Introduction
Methods
Study Design
Physicians Recruited for the Survey
Study Assessments
Data Management and Statistical Analysis
Compliance with Ethics Guidelines
Results
Background Characteristics of Physicians Participating in the Survey
Group 1 (n = 260) | Group 2 (n = 289) | |
---|---|---|
Age, years | 48.0 ± 9.5 | 51.4 ± 9.3 |
Time spent in patient care, % | 89.2 ± 11.2 | 91.0 ± 9.7 |
Practice setting, n (%) | ||
Hospital based | 204 (78.5) | 173 (59.9) |
Office based | 56 (21.5) | 116 (40.1) |
Medical specialty, n (%) | ||
PCP/GP | 6 (2.3) | 58 (20.1) |
Internist | 28 (10.8) | 139 (48.1) |
Diabetologist | 203 (78.1) | 21 (7.3) |
Endocrinologist | 17 (6.5) | 9 (3.1) |
Cardiologist | 6 (2.3) | 62 (21.5) |
Time in clinical practice, years | 16.8 ± 8.8 | 22.2 ± 9.3 |
Region, n (%) | ||
Hokkaido | 18 (6.9) | 19 (6.6) |
Tohoku | 11 (4.2) | 19 (6.6) |
Kanto | 81 (31.2) | 97 (33.6) |
Chubu | 49 (18.8) | 43 (14.9) |
Kinki | 37 (14.2) | 52 (18) |
Chugoku | 14 (5.4) | 12 (4.2) |
Shikoku | 19 (7.3) | 12 (4.2) |
Kyushu | 31 (11.9) | 35 (12.1) |
Number of patients treated with insulin in the last 6 months | 102.2 ± 91.2 | 35.1 ± 44.3 |
Choice of OADGs in Combination with Insulin
Drugs, n (%) | Basal insulin | Pre-mixed insulin | Rapid/ultra-rapid insulin | Intensive insulin |
---|---|---|---|---|
All physiciansa (n = 549) | All physiciansa (n = 549) | All physiciansa (n = 549) | All physiciansa (n = 549) | |
(a) All applicable | ||||
DPP-4 inhibitors | 484 (88.2) | 444 (80.9) | 424 (77.2) | 414 (75.4) |
Metformin | 419 (76.3) | 392 (71.4) | 372 (67.8) | 358 (65.2) |
SGLT-2 Inhibitors | 257 (46.8) | 214 (39.0) | 216 (39.3) | 224 (40.8) |
Alpha-GI | 198 (36.1) | 164 (29.9) | 137 (25.0) | 135 (24.6) |
SU | 160 (29.1) | 116 (21.1) | 116 (21.1) | 80 (14.6) |
GLP-1 RA | 149 (27.1) | 94 (17.1) | 98 (17.9) | 108 (19.7) |
Glinides | 124 (22.6) | 69 (12.6) | 36 (6.6) | 26 (4.7) |
TZD | 78 (14.2) | 76 (13.8) | 61 (11.1) | 60 (10.9) |
None of them (insulin dose adjustment only) | 10 (1.8) | 32 (5.8) | 39 (7.1) | 55 (10.0) |
Average number of drugs as combination therapy with insulin | 3.4 ± 1.5 | 2.9 ± 1.5 | 2.7 ± 1.4 | 2.6 ± 1.5 |
Drugs, n (%) | Basal insulin | Pre-mixed insulin | Rapid/ultra-rapid insulin | Intensive insulin |
---|---|---|---|---|
All physiciansa (n = 539) | All physiciansa (n = 517) | All physiciansa (n = 510) | All physiciansa (n = 494) | |
(b) Frequently used | ||||
DPP-4 inhibitors | 282 (52.3) | 259 (50.1) | 243 (47.6) | 233 (47.2) |
Metformin | 160 (29.7) | 171 (33.1) | 174 (34.1) | 159 (32.2) |
Alpha-GI | 24 (4.5) | 27 (5.2) | 27 (5.3) | 28 (5.7) |
SGLT-2 Inhibitors | 23 (4.3) | 24 (4.6) | 30 (5.9) | 37 (7.5) |
SU | 19 (3.5) | 13 (2.5) | 11 (2.2) | 9 (1.8) |
Glinides | 15 (2.8) | 9 (1.7) | 8 (1.6) | 4 (0.8) |
GLP-1 RA | 12 (2.2) | 12 (2.3) | 13 (2.5) | 18 (3.6) |
TZD | 4 (0.7) | 2 (0.4) | 4 (0.8) | 6 (1.2) |
Expectations on Reducing Insulin Dosage or Injection Frequency with OADs
Treatment Factors Affecting the Drug Choice for Combination Therapy with Insulin
Treatment factors | Basal | Pre-mixed | Rapid/ultra-rapid | Intensive | ||||
---|---|---|---|---|---|---|---|---|
DPP-4i (n = 122) (%) | Met (n = 90) (%) | DPP-4i (n = 109) (%) | Met (n = 98) (%) | DPP-4i (n = 102) (%) | Met (n = 101) (%) | DPP-4i (n = 102) (%) | Met (n = 93) (%) | |
(a) Group 1 | ||||||||
HbA1c-lowering effect | 91.0 | 91.1 | 89.0 | 86.7 | 88.2 | 91.1 | 90.2 | 87.1 |
PPG-lowering effect |
87.7
| 62.2 |
86.2
| 66.3 |
81.4
| 62.4 |
83.3
| 64.5 |
Low risk of hypoglycemia |
83.6
| 70.0 | 72.5 | 68.4 | 72.5 | 72.3 | 75.5 | 69.9 |
No body weight gain | 72.1 | 78.9 | 67.0 |
78.6
| 65.7 |
79.2
| 72.5 |
82.8
|
FPG-lowering effect | 70.5 | 76.7 | 69.7 | 77.6 | 70.6 |
82.2
| 69.6 |
81.7
|
Beta cell function protection | 68.0 | 58.9 | 58.7 | 59.2 |
62.7
| 52.5 | 60.8 | 54.8 |
Effect on glucagon |
64.8
| 38.9 |
62.4
| 38.8 |
59.8
| 38.6 |
62.7
| 35.5 |
Easy to use for patients with renal impairment |
56.6
| 15.6 |
57.8
| 13.3 |
58.8
| 10.9 |
55.9
| 8.6 |
Frequency of administration |
54.1
| 24.4 |
47.7
| 24.5 |
49.0
| 21.8 |
50.0
| 23.7 |
Effect on insulin | 50.0 | 51.1 | 46.8 | 43.9 | 48.0 | 44.6 | 48.0 | 44.1 |
CV benefit | 47.5 |
63.3
| 44.0 | 51.0 | 42.2 | 48.5 | 50.0 | 57.0 |
Low risk of GI side effects |
45.1
| 20.0 |
44.0
| 18.4 |
43.1
| 15.8 |
44.1
| 17.2 |
Easy to use for patients with liver dysfunction |
42.6
| 15.6 |
38.5
| 16.3 |
40.2
| 14.9 |
48.0
| 15.1 |
Insulin resistance improvement | 41.8 |
87.8
| 45.0 |
87.8
| 53.9 |
84.2
| 48.0 |
89.2
|
High scientific evidence | 41.8 |
81.1
| 35.8 |
77.6
| 43.1 |
75.2
| 43.1 |
71.0
|
Low cost | 17.2 |
87.8
| 17.4 |
84.7
| 20.6 |
86.1
| 21.6 |
90.3
|
Treatment factors | Basal | Pre-mixed | Rapid/ultra-rapid | Intensive | ||||
---|---|---|---|---|---|---|---|---|
DPP-4i | Met | DPP-4i | Met | DPP-4i | Met | DPP-4i | Met | |
(n = 160) (%) | (n = 70) % | (n = 150) % | (n = 73) % | (n = 141) % | (n = 73) % | (n = 131) % | (n = 66) % | |
(b) Group 2 | ||||||||
HbA1c-lowering effect | 91.3 | 85.7 | 89.3 | 84.9 | 90.1 | 84.9 | 88.5 | 86.4 |
PPG-lowering effect |
85.6
| 67.1 |
83.3
| 72.6 |
85.1
| 71.2 |
84.7
| 74.2 |
Low risk of hypoglycemia | 71.3 | 74.3 | 73.3 | 71.2 | 76.6 | 69.9 | 71.0 | 68.2 |
No body weight gain | 56.9 |
74.3
| 53.3 |
67.1
| 54.6 |
76.7
| 57.3 |
74.2
|
FPG-lowering effect | 70.6 | 72.9 | 74.7 | 74.0 | 72.3 | 71.2 | 71.8 | 72.7 |
Beta cell function protection | 65.6 | 60.0 |
61.3
| 50.7 | 58.9 | 56.2 | 61.1 | 57.6 |
Effect on glucagon |
51.9
| 28.6 |
55.3
| 23.3 |
51.1
| 23.3 |
55.7
| 31.8 |
Easy to use for patients with renal impairment |
50.0
| 15.7 |
53.3
| 9.6 |
52.5
| 12.3 |
54.2
| 10.6 |
Frequency of administration |
54.4
| 22.9 |
55.3
| 15.1 |
50.4
| 12.3 |
49.6
| 12.1 |
Effect on insulin | 40.6 | 37.1 |
44.0
| 28.8 | 40.4 | 32.9 | 47.3 | 39.4 |
CV benefit | 48.1 | 57.1 | 47.3 | 50.7 | 51.1 | 45.2 | 48.9 | 48.5 |
Low risk of GI side effects |
52.5
| 21.4 |
50.0
| 15.1 |
51.1
| 15.1 |
46.6
| 19.7 |
Easy to use for patients with liver dysfunction |
45.0
| 18.6 |
44.7
| 15.1 |
44.7
| 16.4 |
41.2
| 16.7 |
Insulin resistance improvement | 52.5 |
85.7
| 52.7 |
79.5
| 53.2 |
82.2
| 54.2 |
84.8
|
High scientific evidence | 43.1 |
74.3
| 38.7 |
67.1
| 37.6 |
63.0
| 37.4 |
68.2
|
Low cost | 16.3 |
84.3
| 17.3 |
86.3
| 18.4 |
83.6
| 19.1 |
84.8
|
Perspectives of Diabetologists and General Physicians
Regression Analysis for Drug Features Affecting Selection of DPP-4 Inhibitors or Metformin
Treatment factors | Basal insulin | Pre-mixed insulin | Rapid/ultra-rapid insulin | Intensive insulin | ||||
---|---|---|---|---|---|---|---|---|
DPP-4i | Met | DPP-4i | Met | DPP-4i | Met | DPP-4i | Met | |
Rank 1 (n = 122) | Rank 1 (n = 90) | Rank 1 (n = 109) | Rank 1 (n = 98) | Rank 1 (n = 102) | Rank 1 (n = 101) | Rank 1 (n = 102) | Rank 1 (n = 93) | |
(a) Perspectives of group 1 | ||||||||
HbA1c-lowering effect | 6.131 (1.11–33.853) | |||||||
PPG-lowering effect | 48.369 (2.684–871.783) | 4.778 (1.035–22.066) | ||||||
Easy to use for patients with liver dysfunction | 21.758 (1.488–318.131) | |||||||
Easy to use for patients with renal impairment | 21.631 (1.386–337.686) | |||||||
Frequency of administration | 5.232 (1.247–21.962) | 9.427 (2.079–42.752) | ||||||
Effect on glucagon | 4.940 (1.112–21.950) | |||||||
Low cost |
0.004 (0.000–0.053)
|
0.038 (0.009–0.149)
|
0.022 (0.004–0.114)
| |||||
High scientific evidence |
0.092 (0.020–0.416)
| |||||||
Effect on insulin |
0.142 (0.028–0.727)
| |||||||
Insulin resistance improvement |
0.007 (0.000–0.105)
|
Treatment factors | Basal insulin | Pre-mixed insulin | Rapid/ultra-rapid insulin | Intensive insulin | ||||
---|---|---|---|---|---|---|---|---|
DPP-4i | Met | DPP-4i | Met | DPP-4i | Met | DPP-4i | Met | |
Rank 1 (n = 160) | Rank 1 (n = 70) | Rank 1 (n = 150) | Rank 1 (n = 73) | Rank 1 (n = 141) | Rank 1 (n = 73) | Rank 1 (n = 131) | Rank 1 (n = 66) | |
(b) Perspectives of group 2 | ||||||||
HbA1c-lowering effect | ||||||||
PPG-lowering effect | ||||||||
Easy to use for patients with liver dysfunction | 7.075 (1.038–48.236) | |||||||
Easy to use for patients with renal impairment | 74.490 (6.734–823.992) | |||||||
Frequency of administration | 6.877 (1.134–41.697) | 12.074 (1.407–103.637) | ||||||
Effect on glucagon | 18.772 (2.512–140.291) | |||||||
Low cost |
0.008 (0.001–0.045)
|
0.013 (0.003–0.057)
|
0.017 (0.004–0.072)
|
0.009 (0.001–0.062)
| ||||
High scientific evidence | ||||||||
Effect on insulin | ||||||||
Insulin resistance improvement |
0.063 (0.011–0.362)
|
Patient Characteristics Affecting the Treatment Choice for Combination Therapy with Insulin
Patient characteristics, n (%) | Basal insulin | Pre-mixed insulin | Rapid/ultra-rapid insulin | Intensive insulin | ||||
---|---|---|---|---|---|---|---|---|
DPP-4i (n = 282) | Met | DPP-4i | Met | DPP-4i | Met | DPP-4i | Met | |
(n = 160) | (n = 259) | (n = 171) | (n = 243) | (n = 174) | (n = 233) | (n = 159) | ||
Age | 120 (42.6) |
101 (63.1)
| 105 (40.5) |
109 (63.7)
| 88 (36.2) |
119 (68.4)
| 88 (37.8) |
107 (67.3)
|
Gender | 23 (8.2) | 15 (9.4) | 24 (9.3) | 16 (9.4) | 23 (9.5) | 13 (7.5) | 26 (11.2) | 9 (5.7) |
BMI | 109 (38.7) |
101 (63.1)
| 108 (41.7) |
106 (62.0)
| 76 (31.3) |
109 (62.6)
| 85 (36.5) |
105 (66)
|
Fasting plasma glucose | 92 (32.6) | 46 (28.8) | 94 (36.3) | 59 (34.5) | 94 (38.7) | 62 (35.6) | 95 (40.8) | 55 (34.6) |
Postprandial glucose |
145 (51.4)
| 34 (21.3) | 126 (48.6) | 47 (27.5) |
119 (49.0)
| 52 (29.9) |
124 (53.2)
| 45 (28.3) |
Insulin resistance | 87 (30.9) |
82 (51.3)
| 82 (31.7) |
81 (47.4)
| 80 (32.9) |
93 (53.4)
| 75 (32.2) |
85 (53.5)
|
Concern on hypoglycemia | 144 (51.1) | 50 (31.3) |
125 (48.3)
| 57 (33.3) |
120 (49.4)
| 65 (37.4) |
121 (51.9)
| 51 (32.1) |
Diabetic complication | 82 (29.1) | 34 (21.3) | 70 (27.0) | 35 (20.5) | 66 (27.2) | 35 (20.1) | 65 (27.9) | 30 (18.9) |
Renal function | 137 (48.6) |
100 (62.5)
| 126 (48.6) |
108 (63.2)
| 106 (43.6) |
111 (63.8)
| 100 (42.9) |
100 (62.9)
|
Liver function | 64 (22.7) | 44 (27.5) | 59 (22.8) |
59 (34.5)
| 51 (21.0) |
58 (33.3)
| 53 (22.7) | 48 (30.2) |
CV risk | 71 (25.2) | 38 (23.8) | 55 (21.2) | 34 (19.9) | 55 (22.6) | 32 (18.4) | 52 (22.3) | 28 (17.6) |
Adherence to diet | 45 (16.0) | 18 (11.3) | 38 (14.7) | 14 (8.2) | 33 (13.6) | 22 (12.6) | 34 (14.6) | 18 (11.3) |
Adherence to exercise | 31 (11.0) | 13 (8.1) | 28 (10.8) | 9 (5.3) | 22 (9.1) | 14 (8.0) | 25 (10.7) | 14 (8.8) |
Economic status of the patient | 48 (17.0) |
50 (31.3)
| 36 (13.9) |
44 (25.7)
| 30 (12.3) |
45 (25.9)
| 29 (12.4) |
36 (22.6)
|