Changing use of antidiabetic drugs in the UK: trends in prescribing 2000–2017

Abstract

ObjectivesGuidelines for the use of drugs for type 2 diabetes mellitus (T2DM) have changed since 2000, and new classes of drug have been introduced. Our aim was to describe how drug choice at initiation and first stage of intensification have changed over this period, and to what extent prescribing was in accord with clinical guidelines, including adherence to recommendations regarding kidney function.DesignRepeated cross-sectional study.SettingUK electronic primary care health records from the Clinical Practice Research Datalink.ParticipantsAdults initiating treatment with a drug for T2DM between January 2000 and July 2017.Primary and secondary outcome measuresThe primary outcomes were the proportion of each class of T2DM drug prescribed for initiation and first-stage intensification in each year. We also examined drug prescribing by kidney function and country within the UK.ResultsOf 280 241 people initiating treatment with T2DM drugs from 2000 to 2017, 73% (204 238/280 241) initiated metformin, 15% (42 288/280 241) a sulfonylurea, 5% (12 956/280 241) with metformin and sulfonylurea dual therapy and 7% (20 759/280 241) started other options. Clinicians have increasingly prescribed metformin at initiation: by 2017 this was 89% (2475/2778) of drug initiations. Among people with an estimated glomerular filtration rate of ≤30 mL/min/1.73 m2, the most common drug at initiation was a sulfonylurea, 58% (659/1135). In 2000, sulfonylureas were the predominant drug at the first stage of drug intensification (87%, 534/615) but by 2017 this fell to 30% (355/1183) as the use of newer drug classes increased. In 2017, new prescriptions for dipeptidyl peptidase-4 inhibitors (DPP4i) and sodium/glucose cotransporter-2 inhibitors (SGLT2i) accounted for 42% (502/1183) and 22% (256/1183) of intensification drugs, respectively. Uptake of new classes differs by country with DPP4is and SGLT2is prescribed more in Northern Ireland and Wales than England or Scotland.ConclusionsOur findings show markedly changing prescribing patterns for T2DM between 2000 and 2017, largely consistent with clinical guidelines.

Trends in antidiabetic drug utilization and expenditure in Denmark: A 22‐year nationwide study

“…Similar trends in antidiabetic use have also been observed in other countries, but with smaller changes and variation in use for specific antidiabetic drugs . In 2017, the use of sulphonylureas and GLP‐1RAs each accounted for 8% of the total antidiabetic drug use in Denmark.…”

“…Physicians may add on any available antidiabetic drug while taking the heterogeneous cardiovascular and glycaemic risk profile, kidney function, age and socio‐economic status of their patients into account. To date, a few studies have reported on time trends in the utilization of antidiabetic drugs, but little is known about the correlation between, for example, antidiabetic drug use and costs . Knowledge in this area may provide important insights into and awareness of healthcare costs and help guide diabetologists, specialists in internal medicine, general practitioners and other healthcare professionals in choosing the appropriate antidiabetic drug for their patients with type 2 diabetes.…”

Time trends in prescribing of type 2 diabetes drugs, glycaemic response and risk factors: A retrospective analysis of primary care data, 2010–2017

“…Choice between these agents is left largely to the clinician and patient. Recent studies show that there have been marked changes in which agents are initiated after metformin, with declining use of sulphonylureas and increasing and earlier use of DPP‐4 inhibitors and SGLT2 inhibitors in both the United States, Europe and the United Kingdom …”

“…Hypoglycaemia risk is greater with sulphonylureas and insulin relative to other agents . Despite these known differences in non‐glycaemic effects between agents, evidence of the impact of recent changes in prescribing on population‐level patient outcomes is limited . In the present study we aimed to describe changes in prescribing of glucose‐lowering drugs for patients initiating first‐ to fourth‐line therapy between 2010 and 2017 in the United Kingdom, a setting where prescribing does not reflect the ability of patients to pay.…”

“…Recent studies show that there have been marked changes in which agents are initiated after metformin, with declining use of sulphonylureas and increasing and earlier use of DPP-4 inhibitors and SGLT2 inhibitors in both the United States, Europe and the United Kingdom. [5][6][7][8] Although studies have suggested that the glucose-lowering effectiveness of agents typically added to metformin may be comparable, 1,9,10 there are well established differences between the different drug classes in weight change and side effects. GLP-1 receptor agonists and SGLT2 inhibitors are associated with weight loss, whereas DPP-4 inhibitors are weightneutral and sulphonylureas can promote weight gain.…”