A decision support tool for appropriate glucose-lowering therapy in patients with type 2 diabetes

Abstract

Background: Optimal glucose-lowering therapy in type 2 diabetes mellitus requires a patient-specific approach. Although a good framework, current guidelines are insufficiently detailed to address the different phenotypes and individual needs of patients seen in daily practice. We developed a patient-specific decision support tool based on a systematic analysis of expert opinion.

Materials and methods: Based on the American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) 2012 position statement, a panel of 12 European experts rated the appropriateness (RAND/UCLA Appropriateness Method) of treatment strategies for 930 clinical scenarios, which were permutations of clinical variables considered relevant to treatment choice. These included current treatment, hemoglobin A1c difference from individualized target, risk of hypoglycemia, body mass index, life expectancy, and comorbidities. Treatment options included addition of a second or third agent, drug switches, and replacement by monotherapies if the patient was metformin-intolerant. Treatment costs were not considered. Appropriateness (appropriate, inappropriate, uncertain) was based on the median score and expert agreement. The panel recommendations were embedded in an online decision support tool (DiaScope(®); Novo Nordisk Health Care AG, Zürich, Switzerland).

Results: Treatment appropriateness was associated with (combinations of) the patient variables mentioned above. As second-line agents, dipeptidyl peptidase-4 inhibitors were considered appropriate in all scenarios, followed by glucagon-like peptide-1 receptor agonists (50%), insulins (33%), and sulfonylureas (25%), but not pioglitazone (0%). Ratings of third-line combinations followed a similar pattern. Disagreement was highest for regimens including pioglitazone, sulfonylureas, or insulins and was partly due to differences in panelists' opinions and in drug availability and reimbursement across European countries (although costs were disregarded in the rating process).

Conclusions: A novel decision support tool based on the ADA/EASD 2012 position statement and a systematic analysis of expert opinion has been developed to help healthcare professionals to individualize glucose-lowering therapy in daily clinical situations.

FIG. 1.

Appropriateness of second-line regimens with metformin (percentage of clinical scenarios). A treatment is considered appropriate if its expected benefits exceed its potential negative consequences by a sufficient margin. DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide-1.

FIG. 2.

Appropriateness of second-line treatments (sulfonylureas [SU], glucagon-like peptide-1 receptor agonists [GLP-1 RA], and insulins, all with metformin [Met]) by clinical variables: distance to hemoglobin A1c (HbA1c) target, risk of hypoglycemia; body mass index, and life expectancy. Data are percentages of scenarios considered appropriate. Met+dipeptidyl peptidase-4 inhibitors was always considered appropriate, and Met+pioglitazone was never considered appropriate; therefore these combinations are not shown here.

FIG. 3.

User interface of the DiaScope: patient profile and display of treatment recommendations and additional information. DPP-4-i, dipeptidyl peptidase-4 inhibitors; GLP-1RA, glucagon-like peptide-1 receptor agonists; HbA1c, hemoglobin A1c; INS, insulins; MET, metformin; SU, sulfonylureas; TZD, thiazolidinediones.