Endocrinology Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA.
J Gen Intern Med. 2023 May;38(6):1476-1483. doi: 10.1007/s11606-022-07838-1. Epub 2022 Oct 31.
Over 5 million patients in the United States have type 2 diabetes mellitus (T2D) with chronic kidney disease (CKD); antidiabetic drug selection for this population is complex and has important implications for outcomes.
To better understand how providers choose antidiabetic drugs in T2D with CKD DESIGN: Mixed methods. Interviews with providers underwent qualitative analysis using grounded theory to identify themes related to antidiabetic drug prescribing. A provider survey used vignettes and direct questions to quantitatively assess prescribers' knowledge and preferences. A retrospective cohort analysis of real-world prescribing data assessed the external validity of the interview and survey findings.
Primary care physicians, endocrinologists, nurse-practitioners, and physicians' assistants were eligible for interviews; primary care physicians and endocrinologists were eligible for the survey; prescribing data were derived from adult patients with serum creatinine data.
Interviews were qualitative; for the survey and retrospective cohort, proportion of patients receiving metformin was the primary outcome.
Interviews with 9 providers identified a theme of uncertainty about guidelines for prescribing antidiabetic drugs in patients with T2D and CKD. The survey had 105 respondents: 74 primary care providers and 31 endocrinologists. Metformin was the most common choice for patients with T2D and CKD. Compared to primary care providers, endocrinologists were less likely to prescribe metformin at levels of kidney function at which it is contraindicated and more likely to correctly answer a question about metformin's contraindications (71% versus 41%) (p < .05). Real-world data were consistent with survey findings, and further showed low rates of use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists (<10%) in patients with eGFR below 60 ml/min/1.73m.
Providers are unsure how to treat T2D with CKD and incompletely informed as to existing guidelines. This suggests opportunities to improve care.
美国有超过 500 万名 2 型糖尿病伴慢性肾病（CKD）患者；该人群的抗糖尿病药物选择较为复杂，对结局有重要影响。
深入了解 CKD 合并 2 型糖尿病患者的医护人员如何选择抗糖尿病药物。
混合方法。对医护人员进行访谈，采用扎根理论进行定性分析，以确定与抗糖尿病药物处方相关的主题。使用病例简述和直接提问对医护人员进行问卷调查，以定量评估其知识和偏好。对真实世界处方数据进行回顾性队列分析，以评估访谈和调查结果的外部有效性。
初级保健医生、内分泌科医生、执业护士和医生助理有资格接受访谈；初级保健医生和内分泌科医生有资格接受问卷调查；处方数据来自有血清肌酐数据的成年患者。
访谈为定性分析；对于调查和回顾性队列研究，主要结局是接受二甲双胍治疗的患者比例。
9 名医护人员的访谈确定了一个主题，即对 2 型糖尿病伴 CKD 患者的抗糖尿病药物处方指南存在不确定性。调查共收到 105 名受访者的回复：74 名初级保健提供者和 31 名内分泌科医生。二甲双胍是 T2D 和 CKD 患者最常见的选择。与初级保健提供者相比，内分泌科医生较少在肾功能水平上开具禁忌使用二甲双胍的处方，且更有可能正确回答二甲双胍禁忌的问题（71%对 41%）（p<0.05）。真实世界的数据与调查结果一致，并且进一步表明，在 eGFR 低于 60ml/min/1.73m 的患者中，钠-葡萄糖共转运蛋白 2 抑制剂和胰高血糖素样肽 1 受体激动剂的使用率较低（<10%）。
医护人员不确定如何治疗 CKD 合并 2 型糖尿病，且对现有指南的了解也不充分。这表明有机会改善护理。
