title: 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.
  
  
  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.
authors.affiliation: 1 Department of Medicine, University of Valencia , Valencia, Spain .
authors.forename: F Javier
authors.initials: FJ
authors.lastname: Ampudia-Blasco
authors.forename: Pierre Yves
authors.initials: PY
authors.lastname: Benhamou
authors.forename: Guillaume
authors.initials: G
authors.lastname: Charpentier
authors.forename: Agostino
authors.initials: A
authors.lastname: Consoli
authors.forename: Michaela
authors.initials: M
authors.lastname: Diamant
authors.forename: Baptist
authors.initials: B
authors.lastname: Gallwitz
authors.forename: Kamlesh
authors.initials: K
authors.lastname: Khunti
authors.forename: Chantal
authors.initials: C
authors.lastname: Mathieu
authors.forename: Martin
authors.initials: M
authors.lastname: Ridderstråle
authors.forename: Jochen
authors.initials: J
authors.lastname: Seufert
authors.forename: Cees
authors.initials: C
authors.lastname: Tack
authors.forename: Tina
authors.initials: T
authors.lastname: Vilsbøll
authors.forename: Tra-Mi
authors.initials: TM
authors.lastname: Phan
authors.forename: Herman
authors.initials: H
authors.lastname: Stoevelaar
mesh_terms: D015992:Body Mass Index; D002985:Clinical Protocols / Q000592:standards; D015897:Comorbidity; D020000:Decision Support Systems, Clinical / Q000592:standards*; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000188:drug therapy*; D054873:Dipeptidyl-Peptidase IV Inhibitors / Q000627:therapeutic use; D057915:Drug Substitution / Q000379:methods; D004359:Drug Therapy, Combination / Q000379:methods; D005060:Europe; D000067757:Glucagon-Like Peptide-1 Receptor; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007003:Hypoglycemia / Q000097:blood / Q000188:drug therapy; D007004:Hypoglycemic Agents / Q000600:supply & distribution / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use; D008017:Life Expectancy; D008687:Metformin / Q000627:therapeutic use; D000077205:Pioglitazone; D057285:Precision Medicine / Q000379:methods*; D018027:Receptors, Glucagon / Q000627:therapeutic use; D013453:Sulfonylurea Compounds / Q000627:therapeutic use; D045162:Thiazolidinediones / Q000627:therapeutic use
chemical_list: D054873:Dipeptidyl-Peptidase IV Inhibitors; D000067757:Glucagon-Like Peptide-1 Receptor; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; D008687:Metformin; D000077205:Pioglitazone; D018027:Receptors, Glucagon; D013453:Sulfonylurea Compounds; D045162:Thiazolidinediones; C000593833:GLP1R protein, human; C517652:hemoglobin A1c protein, human