Prescribing for people with type 2 diabetes and renal impairment in Australian general practice: A national cross sectional study
Pharmacological therapy is important in addressing hyperglycaemia in type 2 diabetes (T2D) but care is required in the presence of renal impairment as pharmacokinetic changes may develop that increase the risk of adverse events. The aim of this study was to describe non-insulin anti-hyperglycaemic medication prescribing and dosing for people with T2D and renal impairment in Australian general practice and determine whether these conform to safe prescribing guidelines.
A drug utilisation study was conducted using de-identified data from MedicineInsight, a large-scale general practice data program that currently extracts longitudinal de-identified patient data from 3.8 million ‘active’ patients in over 550 Australian general practices. Patients aged ≥ 18y with diagnosis of T2D recorded during September 2012 and September 2015 were included. T2D was identified by any mention of T2D recorded in the diagnosis, history, reason for visit or reason for prescription coded and free text fields, or prescription of an oral diabetes medicine. Prescriptions for non-insulin anti-hyperglycaemic medicines and eGFR results recorded between 1/10/14 and 1/9/15 were assessed. Prescription and dosing appropriateness was determined using current Australian Diabetes Society guideline recommendations for medication use in T2D patients with renal impairment.
Analyses for 105,135 patients in the dataset showed 69,313 (65.9%) were prescribed at least one non-insulin anti-hyperglycaemic medication. eGFR results were available for 56,831 (82.2%) patients. Of these, 10616 (18.7%) had an eGFR<60ml/min/1.73m2 and of these, 5459 (51.4%) received ≥1 inappropriate prescription based on their eGFR. The medication classes with the highest proportion of potentially inappropriate dosing prescribed to patients were SGLT2 inhibitors (169/175; 95.5%), biguanides (4536/8356; 54.3%) and DPP4 inhibitors (1378/2672; 51.6%).
Results indicate that prescribing and dosing for people with T2D and renal impairment could be further improved. Health information technology has been identified as an important strategy to improve prescribing quality and reduce adverse medication events. Although 70% of GPs report using electronic medical software to check for drug-disease interactions, identification of these interactions currently relies on GPs correctly coding diseases for each patient. Evolution of medical software to cross-check prescriptions and dosages with eGFR and to be reflective of local guidelines may be important to optimise quality prescribing.