title: Clinical Outcomes of Continuation of Metformin Titration Instructions with Electronic Prescribing.
abstract: BACKGROUND
  Anecdotal evidence suggests that metformin titration instructions are not being updated and refill requests are approved without modification of the titration instructions such that the titration instructions is continued for patients newly initiated on metformin.
  
  
  METHODS
  This was a retrospective cohort analysis of adult patients who received newly initiated metformin pharmacotherapy. Patients were followed from their initial metformin purchase through two subsequent metformin refill purchases. Outcomes, including the 3-year incidence rate of patients with at least one set of continued titration instructions and proportions of patients with at least one gastrointestinal adverse effect (AE) and those with an elevated glucose measurement at follow-up, were assessed during the time period between patients' second and third metformin purchases. Analyses were performed comparing the exposure (i.e., patients with continued instructions) group to the control (i.e., patients without continued instructions) group.
  
  
  RESULTS
  The exposure group had a higher mean age and chronic disease score but lower metformin starting dose than the control group (all p < 0.05). The 3-year incidence rate of patients with at least one continuation of titration instructions was 60.3 % (95 % CI 58.3-62.3). Gastrointestinal AEs were rare with equivalent proportions of patients in each group experiencing an event (p > 0.05). Control patients (48.7 % of patients with a measurement) were more likely to have had poorly controlled glucose than exposure patients (35.7 % of patients with a measurement) (p < 0.001).
  
  
  CONCLUSIONS
  A high rate of continuation of titration instructions for patients newly initiated on metformin was observed; however, such continuation did not negatively affect clinical outcomes.
authors.affiliation: Clinical Pharmacy Research, Pharmacy Department, Kaiser Permanente Colorado, 16601 E. Centretech Pkwy., Aurora, CO, 80011, USA. tom.delate@kp.org.
authors.forename: Thomas
authors.initials: T
authors.lastname: Delate
authors.affiliation: Clinical Pharmacy Research, Pharmacy Department, Kaiser Permanente Colorado, 16601 E. Centretech Pkwy., Aurora, CO, 80011, USA.|Rueckert-Hartman College for Health Professions, Regis University, 3333 Regis Boulevard, Denver, CO, 80221, USA.
authors.forename: Nathan
authors.initials: N
authors.lastname: Rader
authors.affiliation: Medication Safety, Pharmacy Department, Kaiser Permanente Colorado, 16601 E. Centretech Pkwy., Aurora, CO, 80011, USA.
authors.forename: Julia E
authors.initials: JE
authors.lastname: Rawlings
authors.affiliation: Rueckert-Hartman College for Health Professions, Regis University, 3333 Regis Boulevard, Denver, CO, 80221, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Smith
authors.affiliation: Clinical Pharmacy Specialties, Pharmacy Department, Kaiser Permanente Colorado, 16601 E. Centretech Pkwy., Aurora, CO, 80011, USA.
authors.forename: Sheryl J
authors.initials: SJ
authors.lastname: Herner