New data shows: Nearly half of adults prescribed Methformis after being newly diagnosed with type 2 diabetes stopped taking it after 1 year.

The findings, from a case-control analysis of administrative data from Alberta, Canada, for 2012-2017, also suggest that the drop in metformin adherence was most severe during the first 30 days and In most cases, there is no alternative simultaneously to another hypoglycemic agent.

Although the majority of newly diagnosed type 2 diabetes patients are prescribed metformin as first-line therapy, patients who initiate other therapies have much higher medical and healthcare costs. .

The data were recently published in the Journal of Diabetes Medicine by David J.TCampbell, MD, PhD, of the University of Calgary, Alberta, Canada, and colleagues.

“We’ve found that even if someone is prescribed metformin it doesn’t mean they’re using it for even a year… the drop-off rate is actually quite surprising,” Campbell told Medscape Medical News. Most people who stop taking it have A1c levels above 7.5%, so it’s not like they don’t need to take their blood sugar-lowering medication anymore, he noted.

People don’t understand about prolonged drug use; Medicines don’t make you feel better

One reason for stopping the medication, he said, is that patients may not realize they need to keep taking the medication.

“When a doctor examines someone with newly diagnosed diabetes, I think it’s important to remember that they may not know the implications of having a chronic condition. So many times we quickly prescribe metformin and forget about it… Doctors could write a prescription for 3 months and prescribe 3 more times and not see a patient again for a year… We may need to let it go. Pay close attention to these people and monitor them more often, and make sure they get early diabetes education. “

Side effects are an issue, but not for most people. “Any clinician who prescribes metformin knows there are side effects, such as abdominal pain, diarrhea, and nausea. But certainly, not half of patients experience this… A lot of people don’t accept having to take it for the rest of their lives, especially when they may not feel better from taking it,” says Campbell.

James Flory, MD, an endocrinologist at Memorial Sloan Kettering Cancer Center in New York City, tells Medscape Medical News that only about 25% of patients taking metformin experience gastrointestinal side effects.

Furthermore, he also noted that the reduction in adherence was also seen with antihypertensive and lipid-lowering agents with fewer side effects than metformin. He points to a “striking example” of this, a 2011 randomized trial published in the New England Journal of Medicine, and as reported by Medscape Medical News, showing rates of adherence to medications. This is only about 50%, even in people who have had a heart attack.

“People really don’t want to use these drugs… They don’t like being medicalized and taking drugs. If they weren’t constantly urged and reminded and told to take medicine, I think they would find a good reason, a reason to stop… I think they want to solve things through lifestyle, not medication use,” notes Flory, who has also published on the topic of metformin adherence.

Furthermore, Flory explains, “These drugs do not make patients feel better. None of these have this effect. They just don’t make you feel worse. To motivate you to continue taking your medication, you must truly believe in the chronic condition and believe that it is hurting you and that you cannot handle it without the medications.

Communication with the patient is key, he said.

“I don’t have empirical data to support this, but I find it helpful to acknowledge downsides with patients. I asked them to tell me [nếu họ có tác dụng phụ] and we will deal with it. Don’t just stop taking it and never come back.” At the same time, he added, “I think it is important to emphasize the safety and effectiveness of metformin. “

For patients experiencing gastrointestinal side effects, options include switching to extended-release metformin or reducing the dose.

Additionally, while patients are often advised to take metformin with food, some develop diarrhea in doing so and prefer to take it before bed rather than dinner. “If doing it works for them, they should,” advises Flory.

“It doesn’t take long to emphasize to patients safety and how much flexibility and control they can exercise with and when. These will really help. ”

Metformin is often prescribed, but not always used

Campbell and colleagues analyzed 17,932 people with type 2 diabetes diagnosed between April 1, 2012 and March 31, 2017. Overall, 89% received metformin monotherapy as a prescription. of their baseline diabetes, 7.6% started metformin in combination with another blood sugar-lowering drug, and 3.3% were prescribed the antidiabetic drug nonmetformin. (Those who were prescribed insulin as a first-line treatment for diabetes were excluded.)

The drugs most commonly prescribed with metformin were sulfonylureas (47%) and DPP-4 inhibitors (28%). Among those who started treatment with only nonmetformin, a sulfonylurea was also the most common (53%) and a dipeptidyl peptidase-4 (DPP-4) inhibitor was second (21%).

Campbell noted that the metformin prescribing rate of 89% reflects current guidelines.

“In hypertension, clinicians didn’t really follow the guidelines… they prescribed more expensive drugs than the guidelines… We found that in diabetes, in contrast to hypertension, clinicians in general actually follow clinical practice guidelines… The majority of people starting metformin are started on monotherapy. That gives us peace of mind. We won’t pay for a bunch of expensive drugs when metformin does the same thing. “

However, the proportion of people who were dispensed with metformin for the full number of days fell by about 10% after 30 days, another 10% after 90 days, and again after 100 days, resulting in only 54% of the drug remaining in 1 year. .

Factors associated with higher adherence include older age, presence of comorbidities, and the highest versus lowest neighborhood income group.

Those who were prescribed nonmetformin therapy had twice the total health care costs as those prescribed metformin monotherapy. Higher healthcare costs are seen in patients who are younger, have lower income, higher baseline A1c, have more comorbidities, and are male.

How will prescribing change with newer drugs for type 2 diabetes?

Campbell notes that “many things have changed since 2017… At least in Canada, sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists are thought to be contraindicated as alternatives for patients with cardiovascular disease, but they are increasingly considered first-line drugs in high-risk patients.

“I think as those guidelines are passed on to primary care colleagues, who are doing most of the prescribing, we will see more and more people receiving these drugs. “

Indeed, Flory says, “The data on metformin at this point in time is very old and many of the trials showing its health benefits are actually very weak compared to the large trials that have been done for newer drugs, to you can imagine a consensus slowly forming as people start to recommend something other than metformin to most people with type 2 diabetes. The cost implications are enormous. , and I think the same goes for the safety implications. “

According to Flory, SGLT2 inhibitors “are not fundamentally as safe as metformin. I think they are very safe drugs – good studies have confirmed that – but if you are going to give them to a large number of people who are basically healthy, the safety standards have to be pretty high.

Flory believes that the increased risk of diabetic ketoacidosis alone is reason for pause. “Although it is manageable… metformin has no such safety issues. I’m comfortable prescribing an SGLT2 inhibitor, but if I were to give a drug to a million people and no one would have a problem, it would be metformin, not SGLT2. [chất ức chế].

Campbell and colleagues will track prescription data through 2019, which will, of course, include newer drugs. They will also investigate the reasons for stopping the drug and the outcomes of those who stopped versus continuing metformin.

Campbell reported no related financial relationships. Flory advises a legal firm on insulin similar pricing-related lawsuits, not involving or involving a particular company.

Source: https://www.medscape.com/viewarticle/955893#vp_1

Refer:

Diabet Med. Published online June 16, 2021: First-line pharmacotherapy for incident type 2 diabetes: Prescription patterns, adherence and associated costs

Miriam E. Tucker is a freelance journalist based in the Washington DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR’s Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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Translator: Gia Minh