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Utilisation of antihyperglycaemic drugs in ten European countries: different developments and different levels

Melander A, Folino-Gallo P, Walley T, et al. Diabetologia. 2006;49:2024-2029.

Antihyperglycemic drugs (AHGDs) include insulin and oral agents, such as sulfonylureas and metformin, that are used to improve blood glucose levels. The United Kingdom Prospective Diabetes Study (UKPDS) demonstrated that tight glycemic control, achieved through use of AHGDs, was more effective than lifestyle management alone in decreasing the occurrence of diabetes-related events in type 2 diabetes patients. However, studies conducted before and after publication of the UKPDS data indicate that AHGD use varies between countries and even within countries. The purpose of the current study was to update and compare the use of insulin and oral AHGDs in European countries with available data on these statistics.

Data were collected from public registers of 10 European countries in which patient costs of AHGDs were reimbursed by the tax systems: Denmark, Finland, Norway, Sweden, Belgium, England, Germany, Italy, Portugal, and Spain. Yearly data on AHGD use were based on sales, expressed as defined daily doses per 1000 inhabitants per day (DDD/TID). Data from 1994 to 2003 were used for all countries except Belgium (1997 to 2003), Italy (2000 to 2003), and Portugal (2000 to 2003). Registers for Denmark, Finland, and Sweden had additional information available for analysis. Comparisons of population proportions treated with AHGDs and the average purchased doses were made for Denmark and Finland; AHGD use in type 1 and type 2 diabetes patients, extrapolated from data on patient age, was evaluated for Denmark and Sweden. Data on insulin, sulfonylureas (SUs), and biguanides were presented. Metformin was the only biguanide used in all countries but Italy. Use of other AHGDs (acarbose, glinides, thiazolidenediones) was very low or none, so data on these agents were not reported.

According to sales information (DDD/TID), insulin use was highest in Sweden until 2000; Germany and Finland approached similar levels thereafter. In England and Germany, insulin use doubled from 1994 to 2003. Germany had the highest use of SUs in 1998 but was subsequently surpassed by Spain, Portugal, and Finland. Metformin use increased in all countries studied and was highest in Finland in 2003. When considered as a percentage of total AHGD use, insulin use was highest in Sweden (>50%) and lowest in Portugal (<20%) in 2003. Again considering 2003 data and reporting highest and lowest usage rates, SUs comprised >50% of total AHGD use in Spain and Portugal and <30% in Sweden and Norway. Similarly, AHGD use attributable to metformin was >30% in Belgium and Portugal and <20% in Spain in 2003. In 2000, the percentage of Finland’s population using AHGDs was about 60% greater than Denmark’s; the population percentages using insulin and metformin were approximately 120% and 80% greater, respectively. Insulin doses were not substantially different in the 2 countries, but glibenclamide and metformin doses were 20% greater in Finland. Considering AHGD use according to age in Sweden and Denmark, oral AHGD use was low and insulin use was similar in patients <45 years old (presumptive type 1 diabetes patients). However, in patients ≥45 years old (presumptive type 2 diabetes patients), insulin and AHGD use were higher than in patients <45 years old and were two-fold higher in Sweden than Denmark.

It is not surprising that AHGD use has increased, given the increasing prevalence of type 2 diabetes. In the current study, this assumption is supported by the observation that differences in AHGD use in Denmark and Sweden were greater among older diabetes patients in 2000. Differences in the prevalence of AHGD use may reflect differences in diabetes prevalence, but they may also reflect variations in habits and attitudes concerning the management of type 2 diabetes. Reimbursement system specifics may also contribute to differences in AHGD use. For example, use of SU and biguanides, but not insulin, was reduced in Sweden when reimbursement of oral AHGDs was reduced. In the future, it will be important to determine whether differences in AHGD use result in differences in glucose control and diabetes complication rates.



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