The management of people with type 2 diabetes with hypoglycaemic agents in primary care: retrospective cohort study

Background. Type 2 diabetes is common, largely managed in primary care and requires effective glycaemic control to reduce the risk of microvascular complications. Oral hypoglycaemic agents are typically the first pharmacological intervention used to improve glycaemic control. Objectives. To evaluate the management of people with type 2 diabetes with oral hypoglycaemic agents in primary care. Methods. This retrospective cohort study included people with type 2 diabetes treated with oral agents drawn from 243 general practices in the UK over a 5-year study period from 1999 to 2003. Primary outcome measures were glycaemic monitoring and control on oral hypoglycaemic agents. Results. Of the 71 561 patients identified with prevalent type 2 diabetes, 20 922 received their first prescription for an oral hypoglycaemic agent during the study. Only 49% of patients had a recorded HbA(1c) within 6 months of starting therapy. Forty per cent of patients had poor glycaemic control (Hb(1c) >= 7.5%) after starting a single hypoglycaemic agent. There was a statistically significant association between post-therapy HbAlc with pre-therapy HbA(1c) metformin dose, age and geodemographical classification. Greater reductions in HbA(1c) were observed in older patients, those with a high pre-treatment HbA(1c) and those from less-deprived areas. Patients remained on a single therapy for a median of 3.8 years. During the study, 7009 of those who started a single agent were prescribed a second agent. Of those with a recorded HbA(1c) 50% had poor glycaemic control (HbAt, > 7.5%) post-therapy. Conclusions. Management of type 2 diabetes with oral hypoglycaemic agents appears to be suboptimal for many patients. Oral treatment is often not started until glycaemic control is poor, and many patients do not receive adequate monitoring or have poor glycaemic control following treatment with oral agents. Many patients with a high pre-treatment HbA,c are not controlled on a single oral agent even at high dose suggesting that earlier, more aggressive treatment in primary care is required.