Patterns of medication initiation in newly diagnosed diabetes mellitus: quality and cost implications.

Currently, 25 million Americans are known to have diabetes, with an additional 7 million cases believed to be undiagnosed. It is estimated that direct and indirect costs of diabetes top $200 billion. Due to the significant health and financial burdens associated with diabetes, it is imperative that this disease be treated quickly and aggressively. In 2009, the American Diabetes Association and the European Association for the Study of Diabetes developed a consensus statement regarding the treatment of type 2 diabetes, citing lifestyle modification and metformin as the preferred first line therapies. In this study, the authors looked at prescription claims data for adults who were newly initiated on oral hypoglycemic monotherapy between January 1, 2006, and December 31, 2008, to determine if initiation patterns changed over time, to evaluate how well the treatment guidelines were being followed, and to assess the economic consequences of prescribing patterns by drug class for both patients and insurers. The results showed that over the course of the study period the proportion of patients initially treated with metformin increased, whereas those receiving sulfonylureas as first-line therapy decreased. Thiazolidinediones experienced the greatest decrease, falling from 20% to 8%, while prescriptions for dipeptidyl peptidase-4 inhibitors increase from 0-7%. Over a 6-month period, patients taking metformin or sulfonylureas paid approximately $38 to $40 in co-pays while insurance paid about $77. Patients taking other agents paid approximately $130 in co-pays and insurance paid over $500. The authors concluded that based its cost and safety profile, metformin should be the first line drug therapy for patients with newly diagnosed type 2 diabetes. This CME multimedia activity, which is part of a 2-part multimedia activity on the management and treatment of diabetes, contains a video presentation and is available through the website of The American Journal of Medicine at http://amjmed.com/content/multimedia. Click on "Patterns of Medication Initiation in Newly Diagnosed Diabetes Mellitus: Quality and Cost Implications" to access this part of the multimedia program.

Liao EP 《-》

Management of type 2 diabetes: new and future developments in treatment.

To date, six classes of oral medication have been approved by the U.S. Food and Drug Administration for the treatment of type 2 diabetes and several new agents are in the pipeline. In 2009, the American Diabetes Association and the European Association for the Study of Diabetes developed a consensus statement regarding the treatment of type 2 diabetes, citing lifestyle modification and metformin as the preferred first line therapies. In addition to the currently available drugs, several new agents have recently been introduced or are in the development pipeline. Incretin therapies include both glucagon-like peptide-1 (GLP-1) inhibitors and dipeptidyl peptidase 4 (DPP-4) inhibitors. Non-incretin beta cell stimulants still in development include glucokinase activators, G-protein-coupled receptors, and anti-inflammatory and anti-oxidant therapies. Additional agents that target glucose synthesis include glucose-6-phosphatase and glycogen phosphorylase. Other new agents target metabolic syndrome, which is often the first clinical condition that presents in patients at risk for type 2 diabetes. Finally, for obese patients who are unable to lose weight through diet and exercise, weight-loss surgery is an option that should be discussed with their physicians. This CME multimedia activity, which is part of a 2-part multimedia activity on the management and treatment of diabetes, contains a video presentation and is available through the website of The American Journal of Medicine at http://amjmed.com/content/multimedia. Click on "Management of Type 2 Diabetes: New and Future Developments in Treatment" to access this part of this multimedia program.

Liao EP 《-》

Patterns of medication initiation in newly diagnosed diabetes mellitus: quality and cost implications.

Six oral medication classes have been approved by the Food and Drug Administration for the treatment of type 2 diabetes. Although all of these agents effectively lower blood glucose, the evidence supporting their impact on other clinical events is variable. There also are substantial cost differences between agents. We aimed to evaluate temporal trends in the use of specific drugs for the initial management of type 2 diabetes and to estimate the economic consequences of non-recommended care. We studied a cohort of 254,973 patients, aged 18 to 100 years, who were newly initiated on oral hypoglycemic monotherapy between January 1, 2006, and December 31, 2008, by using prescription claims data from a large pharmacy benefit manager. Linear regression models were used to assess whether medication initiation patterns changed over time. Multivariate logistic regression models were constructed to identify independent predictors of receiving initial therapy with metformin. We then measured the economic consequences of prescribing patterns by drug class for both patients and the insurer. Over the course of the study period, the proportion of patients initially treated with metformin increased from 51% to 65%, whereas those receiving sulfonylureas decreased from 26% to 18% (P<.001 for both). There was a significant decline in the use of thiazolidinediones (20.1%-8.3%, P<.001) and an increase in prescriptions for dipeptidyl peptidase-4 inhibitors (0.4%-7.3%, P<.001). Younger patients, women, and patients receiving drug benefits through Medicare were least likely to initiate treatment with metformin. Combined patient and insurer spending for patients who were initiated on alpha-glucosidase inhibitors, thiazolidinediones, meglitinides, or dipeptidyl peptidase-4 inhibitors was $677 over a 6-month period compared with $116 and $118 for patients initiated on metformin or a sulfonylurea, respectively, a cost difference of approximately $1120 annually per patient. Approximately 35% of patients initiating an oral hypoglycemic drug did not receive recommended initial therapy with metformin. These practice patterns also have substantial implications for health care spending.

Desai NR ，Shrank WH ，Fischer MA ，Avorn J ，Liberman JN ，Schneeweiss S ，Pakes J ，Brennan TA ，Choudhry NK ... -  《-》

[The increase in the use of drug treatment for diabetes mellitus in the Netherlands, 1998-2003].

Langendam MW ，Hooijkaas C ，Piepenbrink JF 《-》

Cost and clinical implications of diabetes prevention in an Australian setting: a long-term modeling analysis.

Metformin and intensive lifestyle changes (ILC) reduced the incidence of type 2 diabetes (T2D) versus standard care (control) in overweight or obese subjects with impaired glucose tolerance (IGT) in the Diabetes Prevention Program (DPP) trial and Diabetes Prevention Program Outcomes Study (DPPOS). We projected lifetime clinical and economic outcomes based on the results from the DPP+DPPOS, from a 3rd-party payer perspective in Australia. A semi-Markov, 2nd-order Monte Carlo model was developed with four health states: "normal glucose regulation" (NGR); IGT; T2D and 'dead'. Outcomes were discounted at 5% annually. Univariate and probabilistic sensitivity analyses were performed. Incremental cost-effectiveness ratios (ICERs) were calculated. Cumulative incidence (standard deviation) of T2D was 89.7% (0.2), 83.8% (0.2) and 73.4% (0.3%) for control, metformin and ILC respectively. Lifetime incremental direct costs were $1217 (4411) per subject for metformin versus control, with cost savings of $289 (4296) for ILC versus control. ILC therefore dominated control, with improvements in clinical outcomes and overall cost savings. Incremental costs per QALY-gained for metformin versus control were $10,142. Probability of cost-effectiveness at willingness-to-pay threshold of $50,000 was 78% and 100% for metformin or ILC respectively. Results were most sensitive to probabilities of developing T2D and costs of implementing the interventions. Substantial improvements in lifetime clinical outcomes could be expected in high risk subjects treated with metformin or ILC. Prevention of T2D in this group of subjects is good value for money, and may even lead to long term cost savings.

Palmer AJ ，Tucker DM 《-》