Glycemic control and cost-effectiveness attained by the drug utilization of oral antidiabetic agents in a tertiary care hospital in South India

Nirmal George, Ajith Kumar PV, Vijayalekshmi Amma S.


Background: Diabetes mellitus require lifelong intervention and Kerala has high prevalence. New expensive agents require comparison with existing regimens for cost-effectiveness.

Methods: Socio-demographic, anthropometric, FPG and HbA1C (baseline and post treatment) of 150 patients (73 men; 77 women) were obtained from records using standard case report forms in our retrospective study. ANOVA and paired t test were used for between groups and within group comparison.

Results: Metformin was maximum utilized (DDD/1000/day-252.39). All treatment regimens produced significant reduction in FPG (except metformin monotherapy) and HbA1C (except metformin sulfonylurea α-glucosidase inhibitor DPP-4 inhibitor combination). When compared to metformin sulfonylurea pioglitazone combination (best therapy), other regimens were less cost effective in reducing FPG and metformin sulfonylurea α-glucosidase inhibitor DPP-4 inhibitor was more effective and expensive in reducing HbA1C.

Conclusions: High prescription rates of metformin were due to its action on insulin resistance and weight. Addition of pioglitazone was cost effective and DPP-4 inhibitor was expensive but effective.


ATC/DDD antidiabetic agent’s cost-effectiveness analysis pioglitazone DPP-4 inhibitors

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Akter S, Rahman MM, Abe SK, Sultana P. Prevalence of diabetes and prediabetes and their risk factors among Bangladeshi adults: a nationwide survey. Bull World Health Organ. 2014;92(3):204-13.

IDF Diabetes Atlas, 6th edi. Brussels, Belgium: international diabetes federation; 2013.

Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res. 2007;125(3):217-30.

Kutty VR, Joseph A, Soman CR. High prevalence of type 2 diabetes in an urban settlement in Kerala, India. Ethn Health. 1999;4(4):231-9.

Strom BL. Pharmacoepidemiology. 4th edi. John Wiley and Sons; 2006;3-17.

Sutharson L, Hariharan RS, Vamsadhara C. Drug utilization study in diabetology outpatient setting of a tertiary hospital. Indian J Pharmacol. 2003;35(4):237-40.

Merlo J, Wessling A, Melander A. Comparison of dose standard units for drug utilisation studies. Eur J Clin Pharmacol. 1996;50(1-2):27-30.

Gafni A, Birch S. Incremental cost-effectiveness ratios (ICERs): The silence of the lambda. Soc Sci Med. 2006;62(9):2091-100.

Menon VU, Guruprasad U, Sundaram KR, Jayakumar RV, Nair V, Kumar H. Glycaemic status and prevalence of comorbid conditions among people with diabetes in Kerala. Natl Med J India. 2008;21(3):112-5.

Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R, et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase I results of the Indian Council of Medical Research-India Diabetes (ICMR–INDIAB) study. Diabetologia. 2011;54(12):3022-7.

WHO EC. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363(9403):157.

Tiwari RR, Deb PK, Debbarma A, Chaudhuri R, Chakraborti A, Lepcha M, et al. Risk factor analysis in self-reported diabetes in a rural Kerala population. Int J Diabetes Dev Ctries. 2008;28(3):91-4.

Joshi SR. Type 2 diabetes in Asian Indians. Clin Lab Med. 2012;32(2):207-16.

Unnikrishnan AG, Kalra S, Sahay RK, Bantwal G, John M, Tewari N. Prevalence of hypothyroidism in adults: An epidemiological study in eight cities of India. Indian J Endocrinol Metab. 2013;17(4):647-52.

Glyburide, gliclazide or glimepiride for elderly patients with type 2 diabetes: a review of the clinical effectiveness and safety-an update. Ottawa (ON): Canadian agency for drugs and technologies in health; 2015. Available at Accessed 2015.

Kalra S, Aamir AH, Raza A, Das AK, Khan A, Shrestha D, et al. Place of sulfonylureas in the management of type 2 diabetes mellitus in South Asia: A consensus statement. Indian J Endocrinol Metab. 2015;19(5):577-96.

Simpson SH, Lee J, Choi S, Vandermeer B, Abdelmoneim AS, Featherstone TR. Mortality risk among sulfonylureas: a systematic review and network meta-analysis. Lancet Diabetes Endocrinol. 2015;3(1):43-51.

Fisman EZ, Tenenbaum A. Antidiabetic treatment with gliptins: focus on cardiovascular effects and outcomes. Cardiovasc Diabetol. 2015;14(1):129.

Wajchenberg BL. beta-cell failure in diabetes and preservation by clinical treatment. Endocr Rev. 2007;28(2):187-218.

Hashim S, Gomes T, Juurlink D, Hellings C, Mamdani M. The rise and fall of the thiazolidinediones: impact of clinical evidence publication and formulary change on the prescription incidence of thiazolidinediones. J Popul Ther Clin Pharmacol J Thérapeutique Popul Pharamcologie Clin. 2013;20(3):e238-42.

Zhu Z, Shen Z, Lu Y, Zhong S, Xu C. Increased risk of bladder cancer with pioglitazone therapy in patients with diabetes: a meta-analysis. Diabetes Res Clin Pract. 2012;98(1):159-63.

Hermann LS. Biguanides and sulfonylureas as combination therapy in NIDDM. Diabetes Care. 1990;13(S3):37-41.

Giannarelli R, Aragona M, Coppelli A, Del Prato S. Reducing insulin resistance with metformin: the evidence today. Diabetes Metab. 2003;29(4Pt2):6S:28-35.

Levri KM, Slaymaker E, Last A, Yeh J, Ference J, D’Amico F, et al. Metformin as treatment for overweight and obese adults: a systematic review. Ann Fam Med. 2005;3(5):457-61.

Inzucchi SE. Oral antihyperglycemic therapy for type 2 diabetes: scientific review. Jama. 2002;287(3):360-72.

Inukai K, Watanabe M, Nakashima Y, Takata N, Isoyama A, Sawa T, et al. Glimepiride enhances intrinsic peroxisome proliferator-activated receptor-gamma activity in 3T3-L1 adipocytes. Biochem Biophys Res Commun. 2005;328(2):484-90.

Holstein A, Plaschke A, Egberts EH. Lower incidence of severe hypoglycaemia in patients with type 2 diabetes treated with glimepiride versus glibenclamide. Diabetes Metab Res Rev. 2001;17(6):467-73.

Basit A, Riaz M, Fawwad A. Glimepiride: evidence-based facts, trends, and observations. Vasc Health Risk Manag. 2012;8:463-72.

Her AY, Kim JY, Kang SM, Choi D, Jang Y, Chung N, et al. Effects of atorvastatin 20 mg, rosuvastatin 10 mg, and atorvastatin/ezetimibe 5 mg/5 mg on lipoproteins and glucose metabolism. J Cardiovasc Pharmacol Ther. 2010;15(2):167-74.

Simsek S, Schalkwijk CG, Wolffenbuttel BHR. Effects of rosuvastatin and atorvastatin on glycaemic control in Type 2 diabetes the CORALL study. Diabet Med J Br Diabet Assoc. 2012;29(5):628-31.

Patel BM, Mehta AA. Choice of anti-hypertensive agents in diabetic subjects. Diab Vasc Dis Res. 2013;10(5):385-96.

Cruickshank JM. Beta-blockers and diabetes: the bad guys come good. Cardiovasc Drugs Ther Spons Int Soc Cardiovasc Pharmacother. 2002;16(5):457-70.

Mills GA, Horn JR. Beta-blockers and glucose control. Drug Intell Clin Pharm. 1985;19(4):246-51.

Herink M, Ito MK. Medication induced changes in lipid and lipoproteins. In: De Groot LJ, Beck-Peccoz P, Chrousos G, Dungan K, Grossman A, Hershman JM, et al., editors. Endotext. South Dartmouth (MA);, Inc.; 2000. Available at Accessed 2000.

Goldner MG, Zarowitz H, Akgun S. Hyperglycemia and glycosuria due to thiazide derivatives administered in diabetes mellitus. N Engl J Med. 1960;262:403-5.

Christlieb AR. The hypertensions of diabetes. Diabetes Care. 1982;5(1):50-8.