Type 2 Diabetes: Ambulatory Treatment in US

Caleb Alexander, MD, MS Department of Epidemiology, Bloomberg School of Public Health Center for Drug Safety and Effectiveness Johns Hopkins Bloomberg School of Public Health Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MarylandMedicalResearch.com Interview with:
Caleb Alexander, MD, MS
Department of Epidemiology, Bloomberg School of Public Health
Center for Drug Safety and Effectiveness
Johns Hopkins Bloomberg School of Public Health
Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland

MedicalResearch.com: What are the main findings of the study?
Dr. Alexander:

  • There have been large shifts in the types of treatments used to treat Type 2 diabetes during the past decade in the United States.
  • We document large declines in the use of glitazones and sulfonylureas and important increases in the use of the newer DPP-4 inhibitors and GLP-1 agonists.
  • We also found large shifts in the types of insulins used, with substantial reductions in the use of regular and intermediate insulins, and large increases in the use of long-acting and ultra short-acting  therapies.
  • Costs have increased significantly over the past 5 years, driven primarily by insulin and DPP-4 inhibitors
  • All of these changes notwithstanding, biguanides continue to remain a mainstay of therapy.

MedicalResearch.com: Were any of the findings unexpected?

Dr. Alexander:

  • Although the first GLP-1 agonist was approved a year prior to any DPP-4 inhibitor, and evidence suggests that GLP-1 agonists may be more efficacious with respect to glycemic endpoints, there has been low uptake of GLP-1 agonists, particularly compared with DPP-4 inhibitors.
  • There have been larger than expected changes in the types of insulins used.
  • There has been no substantial market recovery by glitazones following their rapid decline associated with emerging evidence of rosiglitazone’s cardiovascular risks, despite the fact that those risks continue to be debated.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Alexander:

  • There have been many important changes in the treatment of Type 2 diabetes in the United States during the past decade.
    • Drugs and therapeutic areas such as diabetes exist in a dynamic landscape, and there are many drivers of the changes that we describe.
    • Our study was not a study of quality of care, but patients and physicians alike should consider the degree to which their diabetes treatments reflects best practices.

Caution and clinical prudence is particularly important to exercise with the use of newer therapies such as DPP-4 inhibitors and GLP-1 agonists whose long-term safety and comparative effectiveness has not been well characterized.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Alexander:

  • Our study shows increases in treatment complexity, which begs for more studies determining the safety and effectiveness of combination products and multiple medications.
  • As use of newer therapies grows, the long-term safety and effectiveness of these agents must be monitored
  • Continued investigations of the benefits of long-acting insulin are important, particularly on its impact on glycemic control, morbidity and mortality.

Citation:

Ambulatory Treatment of Type 2 Diabetes Mellitus in The United States, 1997-2012
Diabetes Care. 2013 Nov 12. [Epub ahead of print]

Turner LW, Nartey D, Stafford RS, Singh S, Alexander GC.
Department of Epidemiology, Bloomberg School of Public Health, Baltimore, Maryland.

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