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      Ethnic and socioeconomic disparities in initiation of second‐line antidiabetic treatment for people with type 2 diabetes in England: A cross‐sectional study


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          To assess any disparities in the initiation of second‐line antidiabetic treatments prescribed among people with type 2 diabetes mellitus (T2DM) in England according to ethnicity and social deprivation level.

          Materials and methods

          This cross‐sectional study used linked primary (Clinical Practice Research Datalink) and secondary care data (Hospital Episode Statistics), and the Index of Multiple Deprivation (IMD). We included people aged 18 years or older with T2DM who intensified to second‐line oral antidiabetic medication between 2014 and 2020 to investigate disparities in second‐line antidiabetic treatment prescribing (one of sulphonylureas [SUs], dipeptidyl peptidase‐4 [DPP‐4] inhibitors, or sodium‐glucose cotransporter‐2 [SGLT2] inhibitors, in combination with metformin) by ethnicity (White, South Asian, Black, mixed/other) and deprivation level (IMD quintiles). We report prescriptions of the alternative treatments by ethnicity and deprivation level according to predicted percentages derived from multivariable, multinomial logistic regression.


          Among 36 023 people, 85% were White, 10% South Asian, 4% Black and 1% mixed/other. After adjustment, the predicted percentages for SGLT2 inhibitor prescribing by ethnicity were 21% (95% confidence interval [CI] 19–23%), 20% (95% CI 18–22%), 19% (95% CI 16–22%) and 17% (95% CI 14–21%) among people with White, South Asian, Black, and mixed/other ethnicity, respectively. After adjustment, the predicted percentages for SGLT2 inhibitor prescribing by deprivation were 22% (95% CI 20–25%) and 19% (95% CI 17–21%) for the least deprived and the most deprived quintile, respectively. When stratifying by prevalent cardiovascular disease (CVD) status, we found lower predicted percentages of people with prevalent CVD prescribed SGLT2 inhibitors compared with people without prevalent CVD across all ethnicity groups and all levels of social deprivation.


          Among people with T2DM, there were no substantial differences by ethnicity or deprivation level in the percentage prescribed either SGLT2 inhibitors, DPP‐4 inhibitors or SUs as second‐line antidiabetic treatment.

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          Most cited references32

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          Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes.

          The effects of empagliflozin, an inhibitor of sodium-glucose cotransporter 2, in addition to standard care, on cardiovascular morbidity and mortality in patients with type 2 diabetes at high cardiovascular risk are not known.
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            Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction

            In patients with type 2 diabetes, inhibitors of sodium-glucose cotransporter 2 (SGLT2) reduce the risk of a first hospitalization for heart failure, possibly through glucose-independent mechanisms. More data are needed regarding the effects of SGLT2 inhibitors in patients with established heart failure and a reduced ejection fraction, regardless of the presence or absence of type 2 diabetes.
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              Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes

              Background Canagliflozin is a sodium-glucose cotransporter 2 inhibitor that reduces glycemia as well as blood pressure, body weight, and albuminuria in people with diabetes. We report the effects of treatment with canagliflozin on cardiovascular, renal, and safety outcomes. Methods The CANVAS Program integrated data from two trials involving a total of 10,142 participants with type 2 diabetes and high cardiovascular risk. Participants in each trial were randomly assigned to receive canagliflozin or placebo and were followed for a mean of 188.2 weeks. The primary outcome was a composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. Results The mean age of the participants was 63.3 years, 35.8% were women, the mean duration of diabetes was 13.5 years, and 65.6% had a history of cardiovascular disease. The rate of the primary outcome was lower with canagliflozin than with placebo (occurring in 26.9 vs. 31.5 participants per 1000 patient-years; hazard ratio, 0.86; 95% confidence interval [CI], 0.75 to 0.97; P<0.001 for noninferiority; P=0.02 for superiority). Although on the basis of the prespecified hypothesis testing sequence the renal outcomes are not viewed as statistically significant, the results showed a possible benefit of canagliflozin with respect to the progression of albuminuria (hazard ratio, 0.73; 95% CI, 0.67 to 0.79) and the composite outcome of a sustained 40% reduction in the estimated glomerular filtration rate, the need for renal-replacement therapy, or death from renal causes (hazard ratio, 0.60; 95% CI, 0.47 to 0.77). Adverse reactions were consistent with the previously reported risks associated with canagliflozin except for an increased risk of amputation (6.3 vs. 3.4 participants per 1000 patient-years; hazard ratio, 1.97; 95% CI, 1.41 to 2.75); amputations were primarily at the level of the toe or metatarsal. Conclusions In two trials involving patients with type 2 diabetes and an elevated risk of cardiovascular disease, patients treated with canagliflozin had a lower risk of cardiovascular events than those who received placebo but a greater risk of amputation, primarily at the level of the toe or metatarsal. (Funded by Janssen Research and Development; CANVAS and CANVAS-R ClinicalTrials.gov numbers, NCT01032629 and NCT01989754 , respectively.).

                Author and article information

                Diabetes Obes Metab
                Diabetes Obes Metab
                Diabetes, Obesity & Metabolism
                Blackwell Publishing Ltd (Oxford, UK )
                02 November 2022
                January 2023
                : 25
                : 1 ( doiID: 10.1111/dom.v25.1 )
                : 282-292
                [ 1 ] Department of Non‐Communicable Disease Epidemiology London School of Hygiene & Tropical Medicine London UK
                [ 2 ] Department of Health Services Research and Policy London School of Hygiene & Tropical Medicine London UK
                [ 3 ] The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute University of Washington School of Pharmacy Seattle Washington
                [ 4 ] Centre for Longitudinal Studies, UCL Social Research Institute University College London London UK
                [ 5 ] Patient Research Champion Team National Institute for Health Research Twickenham UK
                [ 6 ] Diabetes Trials Unit, The Oxford Centre for Diabetes, Endocrinology and Metabolism University of Oxford Headington UK
                [ 7 ] Diabetes Research Centre University of Leicester Leicester UK
                Author notes
                [*] [* ] Correspondence

                Patrick Bidulka, Department of Non‐Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.

                Email: patrick.bidulka1@ 123456lshtm.ac.uk

                Author information
                © 2022 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                : 06 September 2022
                : 13 July 2022
                : 18 September 2022
                Page count
                Figures: 2, Tables: 2, Pages: 11, Words: 7436
                Funded by: National Institute for Health and Care Research (NIHR) , doi 10.13039/501100000272;
                Award ID: NIHR128490
                Original Article
                Original Articles
                Custom metadata
                January 2023
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.2.7 mode:remove_FC converted:12.04.2023

                Endocrinology & Diabetes
                ethnicity,oral antidiabetics,pharmacoepidemiology,socioeconomic deprivation,type 2 diabetes


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