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. 2018 Sep;20(9):2159-2168.
doi: 10.1111/dom.13346. Epub 2018 Jun 5.

Time trends and geographical variation in prescribing of drugs for diabetes in England from 1998 to 2017

Helen J Curtis  1 , John M Dennis  2 , Beverley M Shields  3 , Alex J Walker  1 , Seb Bacon  1 , Andrew T Hattersley  3 , Angus G Jones  3 , Ben Goldacre  1
Affiliations

Time trends and geographical variation in prescribing of drugs for diabetes in England from 1998 to 2017

Helen J Curtis et al. Diabetes Obes Metab. 2018 Sep.

Abstract

Aims: To measure the variation in prescribing of second-line non-insulin diabetes drugs.

Materials and methods: We evaluated time trends for the period 1998 to 2016, using England's publicly available prescribing datasets, and stratified these by the order in which they were prescribed to patients using the Clinical Practice Research Datalink. We calculated the proportion of each class of diabetes drug as a percentage of the total per year. We evaluated geographical variation in prescribing using general practice-level data for the latest 12 months (to August 2017), with aggregation to Clinical Commissioning Groups. We calculated percentiles and ranges, and plotted maps.

Results: Prescribing of therapy after metformin is changing rapidly. Dipeptidyl peptidase-4 (DPP-4) inhibitor use has increased markedly, with DPP-4 inhibitors now the most common second-line drug (43% prescriptions in 2016). The use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors also increased rapidly (14% new second-line, 27% new third-line prescriptions in 2016). There was wide geographical variation in choice of therapies and average spend per patient. In contrast, metformin was consistently used as a first-line treatment in accordance with guidelines.

Conclusions: In England there is extensive geographical variation in the prescribing of diabetes drugs after metformin, and increasing use of higher-cost DPP-4 inhibitors and SGLT-2 inhibitors compared with low-cost sulphonylureas. Our findings strongly support the case for comparative effectiveness trials of current diabetes drugs.

Keywords: antidiabetic drug; cost-effectiveness; glycaemic control; primary care; type 2 diabetes.

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Conflict of interest statement

BG has received funding from the Health Foundation, the National Institute for Health Research School of Primary Care Research, the NIHR Biomedical Research Centre Oxford, the West of England Academic Health Sciences Network and NHS England for work on UK prescribing data. HC, AW and SB are employed on these grants. BG has additionally received funding from the Laura and John Arnold Foundation, the Wellcome Trust, and the World Health Organisation to work on better use of data in medicine; and receives personal income from speaking and writing for lay audiences on the misuse of science. JD, BS, AJ and AH have all received support for this work from the MRC as part of the MASTERMIND funding for stratified medicine. AH is a Wellcome Trust senior investigator and an NIHR senior investigator. AJ is supported by an NIHR Clinician Scientist award.

Figures

Figure 1
Figure 1
Time trends in antidiabetic medication prescribed across the United Kingdom, 1998 to 2016, separated by line of therapy (First‐Line, Second‐Line, Third‐Line and Fourth‐Line, ie, the order in which additional drugs were prescribed to each patient), based on Clinical Practice Research Datalink data. The prescriptions for each class of antidiabetic drug each year are given as a percentage of all antidiabetic prescriptions (British National Formulary [BNF] 6.1.2). In the First‐Line chart, all classes other than metformin and sulphonylurea are grouped into “Other”. DPP‐4, dipeptidyl peptidase‐4; GLP‐1, glucagon‐like peptide‐1; SGLT‐2, sodium‐glucose co‐transporter‐2; TZD, thiazolidinedione
Figure 2
Figure 2
Time trends in antidiabetic medications dispensed in English primary care in Prescription Cost Analysis data, 1998 to 2016. A, Proportion of each class of drug dispensed in England each year, taking items prescribed of each as a percentage of all antidiabetic items prescriptions (British National Formulary [BNF] 6.1.2). B, Number of items and C, inflation‐corrected cost of each class of (and total) non‐metformin diabetes drug dispensed in England per person with type 2 diabetes. DPP‐4, dipeptidyl peptidase‐4; GLP‐1, glucagon‐like peptide‐1; SGLT‐2, sodium‐glucose co‐transporter‐2; TZD, thiazolidinedione
Figure 3
Figure 3
Geographical variation in prescribing of antidiabetic drugs by all Clinical Commissioning Groups in England, May 2017. For each class of drug (Metformin, Sulphonylurea, DPP‐4, TZD, SGLT‐2 and GLP‐1), numbers represent number of items prescribed as a percentage of all antidiabetic drugs prescribed (British National Formulary 6.1.2). Updated versions of each map may be accessed at http://openprescribing.net using links provided in Table S4 (Appendix S1). DPP‐4, dipeptidyl peptidase‐4; GLP‐1, glucagon‐like peptide‐1; SGLT‐2, sodium‐glucose co‐transporter‐2; TZD, thiazolidinedione
Figure 4
Figure 4
Decile charts summarizing the proportion of each drug class of all antidiabetic items prescribed (British National Formulary [BNF] paragraph 6.1.2) across England's general practices, between October 2010 and August 2017. For each class of drug (Metformin, Sulphonylurea, DPP‐4, TZD, SGLT‐2 and GLP‐1), solid lines represent the median, dashed lines are 10th to 90th percentiles. DPP‐4, dipeptidyl peptidase‐4; GLP‐1, glucagon‐like peptide‐1; SGLT‐2, sodium‐glucose co‐transporter‐2; TZD, thiazolidinedione
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References

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