Most second-line treatments for type 2 diabetes modified within year of initiation
Among patients with type 2 diabetes put on a second-line drug, 38.6% discontinued the medication within one year of starting, 19.8% intensified the medications, and 5.2% of patients switched drug classes, according to data from over 82,000 U.S. patients.
The majority of patients with type 2 diabetes discontinue, switch, or intensify their noninsulin second-line medications within one year of initiation, according to new results of a retrospective study.
A total of 82,624 adults on one of five medications—sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), or thiazolidinediones—were included in the analysis. Data were gleaned from health plan enrollment files, medical inpatient and ambulatory claims, and pharmacy claims collected between July 2013 and December 2017. All patients were enrolled in a commercial or Medicare Advantage plan and had no change in health plan structure or insurance segment during the 12-month follow-up period.
Fifty-one percent of patients received sulfonylureas as their second-line therapy, 24% received DPP-4 inhibitors, 11.6% were prescribed SGLT-2 inhibitors, and 8.1% received GLP-1 RAs. Most patients were male, had a non-Medicare insurance plan, and had no diabetes-related complications. Findings were published by the American Journal of Managed Care on Dec. 12, 2023.
Almost two-thirds (63.6%) of patients had their second-line treatment modified during the follow-up period. The most common medication modification was discontinuation (38.6%), with another 5.2% switching and 19.8% intensifying. Just over half (50.3%) of patients prescribed GLP-1 RAs discontinued the medication. Discontinuation was more likely with DPP-4 inhibitors or GLP-1 RAs compared with sulfonylureas (hazard ratios, 1.07 [95% CI, 1.04 to 1.10] and 1.28 [95% CI, 1.23 to 1.33], respectively). All drug classes had higher risks of switching and lower rates of intensification than sulfonylureas.
Younger age and female sex were associated with a higher likelihood of any medication modification. Researchers also found that treatments prescribed by an endocrinologist had a lower discontinuation rate and higher intensification rate than those prescribed by a family or internal medicine physician. One limitation to the study was that it did not include patients prescribed basal insulin as a second-line therapy.
High discontinuation rates among patients taking GLP-1 RAs were likely due to gastrointestinal adverse effects, and the greater persistence of patients on sulfonylureas might relate to cost, the study authors speculated, noting that those who stayed on sulfonylureas “were somewhat more likely than the overall study population to be 65 years or older or to have a Medicare Advantage plan.”
More research is needed to better understand barriers to antidiabetic medication adherence and patients' reasons for discontinuation and to “test new prescribing approaches and patient supports to maximize medication adherence and reduce health system waste among patients who initiate second-line ADM [antidiabetic medication] therapy,” the authors said. “When patients discontinue a second-line ADM soon after treatment initiation, both resources (among health plans and patients) and time (among patients and clinicians) are wasted.”