|Year : 2021 | Volume
| Issue : 1 | Page : 36-40
Prescription pattern and treatment target in patients with type 2 diabetes attending a tertiary health center in Lagos
Akinola O Dada1, Sunday O Ogundele2, Mumuni A Amisu1, Adetutu Williams3
1 Department of Medicine, Lagos State University College of Medicine, Ikeja, Nigeria; Department of Medicine Lagos State University Teaching Hospital, Ikeja, Nigeria
2 Department of Medicine Lagos State University Teaching Hospital, Ikeja, Nigeria; Department of Pharmacology, Therapeutics and Toxicology, Lagos State University College of Medicine, Ikeja, Nigeria
3 Department of Medicine Lagos State University Teaching Hospital, Ikeja, Nigeria
|Date of Submission||10-Mar-2020|
|Date of Decision||23-Apr-2020|
|Date of Acceptance||13-May-2020|
|Date of Web Publication||25-Dec-2020|
Dr. Sunday O Ogundele
Department of Pharmacology, Therapeutics and Toxicology, Lagos State University College of Medicine, 1–5 Oba Akinjobi Street, Ikeja GRA, Lagos.
Source of Support: None, Conflict of Interest: None
Background: The prevalence of diabetes is on the increase worldwide. Type 2 diabetes is the most common form of diabetes and is characterized by disorders of insulin action and insulin secretion; any of these two abnormalities may be the predominant feature of the disease. The aim of the study was to review the drug treatment of patients with type 2 diabetes attending a follow-up clinic. Materials and Methods: The study took place at the outpatient clinic of a tertiary health center among patients attending a follow-up clinic. The study design was a descriptive cross-sectional review of the use of antidiabetic medications among adult males and females with type 2 diabetes. Results: A total of 235 participants took part in this study. 64.3% were females; the average age of the participants was 60.7 years with an age range of 20–88 years. This study showed metformin as the most commonly prescribed medication among the participants. Almost two-thirds of the participants were diagnosed with diabetes after they had developed symptoms or complications of diabetes. The proportion of participants with fasting blood sugar at the target level was 54.5%. Conclusion: In conclusion, this study revealed that metformin is the most commonly prescribed antidiabetic medication among the participants; almost two-thirds of the participants were detected to be diabetic after they have either developed symptoms or complications of the disease. Fasting blood sugar was at target levels in more than half of the participants.
Keywords: Nigeria, oral hypoglycemic agent, prescription, type 2 diabetes
|How to cite this article:|
Dada AO, Ogundele SO, Amisu MA, Williams A. Prescription pattern and treatment target in patients with type 2 diabetes attending a tertiary health center in Lagos. J Diabetol 2021;12:36-40
|How to cite this URL:|
Dada AO, Ogundele SO, Amisu MA, Williams A. Prescription pattern and treatment target in patients with type 2 diabetes attending a tertiary health center in Lagos. J Diabetol [serial online] 2021 [cited 2022 Jun 30];12:36-40. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/1/36/304346
| Introduction|| |
The prevalence of diabetes is on the increase worldwide., The International Diabetes Federation (IDF) estimated that 9.3% of adults aged 20–79 years, which represents 463 million people are currently living with diabetes., It is estimated that there will be 578 million adults with diabetes by 2030 and 700 million by 2045. The largest increase is projected to come from the regions experiencing economic transitions from low-income to middle-income.
Type 2 diabetes is the most common form of diabetes and is characterized by disorders of insulin action and insulin secretion; any of these two abnormalities may be the predominant feature of the disease., Mortality from type 2 diabetes and its complications was estimated to be approximately 1 million in 2017.
Half of the adults living with diabetes today are unaware that they have the condition, and are therefore at high risk of developing serious diabetes-related complications. Diabetes is often diagnosed relatively late after the onset of the disease in most patients. Many patients with the disease often present at a point when they have already developed complications. The impact of diabetes on individuals’ health and the economic burden associated with it have made its prevention a major goal of the current era.
Moderate-to-severe exercise and weight reduction in those who are overweight are recommended as the initial treatment option and this have been shown to be effective in reducing risks of progression to diabetes in many individuals. For patients who progressed to develop diabetes despite adequate weight loss, the addition of antidiabetic medications has been shown to be of benefit to them. Most guidelines recommend that metformin in combination with lifestyle modifications should be the first-line pharmacotherapeutic option in patients with type2 diabetes unless there are contraindications to the medication.
If the A1C target is not achieved after 3 months’ treatment on monotherapy and the patient does not have atherosclerotic cardiovascular disease (ASCVD) or chronic kidney disease (CKD), a combination of metformin with any of the preferred oral hypoglycemic agents (OHAs) or basal insulin should be considered. The available preferred alternative OHAs include sulfonylurea, thiazolidinedione, dipeptidyl peptidase 4 (DPP-4) inhibitor, sodium glucose co-transporter-2 (SGLT2) inhibitors, and glucagon-like peptide (GLP)-1 receptor agonist. The choice of which agent to add is based on drug-specific effects and patient factors.
The primary goal of the management of diabetes mellitus (DM) is to prevent the microvascular complications, reduce mortality, and improve the quality of life. This study is therefore important by helping us to review our current practices and our level compliance with prescription guidelines.
The aim of the study was to review the drug treatment of patients with type 2 diabetes attending a follow-up clinic. The specific objectives were to determine the demographic profiles of the participants, describe the prescription pattern, determine the proportion of patients at blood sugar target for treatment, and determine the source of the first diagnosis of the disease.
| Materials and Methods|| |
The study took place among patients with type 2 diabetes, who were attending the follow-up diabetic clinic of the Endocrinology Unit of the hospital.
The study design was descriptive cross-sectional with the use of a structured questionnaire to retrieve information about the participants from their case records and to get responses to queries in the questionnaires. Adult males and females with type 2 diabetes currently on antidiabetic medication and have been attending follow-up clinics for at least 6 months before their participation in the study were included after given their consent to participate. All patients with nontype 2 diabetes and other patients with type 2 diabetes who were not on any OHAs were excluded from the study.
The sample size was calculated using the Cochrane sample size formula for cross-sectional studies. The pooled national prevalence rate of 5.8% for diabetes in Nigeria was used in the calculation, at standard deviation of 95% that corresponds to 1.96 and a precision of 5%. This gave a minimum sample size of 84 participants. We however recruited all patients seen in outpatient’s clinic over a 3 months’ period to give a total of 235 participants.
The structured questionnaires were administered to patients during clinic attendance by the attending doctors. The questionnaires were used to retrieve information about the sociodemographic profiles, medication history (name of antidiabetic medication, day of last use, and number of antidiabetic medication), source of making diagnosis of diabetes in participants, fasting blood sugar level, history of receiving counseling about diabetes, and dietary control of the disease. Body mass index was classified according to the World Health Organization (WHO) referenced classification.
| Ethical Clearance|| |
Ethical approval for this study (Ethical Committee NHREC04/04/2008) was provided by the Health Research and Ethics Committee of Lagos State University Teaching Hospital, Nigeria on 10 July 2012.
| Results|| |
A total of 235 participants took part in this study. More than half of the participants (151 [64.3%]) were females compared to (84 (35.7)) males. The average age of the participants was 60.7 years with an age range of 20–88 years [Table 1].
|Table 1: : Sociodemographic profile of patients with type 2 diabetes attending follow-up clinic|
Click here to view
The study showed that most of our patients were on metformin either as a monotherapy or in combination with other antidiabetic medications. Most of the participants that were on sulfonylurea used this class of antidiabetic medications in combination with other hypoglycemic agents; only four (1.7%) were on monotherapy of sulfonylureas. Details of the prescription pattern of the antidiabetic medications are given in [Table 2].
|Table 2: Pattern of antidiabetic medications prescribed for patients with type 2 diabetes attending outpatient follow-up clinic|
Click here to view
Review of how patients with type diabetes attending the follow-up clinic were detected before the commencement of treatment showed that 147 (62.6%) were diagnosed after showing symptoms suggestive of diabetes or after they have developed complications associated with the disease [Figure 1].
|Figure 1: Pie chart showing how patients with type 2 diabetes were first detected before commencement of treatment|
Click here to view
This study revealed that almost all, 229 (97.4%), of the patients seen during this review were on metformin for the control of their blood sugar either as a monotherapy in 66 (28.1%) or in combination with other antidiabetic medicines. The use of sulfonylureas in combination with other hypoglycemic agents is next to the metformin combination; 77 (32.8%) of the patients were on a combination of sulfonylurea and metformin. Only six (2.6%) of the study participants were on sulfonylurea monotherapy. Details of the prescription pattern are given in [Table 2].
[Table 3] shows the clinical profile of the study participants. A little over half (54.5%) of our patients had their fasting blood sugar within the target range of 80–130 mg/dL. Almost three-quarters of the participants are hypertensive and a little over half have a positive family history of diabetes in the first-degree relatives.
|Table 3: Clinical profile of patients with type 2 diabetes attending follow-up clinic|
Click here to view
| Discussion|| |
This study showed that metformin is the most commonly prescribed medication in patients with type 2 diabetes who attended our clinic during the study period.
The mean age and the gender distribution of the participants in this study is similar to what was reported in our earlier study and in a similar study that was done across seven different tertiary health-care centers across Nigeria.,
The finding that that metformin is the most commonly prescribed OHA both as a monotherapy and as part of combination with other agents is in keeping with the findings obtained from a similar study in India. In a study conducted in the north-western Nigeria, it was reported that metformin was the most commonly prescribed medication among their group of patients, but the agent was mainly prescribed in combination with other agents. Insulin was the most common single agent prescribed in their study. Some other studies reported sulfonylureas as the preferred first-line agent.,, A European study reported insulin as the preferred first-line agents in their review. Most guidelines recommend that metformin should be the first-line option when starting medication in patients with type 2 diabetes unless there are contraindications.,,, In most patients, this agent is started as a monotherapy in combination with lifestyle modifications. Metformin has high efficacy, does not cause hypoglycemic, causes modest weight loss, and is cheap. The effectiveness of metformin was attributed in part to its induction of weight loss, which averaged 1.7 kg and accounted for 64% of the beneficial effect of metformin., Initiation of dual therapy is indicated in newly diagnosed patients with type 2 diabetes who have hemoglobin A1C (HbA1C) ≥1.5% (12.5 mmol/moL) above their glycemic target. A meta-analysis of studies that compared effects of antidiabetic agents suggests that each new class of noninsulin agents added to initial therapy generally lowers A1C approximately 0.7%–1.0%. The six agents recommended for combination with metformin are sulfonylurea, thiazolidinedione, DPP-4 inhibitor, SGLT2 inhibitors, GLP-1 receptor agonist, or basal insulin. In this review, none of the participants was on SGLT2 and GLP-1. For patients without established ASCVD or CKD, the choice of a second agent to add to metformin is not yet guided by empiric evidence. Rather, drug choice is based on avoidance of side effects, particularly hypoglycemia and weight gain, cost, and patient preferences.,,
A review of how diabetes was detected among the participants showed that most of them were discovered after they have already developed symptoms of diabetes or complications associated with the condition. Reports have shown that many patients with diabetes have already developed complications at the time of clinical diagnosis. Up to 50% of the people with type 2 diabetes are undiagnosed for a variable length of time and may develop complications during that period.,, Screening for diabetes helps with the detection of the disorder in asymptomatic or minimally symptomatic individuals early.  Most guidelines recommend screening for type 2 diabetes in people over 40–45 years of age and/or with high-risk factors such as a family history of diabetes, obesity, and hypertension.,
This study showed that a little over half of the participants had their fasting blood sugar level at the target level using the American Diabetic Association (ADA) and WHO recommended the target level for control for diabetes., We did not use the HbA1C values to evaluate control of blood sugar because this test was not routinely done to monitor blood sugar levels among the participants and only about half of the participants did the test, some for diagnosis and others done more than 3 months before this review. The level of fasting blood sugar control in this study is better than the 32.4% control rates reported in a previous national study across seven tertiary health centers in Nigeria. The high level of control among the participants in this study may be explained by the high rate of adherence to use of medication; 9 in 10 of the participants admitted to using their medications as prescribed within at least 2 days preceding their last follow-up clinic visit. This high rate of adherence is an improvement in the finding in the previous study among patients attending the same clinic.
| Conclusion|| |
In conclusion, this study revealed that metformin is the most commonly prescribed antidiabetic medication among the participants; almost two-thirds of the participants were detected to be diabetic after they have either developed symptoms or complications of the disease. Fasting blood sugar was at target levels in more than half of the participants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khan MAB, Hashim MJ, King JK, Govender RD, Mustafa H, Al Kaabi J Epidemiology of type 2 diabetes: Global burden of disease and forecasted trends. J Epidemiol Global Health 2020;10:107-11.
Zheng Y, Ley SH, Hu FB Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nat Rev Endocrinol 2018;14:88-98.
International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels, Belgium: IDF; 2019. Available from: https://www.diabetesatlas.org. [Last accessed on 15 January 2020].
American Diabetes Association. Clinical practice recommendations. Diabetes Care2005;28:S1-S2.
Khatib, OMN Guidelines for the Prevention, Management and Care of Diabetes Mellitus (EMRO Technical Publications Series no. 32). WHO Regional Office for the Eastern Mediterranean: World Health Organization;2015. Available from: http://applications.emro.who.int/dsaf/dsa664.pdf. [Last accessed on 15 January 2020].
Ahmad LA, Crandall JP Type 2 diabetes prevention: A review. Clin Diabetes 2010;28:53-9.
American Diabetes Association. Pharmacologic Approaches to Glycemic Treatment: Standards of medical care in Diabetes 2019. Diabetes Care 2019;42:S90-102.
Mahmood M, Reddy RC, Lahari JRS, Fatima S, Shinde P, Reddy SA, et al
. Prescription pattern analysis of antidiabetic drugs in diabetes mellitus and associated comorbidities. Clin Invest 2017;8:5-12.
Cochran WG Sampling Techniques. 3rd ed. New York: John Wiley & Sons; 1977.
Uloko AE, Musa BM, Ramalan MA, Gezawa ID, Puepet FH, Uloko AT, et al
. Prevalence and risk factors for diabetes mellitus in Nigeria: A systematic review and meta-analysis. Diabetes Ther 2018;9:1307-16.
World Health Organization. Body Mass Index – BMI. Available from: http://www.euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi. [Last accessed on 15 January 2020].
Ogundele SO, Dada AO, Mosuro OR Clinical profile, knowledge, and beliefs about diabetes among patients attending a tertiary health centre in Lagos: A cross-sectional survey. Niger J Clin Pract 2016;19:508-12.
Chinenye S, Young E State of diabetes care in Nigeria: A review. Niger Health J 2011;11:101-6.
Jimoh A-GO, Sabir AA, Chika A, Sani Z Pattern of Antidiabetic Drugs Use in a Diabetic Outpatient Clinic of a Tertiary Health Institution in Sokoto, North-western Nigeria. J Med Sci 2011;11:241-5.
Agarwal AA, Jadhav PR, Deshmukh YA Prescribing pattern and efficacy of anti-diabetic drugs in maintaining optimal glycemic levels in diabetic patients. J Basic Clin Pharm 2014;5:79-83.
Hasamnis A, Patil S Prescription pattern study in type 2 diabetes mellitus in an Indian referral hospital. Internet J Pharmacol2008;7.
Yusuff KB, Obe O, Joseph BY Adherence to anti-diabetic drug therapy and self management practices among type-2 diabetics in Nigeria. Pharm World Sci 2008;30:876-83.
Kostev K, Rockel T, Jacob L Prescription patterns and disease control in type 2 diabetes mellitus patients in nursing home and home care settings: A retrospective analysis in Germany. J Diabetes Sci Technol 2018;12:136-9.
International Diabetes Federation. Recommendations for Managing Type 2 Diabetes in Primary Care. Brussels Belgium: International Diabetes Federation; 2017. Availablefrom: www.idf.org/managing-type2-diabetes. [Last accessed on 15 January 2020].
Marín-Peñalver JJ, Martín-Timón I, Sevillano-Collantes C, del Cañizo-Gómez FJ Update on the treatment of type 2 diabetes mellitus. World J Diabetes 2016;7:354-95.
Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al
; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.
Vijan S, Sussman JB, Yudkin JS, Hayward RA Effect of patients’ risks and preferences on health gains with plasma glucose level lowering in type 2 diabetes mellitus. JAMA Intern Med 2014;174:1227-34.
Ogundele SO, Dada A, Ale AO Adherence to anti-diabetes medications among adults attending a tertiary health centre in Lagos: A cross-sectional survey. LASU J Health Sci 2018;1:19-23.
[Table 1], [Table 2], [Table 3]