title: Managing glycaemia in older people with type 2 diabetes: A retrospective, primary care-based cohort study, with economic assessment of patient outcomes.
abstract: To describe the relative health and economic outcomes associated with different second-line therapeutic approaches to manage glycaemia in older type 2 diabetes patients requiring escalation from metformin monotherapy.
  
  
  
  The Clinical Practice Research Datalink database was used to inform a retrospective observational cohort study of patients with type 2 diabetes treated with metformin monotherapy requiring escalation (addition or switch) to a second-line oral regimen from January 1, 2008 to December 31, 2014. Primary outcomes included time to first event (any event, myocardial infarction [MI], stroke, or composite of MI/stroke [major adverse cardiovascular event; MACE]) and total event rate. The health economic consequences associated with the choice of second-line treatment in older patients were assessed using the CORE Diabetes Model.
  
  
  
  A total of 10 484 patients were included; the majority escalated to second-line treatment with metformin + sulphonylurea (SU; 42%) or switched to SU monotherapy (28%). In multivariate adjusted analyses, total event rates for MACE with metformin + dipeptidyl peptidase-4 (DPP-4) inhibitor were significantly lower than with metformin + SU (0.61, 95% confidence interval [CI] 0.39-0.98), driven by a lower MI rate in the metformin + DPP-4 inhibitor group (0.52, 95% CI 0.27-0.99). Economic analyses estimated that metformin + DPP-4 inhibitor treatment was associated with the largest gain in health benefit, and cost-effectiveness ratios were favourable (<£30 000 per quality-adjusted life-year) for all second-line treatment scenarios.
  
  
  
  With respect to treatment choice, data from the present study support the notion of prescribing beyond metformin + SU, as alternative regimens have been shown to be associated with reduced outcomes risk and value for money.
authors.affiliation: Health Economics and Outcomes Research Ltd, Cardiff, UK.|School of Medicine, University of Nottingham, Nottingham, UK.|Department of Public Health, University of Adelaide, Adelaide, Australia.
authors.forename: Jason
authors.initials: J
authors.lastname: Gordon
authors.affiliation: Health Economics and Outcomes Research Ltd, Cardiff, UK.|Swansea Centre for Health Economics, Swansea University, Swansea, UK.
authors.forename: Phil
authors.initials: P
authors.lastname: McEwan
authors.affiliation: Diabetes Resource Centre, Llandough Hospital, Cardiff, UK.
authors.forename: Marc
authors.initials: M
authors.lastname: Evans
authors.affiliation: Global Outcomes Research, Takeda Development Centre Europe Ltd, London, UK.
authors.forename: Jorge
authors.initials: J
authors.lastname: Puelles
authors.affiliation: Foundation for Diabetes Research in Older People, Diabetes Frail Ltd, Worcester, UK.
authors.forename: Alan
authors.initials: A
authors.lastname: Sinclair
mesh_terms: D000368:Aged; D000375:Aging; D015331:Cohort Studies; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000150:complications / Q000188:drug therapy* / Q000191:economics; D054873:Dipeptidyl-Peptidase IV Inhibitors / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D016903:Drug Monitoring; D004351:Drug Resistance; D004359:Drug Therapy, Combination / Q000009:adverse effects / Q000191:economics; D005260:Female; D005500:Follow-Up Studies; D006442:Glycated Hemoglobin / Q000032:analysis; D017048:Health Care Costs; D006801:Humans; D006943:Hyperglycemia / Q000517:prevention & control*; D007003:Hypoglycemia / Q000139:chemically induced / Q000517:prevention & control*; D007004:Hypoglycemic Agents / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D008297:Male; D008687:Metformin / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D011320:Primary Health Care / Q000191:economics; D016016:Proportional Hazards Models; D011788:Quality of Life; D012189:Retrospective Studies
chemical_list: D054873:Dipeptidyl-Peptidase IV Inhibitors; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D008687:Metformin; C517652:hemoglobin A1c protein, human
keywords: management; metformin; older patients; second-line; type 2 diabetes