Trends in the Use of Antidiabetic Drugs

A recent survey [11] of antihyperglycaemic drugs in ten European countries showed that their use increased in all countries but with very different treatment patterns. The use of insulin doubled from 1994 to 2003 in some countries (England and Germany) but remained stable in others (Belgium, Portugal, Italy). The use of biguanides increased substantially, whereas the use of sulphonylureas increased more moderately in most countries. Insulin accounted for more than 50% of the daily antidiabetic doses in Sweden, the corresponding number in Portugal was <20% (Fig. 2). In an

Fig. 2. Use of insulins (black), sulphonylureas (white) and biguanides (grey) as proportions of the total use of antidiabetics drugs in ten European countries (2003). Regional variation is substantial. Reproduced with permission from [11].

interesting comparison between Finland and Denmark (with the expected prevalence of diabetes being 7.2% and 6.9% in 2003, respectively) it was found that in 2000, 3.15% of the population in Finland (insulin 1.76%, oral agents 2.40%) was treated with antidiabetic drugs, the corresponding numbers for Denmark was 1.96% for any antidiabetic treatment (insulin 0.78%, oral agents 1.31%) [11]. It is unlikely that differences in detection levels of diabetes or different diabetic phenotypes, let alone drug availability, can explain such a difference. Local therapeutic convention is a plausible explanation. As described in a comparison of two neighbouring communities in Sweden [12] tradition (specialized diabetes clinician compared with non-specialist clinicians) may have major influences on both drug type and dose. Along with progressively more aggressive treatment of glycaemia, the use of cardiovascular and lipid-lowering drugs also increases with time in patients with diabetes [13]. Although the result is improvements in a number of biochemical risk factors, the relation between prescriptions and improved survival remains somewhat elusive since time-related changes are severely confounded by improved diagnostic awareness and, particularly in the case of diabetes, of recent changes in diagnostic levels of blood glucose [14].

The impact of recommendations or guidelines (more similar between countries for cardiovascular diseases) has been studied in the Euroaspire programme [15]. Among patients with coronary heart disease there appears to be room for improvement in aspects of cardiovascular prescribing if international guidelines were to be rigorously applied. For antidiabetic drugs, however, it has been shown that changes in recommendations coincide with substantial changes in drug prescription [16].

Use of drugs to prevent diabetes or to treat related diagnoses (e.g. polycystic ovary syndrome) may result in changes in prescription patterns in the future. Such changes may confound the interpretation of data on drug use. At present there is some evidence for the efficacy of metformin, troglita-zone (now withdrawn), orlistat, rosiglitazone and rimonabant [17-19] on delaying the development from impaired glucose tolerance to diabetes. However, use of these drugs to prevent diabetes is not currently recommended.

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