Documentation:DiabetesMedChoice
What does the PEER Diabetes Medication Decision Aid do?
The PEER Diabetes Medication Decision Aid is an interactive decision support tool to assess individualized prognosis and potential impact of medication for patients with type 2 diabetes. It is not intended for use in people under the age of 18, adults with type 1 diabetes, or persons with gestational diabetes. The PEER Diabetes Medication Decision Aid is divided into 4 steps designed to emulate the process of shared decision-making at the point of care: (1) risk prediction, (2) preference elicitation, (3) discussion of options and their pros/cons, and (4) documentation.
Step 1: The clinician enters patient information into a validated clinical prediction model (called RECODe) to estimate the patient's risk of diabetes-related outcomes. The evidence behind this model is summarized and referenced on this page.
Step 2: An area of focus is selected based on what outcome is most important to the patient given their estimated risks. This will simplify Step 3 by only displaying the patient's most important outcome by default.
Step 3: Treatment options are selected to manage the risks associated with type 2 diabetes. Each option will display the estimated impact on diabetes-related outcomes, potential side-effects, and other relevant considerations. These options have all been evaluated in at least one high-quality randomized controlled trial; this evidence is summarized below. A bar graph displays the absolute risk (%) of diabetes-related outcomes with and without therapy.
Step 4: A comparative risk summary (with and without treatment) is generated based on final medication decisions. A link for future reference can also be generated which will contain the patient’s personalized risks and treatment choices. These personalized risks and choices are also documented onto a displayable EMR note which can be copied into an electronic medical record.
How do I use the PEER Diabetes Medication Decision Aid?
Step 1
- Input patient data for sex, age, race, current medications, medical history, and clinical information such as blood pressure and labs.
- This information is automatically entered into the model and instantly updates the risk estimates in Step 3.
Step 2
- Select an area of focus based on which outcome matters most to the patient. Step 3 will default to displaying this outcome.
Step 3
- Select from the available drug therapy options. Any drugs that the patient is already taking as selected in Step 1 will be highlighted in green and will not be selectable again in Step 3. Medications with no proven benefit are also not selectable and are greyed out.
- Clicking the dropdown arrow will display a treatment's possible side-effects and other relevant considerations.
- The patient's current risk (based on the inputs in Step 1) as well as the patient's risk on selected medications is displayed here. By default, only the area of focus from Step 2 will be displayed, but there is an option to display all outcomes as well.
- If multiple treatment options are selected, the cumulative relative benefit will be shown based on the assumption that the benefits of the different treatments are additive.
Step 4
- The medications selected in Steps 1 and 3 are displayed here. From these options, select the intended strategy going forward (e.g. start a new medication, stop previous medication, take more time to consider).
- The patient's current risk (based on inputs in Step 1) compared to their risk on therapies being either started or continued (based on Steps 3 and 4) is displayed numerically.
- Click “Link to Save/Share” to generate a link to this personalized assessment of patient risk and treatment choices for future reference.
- Click “Generate Note for EMR” to create a note detailing the patient’s risk and treatment choices that can be copied into an electronic medical record.
A variety of clinical prediction models (also known as "risk scores" or "risk calculators") have been developed to predict outcomes in people with type 2 diabetes, each with their own strengths and limitations. To identify the best risk scores to use in our decision aid, we performed a targeted search of existing diabetes guidelines (http://guidelines.diabetes.ca/cpg, https://diabetesjournals.org/care/issue/45/Supplement_1) and PubMed (to December 2021) for systematic reviews and validation studies of clinical prediction models in patients with type 2 diabetes. Specifically, we considered clinical prediction models based on the following factors:
- Evaluated diabetes-related outcomes, including death, cardiovascular complications (e.g. myocardial infarction, stroke, heart failure), and microvascular complications (nephropathy, neuropathy, and retinopathy);
- Incorporated variables that are readily available in clinical practice;
- Had been externally validated in at least 1 study; and
- Demonstrated good predictive power based on discrimination and calibration.
RECODe was found to have the best predictive power among clinical prediction models for cardiovascular and kidney outcomes in patients with type 2 diabetes in a 2021 systematic review and meta-analysis.
| Outcomes | Definition | Discrimination: C-statistic | Calibration | Note |
|---|---|---|---|---|
| Death | - | 0.71-0.81 | Good | - |
| Heart attack/stroke | Fatal or non-fatal myocardial infarction or stroke | 0.73-0.77 | Good/underestimated at lower risk | Outperformed UKPDS risk calculator & ACC/AHA Pooled Cohort Equations |
| Heart failure | Symptomatic heart failure (regardless of ejection fraction) | 0.73-0.80 | Good/over-predicted at lower risk | Outperformed UKPDS risk calculator |
| Kidney failure | Need for dialysis, or serum creatinine concentration >290 umol/L | 0.78-0.91 | (internal validation only) Risk estimates too moderate, but no under/over-prediction | Outperformed UKPDS risk calculator |
| Severe vision loss | <20/200 visual acuity by Snellen chart | (Internal validation only): 0.62 (0.60-0.64) | (internal validation only) Good | |
| Neuropathy | Pressure sensation loss | 0.69 (0.63-0.74) | Good |
How were options in Step 3 chosen and where do the estimates of benefits and harms
We selected pharmacological interventions for inclusion in the PEER Diabetes Medication Decision Aid based on a comprehensive review of guidelines, reviews, as well as consultation with content experts. Treatments are sub-categorized as (1) general treatment strategies (i.e. intensity of blood glucose or blood pressure control), (2) specific glucose-lowering medications, and (3) non-glucose-lowering medications intended to reduce one or more diabetes-related outcomes. The estimates of benefits and side-effects come from randomized controlled trials (RCTs) and meta-analyses of RCTs. A patient’s individualized benefit is estimated by applying the cumulative relative risk reduction of all treatments selected in Step 2 to the estimated risk calculated using RECODe in Step 1. For side-effects, adverse events that were statistically significantly higher with therapy in RCTs are reported as absolute risk increases.
| Treatment | Death | ASCVD | HF | Kidney failure | Severe vision loss | Neuropathy | References |
|---|---|---|---|---|---|---|---|
| ACE inhibitors | 0.76 (1) | 0.75 (1) | 0.80 (1) | No CKD: NA
CKD: 0.60 (2) |
NA | NA | 1 HOPE-diabetes. Lancet 2000;355:253-9
2 Cochrane Database Syst Rev 2006;4:CD006257 |
| Aspirin | 1.00 | 0.88 | NA | NA | NA | NA | ASCEND. NEJM 2018;379:1529-39 |
| Blood pressure lowering | 1.00 | 0.98 per 1 mmHg lowered | 0.97 per 1 mmHg lowered | NA | NA | NA | Lancet. 2021;397(10285):1625-1636. |
| DPP-4 inhibitors | 1.00 (1-4) | 1.00 (1-4) | 1.00 (1)(Exception: Increase in HF with saxagliptin included in other considerations) | 1.00 (1-4) | NA | NA | 1 CJHP 2019;72:385-7
2 CARMELINA. JAMA 2019;321:69-79 3 CARMELINA renal subgroup. Diabetes Care 2020;43:1803-12 4 SAVOR. NEJM 2013;369:1317-26 |
| Ezetimibe | 1.00 (1,2) | 0.90 (1) | NA | NA | NA | NA | 1 IMPROVE-IT. NEJM 2015;372:2387-97
2 EWTOPIA 75. Circulation 2019;140:992-1003 (also reported ASCVD, but not used here given open-label design) |
| GLP-1 receptor agonists | 0.88 (1) | 0.88 (2) | 1.00 (1) | 0.78 (1) | NA | 1.00 (1) | 1 BMJ 2021;372:m4573
2 Lancet Diabetes Endocrinol 2019;7:776-85 |
| Insulin | 1.00 (1,2) | 1.00 (1,2) | 1.00 (1) | 1.00 (1) | 1.00 (1) | NA | 1 Lancet. 1998;352(9131):837-853.
2 N Engl J Med. 2012;367(4):319-328. |
| Metformin | 0.73 (1) | 0.70 (1; note, no RR available for ASCVD composite, using approximate RR from myocardial infarction [0.67] & stroke [0.80]) | 1.00 (2) | 1.00 (2) | 1.00 (2) | NA | 1 UKPDS 80; NEJM 2008;359:1577-89
2 UKPDS 34. Lancet 1998;352:854-65 |
| SGLT2 inhibitors | 0.77 (1) | No ASCVD: 1.00 (2)
Existing ASCVD: 0.89 (2) |
0.70 (1) | No CKD: 0.71 (1)
CKD: 0.65 (2-5) |
NA | 1.00 (1) | 1 BMJ 2021;372:m4573
2 JAMA Cardiol 2021;6:148-58 3 CREDENCE. NEJM 2019;380:2295-306 4 DAPA-CKD. NEJM 2020;383:1436-46 5 Diabetes Research and Clinical Practice 2021;180:109033 |
| Statins | 0.88 | 0.79 | NA | NA | NA | NA | Lancet 2008;371:117-25 |
| Sulfonylureas | 1.00 (1,2) | 1.00 (1,2) | 1.00 (1) | 1.00 (1) | 1.00 (1) | NA | 1 Lancet. 1998;352(9131):837-853.
2 Tools for Practice #202. |
NA: No RCT data available. For a given outcome, an intervention with no RCT data available is given RR=1.00, conservatively assuming no positive or negative effect of the intervention on that particular outcome.
| Treatment | Adverse effects (absolute % increase) | References | Cost | Routine | Caution & Others |
|---|---|---|---|---|---|
| ACE inhibitors | Dizziness (+1%)
Cough (+5%) Angioedema (+0.2%) |
1 HOPE-diabetes. Lancet 2000;355:253-9
2 Am J Cardiol 2012;110:383-91 |
About $25 for 90 days ($100/year) | One pill once a day | |
| Aspirin | Major bleed (+1%) | ASCEND. NEJM 2018;379:1529-39 | About $40/year | One pill once a day | Consider taking with food to minimize stomach upset. |
| Blood pressure lowering | Varies based on which medications are used | Varies based on which medications are used | Varies based on which medications are used | ||
| DPP-4 inhibitor | "Gallbladder attack" (cholecystitis) (+0.15%)
(Saxagliptin only) Heart failure hospitalization (+0.7%) |
BMJ 2022;377:e068882
SAVOR. Circulation 2014;130:1579-88 |
About $335 for 90 days ($1400/year) | One pill once a day | Does not increase the risk of severe hypoglycemia |
| Ezetimibe | None | IMPROVE-IT. NEJM 2015;372:2387-97 | About $30 for 90 days ($120/year) | One pill once a day | |
| GLP-1 receptor agonist | Vomiting and/or diarrhea) (+6%) | BMJ 2021;372:m4573 | About $500-900 for 90 days ($1800-3600/year) | Semaglutide: Available as a tablet (one table once a day) or injection (one injection once a week).
Others: Once injection once or twice a day. |
Does not increase the risk of severe hypoglycemia. Causes weight loss (average ~2 kg) |
| Insulin | Severe low blood sugar (+4%)
Symptomatic low blood sugar (+32%) |
N Engl J Med. 2012;367(4):319-328. | Varies based on dose | Varies from one injection once a day to several times per day | Causes weight gain (average ~2 kg)
Make sure to follow good sick-day management: https://www.rxfiles.ca/rxfiles/uploads/documents/SADMANS-Rx.pdf Does not increase the risk of severe hypoglycemia |
| Metformin | Nausea, vomiting, flatulence, and/or diarrhea (+16%) | NEJM 2006;355:2427-43 | About $25 for 90 days ($100/year). May be combined with other diabetes medications in a combination pill | One or two pills twice a day | Make sure to follow good sick-day management: https://www.rxfiles.ca/rxfiles/uploads/documents/SADMANS-Rx.pdf
Does not increase the risk of severe hypoglycemia |
| SGLT2 inhibitor | Genital yeast infection (+14%)
Ketoacidosis (+0.1%) |
BMJ 2021;372:m4573 | About $285 for 90 days (or $1200/year). Can prescribe empagliflozin 12.5 mg daily (splitting 25-mg tablets) to cut the cost to $143 for 90 days (or $600/year) | One pill once a day | Make sure to follow good sick-day management: https://www.rxfiles.ca/rxfiles/uploads/documents/SADMANS-Rx.pdf
Does not increase the risk of severe hypoglycemia |
| Statins | Muscle pain (+0.3%)
Rhabdomyolysis (+0.01%) Elevated liver enzymes (+1%) New diabetes (+0.5%) |
Am Heart J 2014;168:6-15
STOMP. Circulation 2013;127:96-103, Eur J Prev Cardiol 2014;21:464-74, NEJM 2016;374:2021-31 |
About $30 for 90 days ($120/year) | One pill once a day | |
| Sulfonylureas | Severe low blood sugar (+0.6%) | N Engl J Med. 2006;355(23):2427-2443. | About $25-35 for 90 days ($100-140/year) | One pill once or twice a day | Causes weight gain (~2kg)
Make sure to follow good sick-day management: https://www.rxfiles.ca/rxfiles/uploads/documents/SADMANS-Rx.pdf |
Why are only some medications listed in both Step 1 and Step 3?
Medications that are included in Step 1 are used directly by the risk calculator to estimate current risk. On the other hand, the effect of medications listed in Step 3 is based on applying the relative risk reduction derived from randomized controlled trials to the current risk. As a result, for example, the effect of receiving a statin at baseline can be different from the estimated effect of adding a statin "during the visit".
How were costs estimated? (last updated 28 Feb 2020)
Cost estimates are based on Canadian dollars (CAD), updated annually or more frequently as needed, and estimated using the following websites:
- https://acfp.ca/wp-content/uploads/2019/02/ACFPPricingDoc2019.pdf
- http://www.medi-mouse.com/drugfind.php
- https://www.studybuffalo.com/tools/drug-price-calculator/
Quality checklist: International Patient Decision Aid Standards instrument (IPDASi)
| Criteria | Answer |
|---|---|
| INFORMATION: Providing information about options in sufficient detail for making a specific decision | 8/8 |
| 1. Describes the health condition or problem for which the index decision is required | Yes |
| 2. Describes the decision that needs to be considered | Yes |
| 3. Describes the options available for the decision | Yes |
| 4. Describes the natural course of the health condition or problem if no action is taken | Yes |
| 5. Describes the positive features (benefits or advantages) of each option | Yes |
| 6. Describes negative features (harms, side-effects or disadvantages) of each option | Yes |
| 7. Makes it possible to compare the positive and negative features of the available options | Yes |
| 8. Shows the negative and positive features of options with equal detail | Yes |
| PROBABILITIES: Presenting outcome probabilities | 7/8 |
| 1. Provides information about outcome probabilities associated with the options | Yes |
| 2. Specifies the defined group of patients for which the outcome probabilities apply | Yes |
| 3. Specifies the event rates for the outcome probabilities (in natural frequencies) | Yes |
| 4. Specifies the time period over which the outcome probabilities apply | Yes |
| 5. Allows the user to compare outcome probabilities across options using the same denominator and time period | Yes |
| 6. Provides information about the levels of uncertainty around event or outcome probabilities | No |
| 7. Provides more than one way of viewing the probabilities (e.g. words, numbers & diagrams) | Yes |
| 8. Provides balanced information about event or outcome probabilities to limit framing biases | Yes |
| VALUES: Clarifying and expressing values | 4/4 |
| 1. Describes the features of options to help patients imagine what it is like to experience the physical effects | Yes |
| 2. Describes the features of options to help patients imagine what it is like to experience the psychological effects | Yes |
| 3. Describes the features of options to help what it is like to experience the social effects | Yes |
| 4. Asks patients to think about which positive and negative features of the options matter most to them | Yes |
| DECISION GUIDANCE: Structured guidance in deliberation and communication | 1/2 |
| 1. Provides a step-by-step way to make a decision | Yes |
| 2. Includes tools like worksheets or lists of questions to use when discussing options with a practitioner | No |
| DEVELOPMENT: Using a systematic development process | 2/6 |
| 1. The development process includes finding out what patients need to prepare them to discuss a specific decision | Yes |
| 2. The development process included finding out what health professionals need to prepare them to discuss a specific decision with patients | Yes |
| 3. The development process included expert review by patients not involved in producing the decision support technology | *Pending* |
| 4. The development process included expert review by health professionals not involved in producing the decision support technology | *Pending* |
| 5. Field tested with patients who were facing the decision | *Pending* |
| 6. Field tested with practitioners who counsel patients who face the decision | *Pending* |
| EVIDENCE: | 4/4 |
| 1. Provides citations to the studies selected | Yes |
| 2. Describes how research evidence was selected or synthesized | Yes |
| 3. Provides a production or publication date | Yes |
| 4. Provides information about the proposed update policy | Yes |
| DISCLOSURE: | 2/2 |
| 1. Provides information about the funding used for development | Yes |
| 2. Includes author/developer credentials or qualifications | Yes |
| PLAIN LANGUAGE: | 0/1 |
| 1. Reports readability levels | *Pending* |
| EVALUATION: | 0/2 |
| 1. Evidence that the decision aid improves the match between the features that matter most to the informed patient and the option that is chosen | No |
| 2. Evidence that the patient decision aid helps patients improve their knowledge about options’ features | No |
Developed by:
This tool was developed by the PEER Diabetes Medication Decision Aid Development Panel:
Ricky D. Turgeon BSc(Pharm), ACPR, PharmD (ricky.turgeon@ubc.ca)
Assistant Professor – Greg Moore Professor in Clinical and Community Cardiovascular Pharmacy, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
Clinical Pharmacy Specialist - PHARM-HF, St. Paul's Hospital, Vancouver, BC
James McCormack BSc, BSc(Pharm), PharmD
Professor, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
Blair MacDonald BA, PharmD
Research Coordinator, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
Funding: None.
Conflict of interest: Drs. MacDonald, Turgeon, and McCormack declared no conflict of interest.
Peer reviewed by:
Version history
Version 1.0 (last update: December 2022 | last evidence review December 2022)
Update policy: Update at least annually in January, or more frequently as needed with availability of new evidence.