Heald Adrian H, Fryer Anthony A, Anderson Simon G, Livingston Mark, Lunt Mark, Davies Mark, Moreno Gabriela Y C, Gadsby Roger, Young Robert J, Stedman Mike
School of Medicine Sciences and Manchester, Academic Health Sciences Centre, University of Manchester, Manchester, UK.
Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK.
Diabetes Obes Metab. 2018 Jul;20(7):1659-1669. doi: 10.1111/dom.13281. Epub 2018 Apr 17.
To determine, using published general practice-level data, how differences in Type 2 diabetes mellitus (T2DM) prescribing patterns relate to glycaemic target achievement levels.
Multiple linear regression modelling was used to link practice characteristics and defined daily dose (DDD) of different classes of medication in 2015/2016 and changes between that year and the year 2014/2015 in medication to proportion of patients achieving target glycaemic control (glycated haemoglobin A1c [HbA1c] ≤58 mmol/mol [7.5%]) and proportion of patients at high glycaemic risk (HbA1c >86 mmol/mol [10.0%]) for practices in the National Diabetes Audit with >100 people with T2DM on their register.
Overall, HbA1c outcomes were not different between the years studied. Although, in percentage terms, most practices increased their use of sodium-glucose co-transporter-2 (SGLT2) inhibitors (96%), dipeptidyl peptidase-4 (DPP-4) inhibitors (76%) and glucagon-like peptide 1 (GLP-1) analogues (53%), there was wide variation in the use of older and newer therapies. For example, 12% of practices used >200% of the national average for some newer agents. In cross-sectional analysis, greater prescribing of metformin and analogue insulin were associated with a higher proportion of patients achieving HbA1c ≤58 mmol/mol; the use of SGLT2 inhibitors and metformin was associated with a reduced proportion of patients with HbA1c >86 mol/mol; otherwise associations for sulphonylureas, GLP-1 analogues, SGLT2 inhibitors and DPP-4 inhibitors were neutral or negative. In year-on-year analysis there was ongoing deterioration in glycaemic control, which was offset to some extent by increased use of SGLT2 inhibitors and GLP-1 analogues, which were associated with a greater proportion of patients achieving HbA1c levels ≤58 mmol/mol and a smaller proportion of patients with HbA1c levels >86 mmol/mol. SGLT2 inhibitor prescribing was associated with significantly greater improvements than those found for GLP-1 analogues.
Greater use of newer agents was associated with improvement in glycaemic outcomes but was not sufficient to compensate for the prevailing decline. This may reflect wide variability in the prescribing of newer agents. We found that SGLT inhibitors may be superior to other oral agents in relation to HbA1c outcome. Serious consideration should be given to their use.
利用已发表的基层医疗水平数据，确定2型糖尿病（T2DM）处方模式的差异与血糖目标达成水平之间的关系。
采用多元线性回归模型，将2015/2016年不同类别药物的医疗机构特征和限定日剂量（DDD）以及该年份与2014/2015年之间药物使用的变化与达到血糖控制目标（糖化血红蛋白A1c[HbA1c]≤58 mmol/mol[7.5%]）的患者比例和血糖高风险（HbA1c>86 mmol/mol[10.0%]）的患者比例相关联，这些医疗机构来自国家糖尿病审计，其登记册上有超过100名T2DM患者。
总体而言，在所研究的年份之间，HbA1c结果没有差异。尽管从百分比来看，大多数医疗机构增加了钠-葡萄糖协同转运蛋白2（SGLT2）抑制剂（96%）、二肽基肽酶-4（DPP-4）抑制剂（76%）和胰高血糖素样肽1（GLP-1）类似物（53%）的使用，但新旧疗法的使用存在很大差异。例如，12%的医疗机构某些新药的使用量超过全国平均水平的200%。在横断面分析中，二甲双胍和胰岛素类似物的处方量增加与达到HbA1c≤58 mmol/mol的患者比例较高相关；SGLT2抑制剂和二甲双胍的使用与HbA1c>86 mol/mol的患者比例降低相关；否则，磺脲类药物、GLP-1类似物、SGLT2抑制剂和DPP-4抑制剂的关联为中性或阴性。在逐年分析中，血糖控制持续恶化，SGLT2抑制剂和GLP-1类似物使用量的增加在一定程度上抵消了这种恶化，这与达到HbA1c水平≤58 mmol/mol的患者比例较高和HbA1c水平>86 mmol/mol的患者比例较低相关。SGLT2抑制剂的处方与比GLP-1类似物显著更大的改善相关。
更多地使用新药与血糖结果的改善相关，但不足以弥补普遍存在的下降。这可能反映了新药处方的广泛差异。我们发现，就HbA1c结果而言，SGLT抑制剂可能优于其他口服药物。应认真考虑使用它们。
