BACKGROUND: Although practice guidelines stress individualization of glucose management in patients with type 2 diabetes (T2D), the extent to which providers take patient factors into account when selecting medications is not well known. We used data from the Diabetes Collaborative Registry (DCR) to evaluate the current real-world use of glucose-lowering drugs in key subsets of patients with T2D. METHODS: DCR is the first large-scale US outpatient registry of patients with diabetes recruited from primary care, cardiology, and endocrinology practices and currently encompasses 374 practices and 5114 providers. T2D medications were grouped as those which may be suboptimal for key patient subgroups, including 1) obesity (i.e. propensity for weight gain): insulin, sulfonylurea, TZD; 2) elderly (i.e., high hypoglycemia risk): insulin, sulfonylurea; 3) advanced chronic kidney disease (CKD 4/5): metformin, sulfonylurea; and 4) coronary artery disease (i.e. potential safety issues): sulfonylurea. We examined patient factors associated with use of these groups of agents using 4 hierarchical (for both specialty and site) Poisson models, adjusting for HbA1c, number of T2D medications, and insurance status. RESULTS: Overall, 157,551 patients with T2D were prescribed a glucose-lowering medication: metformin 75.1%, sulfonylurea 34.4%, insulin 27.7%, DPP-4i 18.3%, TZD 10.9%, GLP-1 RA 6.4%, SGLT2i 4.8%. After adjusting for patient factors, glycemic control, and insurance status, patients with morbid obesity were more likely treated with medications prone to cause weight gain (relative rate [RR] 1.09, 95% CI 1.07–1.11). Older patients were more likely to be treated with medications with increased risk of hypoglycemia (RR 1.04 per 5 years, 95% CI 1.04–1.05). Patients with CKD 4/5 were less likely to be treated with agents with known risk in patients with advanced CKD (RR 0.74, 95% CI 0.71–0.77). Patients with coronary artery disease were no more or less likely to be treated with medications with potential cardiovascular safety issues (RR 0.99, 95% CI 0.96–1.01). CONCLUSIONS: In a large US-based registry of T2D patients, we observed some evidence for targeted use of glucose-lowering therapies in certain subgroups but also identified potential opportunities for better personalization of treatment. In an era of increasing number and complexity of medication choices with varying risks/benefits, data sources such as the DCR can highlight potential areas for improving targeted approaches to pharmacologic therapy in order to optimize selection of patients most likely to benefit (and least likely to be harmed) from treatments.
