Antihyperglycemic Medications: A Claims-Based Estimate of First-line Therapy Use Prior to Initialization of Second-line Medications.

The American Diabetes Association recommends metformin as first-line therapy for type 2 diabetes. However, nonadherence to antihyperglycemic medication is common, and a clinician could confuse nonadherence with pharmacologic failure, potentially leading to premature prescribing of second-line therapies. We measured metformin use prior to second-line therapy initialization. This retrospective cross-sectional study used unidentifiable member claims data from individuals covered from 2010 to 2015 by Aetna, a U.S. health benefits company. Beneficiaries with two physician claims or one hospitalization with a type 2 diabetes diagnosis were included. Recommended use of metformin was measured by the proportion of days covered over 60 days. Through sensitivity analysis, we varied estimates of the percentage of beneficiaries who used low-cost generic prescription medication programs. A total of 52,544 individuals with type 2 diabetes were eligible. Of 22,956 patients given second-line treatment, only 1,875 (8.2%) had evidence of recommended use of metformin in the prior 60 days, and 6,441 (28.0%) had no prior claims evidence of having taken metformin. At the top range of sensitivity, only 49.5% patients could have had recommended use. Patients were more likely to be given an additional second-line antihyperglycemic medication or insulin if they were given their initial second-line medication without evidence of recommended use of metformin (P < 0.001). Despite published guidelines, second-line therapy often is initiated without evidence of recommended use of first-line therapy. Apparent treatment failures, which may in fact be attributable to nonadherence to guidelines, are common. Point-of-care and population-level processes are needed to monitor and improve guideline adherence.

美国糖尿病协会推荐二甲双胍作为2型糖尿病的一线治疗药物。然而，不遵医嘱服用降糖药物的情况很常见，临床医生可能会将不遵医嘱与药物治疗失败相混淆，这可能导致过早开具二线治疗药物。我们测量了在开始二线治疗之前二甲双胍的使用情况。 这项回顾性横断面研究使用了美国一家健康福利公司安泰（Aetna）2010年至2015年所涵盖个人的无法识别身份的会员索赔数据。纳入标准为有两次医生诊断索赔或一次因2型糖尿病住院的受益人。通过计算60天内药物覆盖天数的比例来衡量二甲双胍的推荐使用情况。通过敏感性分析，我们对使用低成本仿制药处方药物计划的受益人百分比的估计进行了调整。 共有52544名2型糖尿病患者符合条件。在接受二线治疗的22956名患者中，只有1875名（8.2%）在之前60天内有推荐使用二甲双胍的证据，6441名（28.0%）之前没有服用二甲双胍的索赔证据。在敏感性的最高范围内，只有49.5%的患者可能有推荐使用情况。如果患者在开始使用初始二线药物时没有推荐使用二甲双胍的证据，他们更有可能被给予额外的二线降糖药物或胰岛素（P<0.001）。 尽管有已发布的指南，但二线治疗常常在没有一线治疗推荐使用证据的情况下就开始了。明显的治疗失败（实际上可能是由于不遵守指南）很常见。需要在医疗点和人群层面进行监测和提高指南依从性的流程。