Category: Federal Forum Posters
Purpose: According to the 2017 VA/DoD Clinical Practice Guidelines for the Management of Type 2 Diabetes Mellitus, pioglitazone, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium-glucose cotransporter-2 (SGLT-2) inhibitors are considered second line agents when non-pharmacological therapy, metformin, and/or insulin has not achieved adequate A1c reduction. The VA Pharmacy Benefits Manager (PBM) has developed criteria for use to ensure that these agents are being used properly. This medication use evaluation (MUE) was conducted to assess if antidiabetic agents have achieved expected A1c reduction, are being used safely, and renewal criteria for use have been met.
Methods: A patient list was generated from Microsoft SQL that included all Veterans within the Sheridan VA Healthcare System (SVAHCS) with active prescriptions for pioglitazone, GLP-1 agonists, DPP-4 inhibitors, and SGLT-2 inhibitors issued between 01/01/2018 – 11/27/2018. Education was provided to pharmacists regarding appropriate use of second line antidiabetic therapy. Retrospective chart reviews were performed for each patient using the electronic medical record. Patients were excluded upon chart review if it was determined they were no longer taking second line antidiabetic therapy. The following data were collected: age; sex; race; pertinent laboratory values including serum creatinine, A1c, lipid panel, and liver/kidney function; allergies; current antidiabetic medications being used; and adverse effects. Recommendations for continuation or discontinuation of antidiabetic therapy and future monitoring were provided to prescribers through documentation entered into the patient’s chart.
Results: There were 109 patients identified with active prescriptions for second line antidiabetic agents including pioglitazone (n = 41), GLP-1 agonists (n = 25), DPP-4 inhibitors (n = 41), and SGLT-2 inhibitors (n = 2). Only 36% of patients were followed in the pharmacotherapy clinic. After initiation of second line agents, the average A1c reduction observed was 1% (pioglitazone and GLP-1 agonists), 0.7% (DPP-4 inhibitors), and 0.2% (SGLT-2 inhibitors). In patients receiving pioglitazone, there were 4 reports of edema and 1 report of a fracture. These patients had an average weight gain of 2.35 kg. In patients receiving GLP-1 agonists, there were 2 reports of cholelithiasis and 4 gastrointestinal adverse events documented. These patients also had an average weight loss of 4.4 kg and a 75 mg/dL decrease in triglycerides. There were reports of pancreatitis (n = 2), arthralgia (n = 1), heart failure (n = 2), and infection (n = 7) in patients taking DPP-4 inhibitors. There were no adverse events reported in patients receiving SGLT-2 inhibitors. It was determined that 49% of patients on DPP-4 inhibitors, 44% of patients on GLP-1 agonists, 76% of patients on pioglitazone, and 0% of patients on SGLT-2 inhibitors met renewal criteria for use.
Conclusion: The results of this MUE were presented to the Pharmacy and Therapeutics Committee. Clinical education was provided to prescribers and pharmacists regarding the need for reassessment of second line antidiabetic agents upon renewal. In patients not currently meeting renewal criteria, it was recommend to providers to consider a consult to the pharmacotherapy clinic.