Patterns of anti-diabetic medication use in patients with type 2 diabetes mellitus in England and Wales

Purpose The purpose of this study is to characterise how Type 2 Diabetes Mellitus (T2DM) is treated in England and Wales and whether this adheres to 2009 National Institute for Health and Care Excellence (NICE) guidance on management of T2DM. Methods Data for T2DM patients aged 18+ years prescribed at least one anti-diabetic drug between 01/01/2000-30/06/2012 were extracted from the Clinical Practice Research Datalink. We examined the sequences in which anti-diabetic drugs were prescribed and, for patients on the most common anti-diabetic drug pathways, evaluated average HbA1c values at treatment initiation and at progression to a second or third-line anti-diabetic drug class, including insulin. Results The cohort included 123 671 patients, 56% males, 95% aged 40+ and 79% with at least one recorded HbA1c level. Metformin was the first prescription for 98 957 (80%) patients, with mean HbA1c of 8.68% prior to initiation (95% confidence interval [CI] 8.67, 8.69). A total of 19 890 (16%) patients received sulphonylureas first-line (mean HbA1c = 9.31%, 95% CI 9.27, 9.35). 1402 (12%) insulin users were prescribed insulin first-line (mean HbA1c = 9.89%, 95% CI 9.59, 10.19). A total of 96 895 (78%) patients were managed in line with one of the treatment pathways recommended by NICE. Patients prescribed insulin second-line after metformin had a mean HbA1c of 10.11% (95% CI 9.83, 10.38) prior to first prescription of insulin and 9.98% (95% CI 9.73, 10.23) at baseline. Both values were significantly higher than other groups initiating new treatment. Conclusions In over three-quarters of patients, anti-diabetic drugs are being prescribed per NICE guidance. When insulin is being used earlier than recommended, there appears to be a need for urgent and rapid glycaemic control. (C) 2016 Crown Copyright. Pharmacoepidemiology and Drug Safety (C) 2016 John Wiley & Sons, Ltd.