSAIDs and underestimated for the remaining drug groups, relative to days' supply. Spearman correlation coefficients ranged from 0.2 to 0.8.ConclusionUsing DDDs to estimate drug exposure duration can result in misclassification. The magnitude of this misclassification might depend on doses used which can vary according to factors such as local prescribing practices, renal function, and age.     

贵州省安顺市流行区域药物滥用情况的三年间对比调查

目的 了解贵州省安顺市的药物滥用情况。方法 于１９９６年７月对１９９３年７月调查过的相同的流行地区的阿片类药物滥用情况再次进行调查。采用问卷方式随机抽查１１７２０人。结果 １１７２０人中有阿片类药物滥用者３１７例（２．７％）,其中滥用海劣因３０５例（９６．２％）,３０５例中我例（２３．３％）合并滥用苯二氮卓类药物。使用方法以吸入为主,有７例（２．２％）海洛因滥用者采用静脉注射。结论 与１９９３年７     

Large intercommunity difference in cardiovascular drug consumption: relation to mortality,risk factors and socioeconomic differences

Summary A comparison of cardiovascular drug sales and cardiovascular mortality was made between two Swedish counties (Värmland and Malmöhus) and between two rural municipalities in those counties (Torsby in Värmland and Hörby in Malmöhus).Cardiovascular drug sales (defined daily doses (DDD) per 1,000 inhabitants per day) during 1986–87 were 25 higher in Vdrmland than in Malmöhus county, and the age-standardized mortality of coronary heart disease (CHD) was 36% (men) and 54% (women) higher. In Torsby, age-standardized CHD mortality (1986–87) was 71 % (both sexes) higher than in H6rby, and the sales of cardiovascular drugs (1978–87) were 58 % higher. Statistically, every third inhabitant of Torsby took one DDD of a cardiovascular drug every day, as compared to every fifth inhabitant in Hörby. In Torsby there was a 6 % higher serum cholesterol, 71 % lower tap water hardness, 33 lower income, a lower educational level, a three-fold higher unemployment rate, and a different ethnic background (20 % eastern Finnish ancestry), all factors assumed to promote a high CHD rate.All of these factors may contribute to the higher CHD mortality, which was in turn reflected in higher sales of cardiovascular drugs.