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AIMS: UK guidelines for type II diabetes leave the choice of glucose lowering therapies after metformin largely to prescribers. They vary greatly in cost, and comparative effectiveness data is lacking. We set out to measure the variation in prescribing of these second-line non-insulin diabetes drugs. MATERIALS AND METHODS: We evaluated time trends 1998-2016, using England's publicly available prescribing datasets, and stratified by the order prescribed to patients using the Clinical Practice Research Datalink (CPRD). We calculated the proportion of each class of diabetes drug as a percentage of the total per year. We evaluated geographical variation in prescribing using general practice-level data for the latest 12-months (to August 2017), with aggregation to Clinical Commissioning Groups (CCGs). We calculated percentiles, ranges and plotted maps. RESULTS: Prescribing of therapy after metformin is changing rapidly. DPP4-inhibitor use has increased markedly, now the most common second-line drug (43% prescriptions in 2016). Use of SGLT-2 inhibitors also increased rapidly (14% new second-line, 27% new third-line prescriptions in 2016). There is wide geographical variation in choice of therapies and average spend per patient. In contrast, metformin is consistently used first-line in accordance with guidelines. CONCLUSIONS: In England there is extensive geographical variation in the prescribing of diabetes drugs after metformin, and increasing use of higher-cost DPP4-inhibitors and SGLT-2 inhibitors over low-cost sulfonylureas. Our findings strongly support the case for comparative effectiveness trials of current diabetes drugs.

Original publication




Journal article


Diabetes Obes Metab

Publication Date