Compared to Thiazolidinediones, Sulfonylureas More Likely to Cause Death and Hospitalization for Veterans with Diabetes
BACKGROUND:
With more than 12 classes of glucose-lowering drugs currently approved, choosing the correct medications is becoming increasingly complex for patients with diabetes and their providers. There are few systematic comparisons of long-term outcomes related to specific medications, especially beyond first-line treatments. This study compared long-term outcomes of the two most commonly used second-line oral hypoglycemic medications in the VA healthcare system – sulfonylureas (SUs) and thiazolidinediones (TZDs). Current diabetes treatment guidelines outside VA promote metformin (MET) as the preferred first drug, but no longer recommend a particular second-line agent; in contrast, VA guidelines continue to recommend SUs as the second-line agent. Using VA and Medicare data from 2000 to 2010, investigators identified Veterans with diabetes who were dually enrolled in VA and Medicare who received a prescription for metformin and then initiated either SUs (n=73,726) or TZDs (n=7,210). The initiation date of SU or TZD was the start of the study period (index date) for each patient, and the previous 12 months was the baseline period. Variables at baseline included patient demographics, HbA1c levels, serum creatinine, urine microalbumin, body mass index, and comorbidities. Outcomes included all-cause mortality, hospital admission (VA or Medicare) for any of 13 ACSCs (ambulatory care sensitive conditions), and acute myocardial infarction (AMI) or stroke.
FINDINGS:
- Veterans with diabetes who started on sulfonylureas compared to thiazolidinediones as a second-line agent after metformin were significantly more likely to die or have an ACSC hospitalization.
- Patients in this study were elderly (mean age 69), primarily white (88%), and had high rates of cardiovascular comorbidities (e.g., chronic pulmonary disease, hypertension), and obesity (41%).
LIMITATIONS:
- It is possible that some uncontrolled provider factors were responsible for the results.
- Although TZD use was associated with fewer adverse outcomes than SU use, this does not inform the relative safety profile of SUs and TZDs in comparison to other newer agents.
AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D (IIR 10-136). Drs. Prentice and Pizer are part of VA's Health Care Financing & Economics. Drs. Prentice, Conlin, and Pizer are part of the VA Boston Healthcare System. Dr. Gellad was supported by an HSR&D Career Development Award and is part of HSR&D's Center for Health Equity Research and Promotion in Pittsburgh, PA. Dr. Edelman is part of HSR&D's Center for Health Services Research in Primary Care, Durham, NC.
Prentice J, Conlin P, Gellad W, Edelman D, Lee T, Pizer S. Capitalizing on Prescribing Pattern Variation to Compare Medications for Type 2 Diabetes. Value in Health. December 2014;17(8):854-62.
