Abstract
AimsTo identify patient-specific factors associated with early metformin treatment modification among type 2 diabetes patients before and after implementation of the updated 2015 NICE (National Institute for Health and Care Excellence) guideline. MethodsWe conducted a population-based cohort study using data from the Clinical Practice Research Datalink GOLD database (2009–2016). Patients ≥ 18 years, newly treated with metformin only, during the period of valid data collection were included. The first prescription defined start of follow-up. Determinants of treatment modification in two cohorts (before and after implementation of the updated guideline) were studied by time-dependent Cox proportional hazards regression. ResultsAfter implementation of the updated guideline, patients were less likely to receive sulphonylureas (62.3% vs 41.3%) or thiazolidediones (4.7% vs 2.2%) and more likely to receive dipeptidyl peptidase-4 inhibitors (15.8% vs 27.1%) or sodium-glucose cotransporter-2 inhibitors (0.8% vs 9.9%). Some determinants influenced general practitioners’ prescribing differently after implementation of the updated guideline compared to before, including a high body mass index and heart failure. ConclusionsOur results indicate that a first step towards tailored prescribing has been made. However, not all determinants that are important to consider when prescribing second-line glucose-lowering agents were of influence on general practitioners’ prescribing.
Highlights
Metformin has been the recommended first-line treatment for patients with type 2 diabetes as it lowers fasting blood glucose levels by 20 percent and glycated haemoglobin (HbA1c) levels by 1.5 percent points [1]
While sulphonylureas were the preferred second-line therapy in the 2009 guideline [2], the new guideline recommends to choose the second-line treatment based on patient characteristics, risk factors, treatment efficacy, safety and tolerability, costs and patient preferences [3]
Population-based study we identified patientspecific determinants related to early treatment modification in patients with type 2 diabetes before and after the implementation of the updated NICE guideline in the UK
Summary
Metformin has been the recommended first-line treatment for patients with type 2 diabetes as it lowers fasting blood glucose levels by 20 percent and glycated haemoglobin (HbA1c) levels by 1.5 percent points [1]. Sulphonylureas have been the second-line therapy for many years, the arrival of several new therapies (e.g. dipeptidyl peptidase-4 [DPP-4] inhibitors, sodium-glucose cotransporter-2 [SGLT-2] inhibitors and glucagon-like peptide-1 [GLP-1] receptor agonists) has enabled tailoring of treatment to individual patient characteristics This has led to substantial changes in type 2 diabetes management guidelines in many countries, including the UK NICE (National Institute for Health and Care Excellence) guideline in 2015. Body mass index (BMI), HbA1c, age, cardiovascular risk and renal function have been identified as significant determinants of general practitioners’ prescribing [4,5] These studies were performed with British data prior to 2015, with sulphonylureas as the recommended second-line therapy. The objective of this study was to identify patient-specific determinants of early treatment modification (addition of or switching to second-line therapy within one year) in patients with type 2 diabetes before and after implementation of the updated NICE guideline in the UK
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