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Controversies in the management of patients with type 2 diabetes: final report
Controversies in the management of patients with type 2 diabetes: final report
- Collection:
- Health Policy and Services Research
- Contributor(s):
- Institute for Clinical and Economic Review, issuing body.
New England Comparative Effectiveness Public Advisory Council, issuing body. - Publication:
- [Boston, MA] : Institute for Clinical and Economic Review, December 2014
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Comparative Effectiveness Research
Diabetes Mellitus, Type 2 -- drug therapy
Disease Management
Blood Glucose -- analysis
Blood Glucose -- metabolism
Dipeptidyl-Peptidase IV Inhibitors -- therapeutic use
Drug Therapy, Combination
Hemoglobin A, Glycosylated -- analysis
Hypoglycemic Agents -- administration & dosage
Hypoglycemic Agents -- therapeutic use
Insulin -- therapeutic use
Metformin -- administration & dosage
Metformin -- therapeutic use
Monitoring, Ambulatory
Randomized Controlled Trials as Topic
Receptors, Glucagon -- agonists
Sulfonylurea Compounds -- administration & dosage
Sulfonylurea Compounds -- therapeutic use
Treatment Outcome
Humans
New England
United States - Genre(s):
- Technical Report
- Abstract:
- On October 29, 2014 the New England Comparative Effectiveness Public Advisory Council (CEPAC) held a public meeting in Providence, RI on "Controversies in Type 2 Diabetes Management." The Council reviewed evidence summarized by the Institute for Clinical and Economic Review (ICER) on the comparative clinical effectiveness and comparative value of multiple pharmacological options for second- and third-line treatment in patients with inadequate glycemic control on metformin monotherapy or the combination of metformin and a sulfonylurea, the most widely accepted initial medication choices for type 2 diabetes. The drug classes assessed in the review include: sulfonylureas, insulin, and two relatively new classes of medications, dipeptidyl peptidase-4 (DPP-4) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. CEPAC also reviewed the evidence on multiple forms of insulin and methods for insulin delivery, as well as the potential benefits of continuous blood glucose monitoring in this population. Following their votes, CEPAC then explored how best to apply the evidence to practice and policy with a distinguished Policy Expert Roundtable of clinical experts, health plan representatives, and a patient advocate from across New England. In evaluating the evidence on different insulin formulations, CEPAC determined that NPH insulin (intermediate-acting human insulin) is functionally equivalent to long-acting insulin analogs, and has "high" comparative value. A Cochrane review of eight randomized control trials (RCTs) comparing NPH insulin to insulin analogs found no significant between-group differences in glycemic control, changes in body weight, or adverse events, with the exception of a reduction in nonsevere hypoglycemia for insulin analogs. NPH insulin is also much less expensive--average wholesale prices are approximately one-third of those for insulin analogs. The results of ICER's economic modeling suggest that for every 1,000 patients treated with insulin, a switch from insulin analogs to NPH insulin would result in approximately $1.7 million in cost savings. In New England, reducing the percentage of patients using insulin analogs from the current estimate of 80% to 50% would result in over $100 million in savings. In assessing the evidence on second-line treatment options, CEPAC determined that the available evidence was inadequate to determine the superiority of DPP-4 inhibitors when added to metformin compared to metformin plus sulfonylurea. The Council also considered the evidence inadequate for DPP-4 inhibitors when used as a third-line option with metformin and a sulfonylurea, in comparison to metformin plus sulfonylurea plus insulin. In the case of GLP-1 receptor agonists, the Council voted that this drug class is more effective than sulfonylureas and insulin as either a second- or third-line treatment option, but has low comparative value due to substantially higher treatment costs (details of cost-effectiveness analysis included in full report). A systematic review by the Canadian Agency for Drugs and Technologies in Health (CADTH) of RCTs assessing the effectiveness of different second-line agents found statistically significant reductions in HbA1c versus placebo across all major drug classes analyzed, with the greatest reductions for GLP-1 receptor agonists and insulin. Another CADTH systematic review of randomized control trials comparing third-line pharmacotherapy added to metformin and a sulfonylurea for type 2 diabetes found statistically significant reductions in HbA1c across all drug combinations, with the most significant reduction with insulin. The addition of a GLP-1 receptor agonist was associated with reductions in HbA1c similar to those of insulin, but with significant weight loss compared to other combination therapies. CEPAC also concluded that the evidence is inadequate to determine the comparative effectiveness of insulin pump therapy versus multiple daily injections or continuous glucose monitors versus self-monitoring of blood glucose, as data are very limited on the benefit of these management tools in the type 2 diabetes population.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY license. (More information)
- Extent:
- 1 online resource (1 PDF file (129 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101648696 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101648696