OBJECTIVE The American Diabetes Association recommends metformin as first-line therapy for type 2 diabetes. However, nonadherence to antihyperglycemic medication is common, and a clinician could confuse nonadherence with pharmacologic failure, potentially leading to premature prescribing of second-line therapies. We measured metformin use prior to second-line therapy initialization. RESEARCH DESIGN AND METHODS This retrospective cross-sectional study used unidentifiable member claims data from individuals covered from 2010 to 2015 by Aetna, a U.S. health benefits company. Beneficiaries with two physician claims or one hospitalization with a type 2 diabetes diagnosis were included. Recommended use of metformin was measured by the proportion of days covered over 60 days. Through sensitivity analysis, we varied estimates of the percentage of beneficiaries who used low-cost generic prescription medication programs. RESULTS A total of 52,544 individuals with type 2 diabetes were eligible. Of 22,956 patients given second-line treatment, only 1,875 (8.2%) had evidence of recommended use of metformin in the prior 60 days, and 6,441 (28.0%) had no prior claims evidence of having taken metformin. At the top range of sensitivity, only 49.5% patients could have had recommended use. Patients were more likely to be given an additional second-line antihyperglycemic medication or insulin if they were given their initial second-line medication without evidence of recommended use of metformin ( P < 0.001). CONCLUSIONS Despite published guidelines, second-line therapy often is initiated without evidence of recommended use of first-line therapy. Apparent treatment failures, which may in fact be attributable to nonadherence to guidelines, are common. Point-of-care and population-level processes are needed to monitor and improve guideline adherence.

中文翻译：

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抗高血糖药物：基于二线药物初始化之前基于索赔的一线治疗的估计

目的美国糖尿病协会推荐二甲双胍作为2型糖尿病的一线治疗药物。但是，不坚持使用降血糖药是很常见的，临床医生可能会将不坚持使用与药理学上的混淆相混淆，可能导致过早开出二线疗法的处方。在开始二线治疗之前，我们测量了二甲双胍的使用量。研究设计和方法这项回顾性横断面研究使用了美国健康保险公司Aetna从2010年至2015年所涵盖的无法确定的会员索赔数据。受益人有两个医师要求或一个因2型糖尿病诊断而住院。二甲双胍的推荐使用量是根据60天内的使用天数来衡量的。通过敏感性分析，我们对使用低成本仿制处方药计划的受益人百分比的估计值有所不同。结果共有52544名2型糖尿病患者符合条件。在接受第二线治疗的22,956名患者中，只有1,875（8.2％）的证据表明在过去60天内推荐使用二甲双胍，而6,441（28.0％）的患者没有先前声称服用二甲双胍的证据。在最高敏感度范围内，只有49.5％的患者可以推荐使用。如果患者在没有推荐使用二甲双胍证据的情况下进行了初次二线药物治疗，则他们更有可能接受其他二线降糖药物或胰岛素治疗（P <0.001）。结论尽管已发布指南，但通常在没有证据表明推荐使用一线治疗的情况下开始二线治疗。明显的治疗失败很常见，实际上可能归因于不遵守准则。需要监督点和人群一级的流程来监视和改善准则的遵守情况。