First-line drugs for diabetes not always chosen

More than a third of patients newly diagnosed with type 2 diabetes mellitus (DM) did not receive the recommended first-line drug, a finding that could have substantial implications for healthcare spending, according to a study published in the American Journal of Medicine.

“A substantial proportion of patients initiating an oral hypoglycemic drug do not receive guideline-recommended therapy,” Niteesh K. Choudhry, MD, PhD, one of the study authors, told Drug Topics.

“We found substantial variability in contemporary clinical practice for patients initiating drug therapy for diabetes,” said Choudhry, associate professor, Harvard Medical School, and associate physician, Division of Pharmacoepidemiology and Pharmacoeconomics and the Hospitalist Service, Brigham and Women's Hospital in Boston.

 “Further, our results highlight a situation where consensus statement recommended care, clinical efficacy, and cost-conscious prescribing are all aligned. Pharmacotherapy for diabetes presents a significant opportunity for quality and performance improvement initiatives and holds the potential to realize significant savings for patients, payers, and the entire healthcare system.”

Choudhry and colleagues studied a large group of managed-care enrollees starting oral diabetes treatment and found that 35% of patients did not receive the recommended first-line drug. Further, the medication costs for this subgroup of patients comprised 66.3% of the total expenditures for hypoglycemic drugs in the entire cohort.

Nationally, there are approximately 2 million new cases of diabetes each year, according to the researchers. If the medication patterns and insurance coverage for their cohort are representative of the U.S. population, an excess expenditure of $1,120 per patient per year would translate to more than $420 million in additional direct medication costs for diabetes therapy outside established consensus recommendations, they noted.

“Because the prevalence of diabetes is increasing quite dramatically, the potential savings from improved adherence to these recommendations could far exceed these estimates,” Choudhry said.

DM has emerged as one of the most significant public health issues worldwide. In the United States, more than 20 million people have diabetes, and an additional 6 million have undiagnosed disease.

The number of Americans with diabetes is projected to increase 165% by 2050. In the United States, this disease alone accounts for nearly $200 billion in direct and indirect medical costs each year. Six different oral medication classes have been approved by FDA for the treatment of type 2 diabetes but only metformin and sulfonylurea are recommended as first-line therapy.

“Despite the widespread dissemination of professional society recommendations, little is known about current clinical practice patterns for patients who initiate an oral hypoglycemic agent,” Choudhry said.  

“We therefore explored patterns of use and temporal trends in the utilization of different drugs in the initial management of type 2 diabetes,” Choudhry added. “Because there are substantialprice differences between agents, we also were interested in estimatingthe financial implications of current practice patterns and the potentialsavings derivable through care that is more evidence-based.”