Choice of Treatment Regimen as Add-On to Insulin in Japanese Patients with Type 2 Diabetes Mellitus: Physicians' Perspective in a Real-World Setting, Insight from a Web Survey

The Japanese guidelines emphasize treatment individualization and intensification with oral anti-diabetes drugs and glucagon-like peptide-1 receptor agonists (OADGs) as add-on therapy to insulin in the management of type 2 diabetes mellitus (T2DM). However, a step-wise treatment algorithm is not clearly defined in the Japanese guidelines. This study explores the treatment factors and patient characteristics for selecting the OADGs as add-on therapy to insulin from physicians' perspectives in a real-world setting in Japan. This web-based survey comprised a questionnaire designed for physicians (diabetologists with board certification and general physicians without board certification) across Japan. The primary endpoint was the proportion of treatment factors and patient characteristics influencing the selection of OADGs as add-on therapy to insulin by the physicians. In total, 549 physicians participated. The mean number of patients treated with insulin by diabetologists (102.2 +/- 91.2) in the past 6 months was higher than the number by general physicians (35.1 +/- 44.3). The dipeptidyl peptidase-4 (DPP-4) inhibitors were the most frequently prescribed OADGs as add-on therapy to insulin types among the physicians (75.4-88.2%), followed by metformin (65.2-76.3%). The treatment factors influencing the choice of a DPP-4 inhibitor were glycated hemoglobin (HbA1c) and postprandial glucose (PPG) lowering effect, frequency of administration, effect on glucagon, and ease of use in patients with renal or liver impairment. For metformin, cost-effectiveness was the key deciding factor. The patient characteristics for the choice of DPP-4 inhibitors among diabetologists were predominantly PPG, concern about hypoglycemia, diabetes complications, and adherence to diet and exercise. For metformin, it was age, body mass index (BMI), insulin resistance, renal and liver function, and economic status of the patients. DPP-4 inhibitors, followed by metformin, were the most frequently prescribed OADGs in combination with insulin in a real-world setting in Japan. The diabetologists considered more drug characteristics for DPP-4 inhibitor or metformin-insulin combinations. The treatment factors and patient characteristics for the choice of DPP-4 inhibitors and metformin were comparable across different insulin types. Novartis Pharma K.K.