Background: Although practice guidelines stress individualization of glucose management in patients with type 2 diabetes (T2D), the extent to which providers take patient factors into account when selecting medications is not well known. We used data from DCR to evaluate the current real-world landscape of glucose-lowering drugs in key subsets of patients with T2D.
Methods: DCR is the first large-scale US outpatient registry of patients with diabetes recruited from cardiology, endocrinology, and primary care practices and currently encompasses 374 practices and 5114 providers. T2D medications were grouped as those which are suboptimal for patients with 1) obesity: insulin, sulfonylurea, TZD; 2) elderly (i.e., high hypoglycemia risk): insulin, sulfonylurea; 3) CKD 4/5: metformin, sulfonylurea; and 4) CV disease: sulfonylurea. We examined patient factors associated with use of these groups of meds using 4 hierarchical (for both specialty and site) modified Poisson models, adjusting for HbA1c, number of T2D meds, and insurance.
Results: Overall, 157,551 patients with T2D were prescribed a med for glycemic control: metformin 75%, sulfonylurea 34%, insulin 28%, DPP-4i 18%, TZD 11%, GLP-1 RA 6.4%, SGLT2i 4.8%. After adjusting patient factors, glycemic control, and insurance status, patients with higher BMIs were more likely treated with medications prone to cause weight gain (obesity class I/II: rate ratio [RR] 1.02, 95% CI 1.00-1.03; obesity class III: RR 1.09, 95% CI 1.05-1.12). Older patients were more likely to be treated with meds with increased risk of hypoglycemia (RR 1.04 per 5 years, 95% CI 1.03-1.05). Patients with GFR <30 were less likely to be treated with meds with known risk in patients with CKD (RR 0.72, 95% CI 0.68-0.76). Patients with CAD were less likely to be treated with meds with known CV harm (RR 0.97, 95% CI 0.96-1.00).
Conclusion: In a large US-based registry of T2D patients, we observed some targeted use of glucose-lowering therapy—in particular, patients with advanced CKD and CAD were not given meds known to be harmful to these patients. However, risk of hypoglycemia and risk of weight gain did not appear to factor substantially into decision making. As these are among several factors that go into drug selection for complicated patients with T2D, conclusions from these data are limited. Nonetheless, in an era of increasing number and complexity of medication choices with varying risk/benefits, databases like the DCR may allow investigators to assess these trends and to highlight potential areas for improvement in pharmacologic personalization, particularly as the use of newer drug classes grows.