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G. Caleb Alexander, MD, MS; Niraj L. Sehgal, MD, MPH; Rachael M. Moloney, BA; Randall S. Stafford, MD, PhD

Arch Intern Med. 2008;168(19):2088-2094.

Background  Diabetes mellitus is common, costly, and increasingly prevalent. Despite innovations in therapy, little is known about patterns and costs of drug treatment.

Methods  We used the National Disease and Therapeutic Index to analyze medications prescribed between 1994 and 2007 for all US office visits among patients 35 years and older with type 2 diabetes. We used the National Prescription Audit to assess medication costs between 2001 and 2007.

Results  The estimated number of patient visits for treated diabetes increased from 25 million (95% confidence interval [CI], 23 million to 27 million) in 1994 to 36 million (95% CI, 34 million to 38 million) by 2007. The mean number of diabetes medications per treated patient increased from 1.14 (95% CI, 1.06-1.22) in 1994 to 1.63 (1.54-1.72) in 2007. Monotherapy declined from 82% (95% CI, 75%-89%) of visits during which a treatment was used in 1994 to 47% (43%-51%) in 2007. Insulin use decreased from 38% of treatment visits in 1994 to a nadir of 25% in 2000 and then increased to 28% in 2007. Sulfonylurea use decreased from 67% of treatment visits in 1994 to 34% in 2007. By 2007, biguanides (54% of treatment visits) and glitazones (thiazolidinediones) (28%) were leading therapeutic classes. Increasing use of glitazones, newer insulins, sitagliptin phosphate, and exenatide largely accounted for recent increases in the mean cost per prescription ($56 in 2001 to $76 in 2007) and aggregate drug expenditures ($6.7 billion in 2001 to $12.5 billion in 2007).

Conclusions  Increasingly complex and costly diabetes treatments are being applied to an increasing population. The magnitude of these rapid changes raises concerns about whether these more costly therapies will result in proportionately improved outcomes.

Author Affiliations: Department of Medicine, University of Chicago Hospitals (Dr Alexander and Ms Moloney), MacLean Center for Clinical Medical Ethics, University of Chicago (Dr Alexander), and Department of Pharmacy Practice, University of Illinois at Chicago School of Pharmacy (Dr Alexander), Chicago, Illinois; Division of Hospital Medicine, University of California, San Francisco (Dr Sehgal); and Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, and Stanford University School of Medicine, Stanford, California (Dr Stafford).

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