key: cord-0693049-wkjpzong authors: Jacob, Louis; Yakkali, Balaji; Parekh, Mahir; Kostev, Karel title: No effects of the COVID-19 pandemic on the prescription of insulin in Germany date: 2022-04-25 journal: Prim Care Diabetes DOI: 10.1016/j.pcd.2022.04.007 sha: 67369a81af290386147cd45064293016d5db0818 doc_id: 693049 cord_uid: wkjpzong AIMS: Aim of the study was to investigate the change of insulin doses in Germany between 2017 and 2021. METHODS: This retrospective study used data from the longitudinal prescription (LRx) database (IQVIA) and included all patients with at least two insulin prescriptions per year in 2017-2021. Calculated daily dose (CDD) was assessed in 2017, 2018, 2019, 2020, and 2021, separately. RESULTS: The number of patients was comprised between 1,120,276 in 2017 and 1,079,894 in 2021. Median (interquartile range) CDD of basal insulin was relatively stable across the years and ranged between 27.9 (18.5-38.8) in 2021 and 28.3 (18.7-39.5) in 2020. In terms of short-acting insulin, median (interquartile range) CDD slightly decreased from 40.1 (28.2-54.3) in 2017 to 38.1 (27.2-52.2) in 2021. A slight decrease was also observed for mix insulin, from 39.4 (27.5-55.3) in 2017 to 37.9 (26.5-54.2) in 2021. These results were corroborated in most age and sex subgroups. CONCLUSIONS: COVID-19 had no substantial effects on insulin doses in Germany. Further data are warranted to corroborate or refute these findings in other settings and countries. Coronavirus disease 2019 (COVID-19) is a global pandemic that has been associated with more than 440 million positive cases and almost six million deaths worldwide [1] . The respective numbers were 15 million and 124,000 in Germany. Healthcare systems have been disrupted since the beginning of the COVID-19 pandemic, and the management of multiple chronic conditions may have suffered from this health crisis [2] . However, the effects of the COVID-19 pandemic on glycemic control in patients with diabetes remain under debate [3] [4] [5] [6] [7] . For example, a study, including 101 individuals with type 2 diabetes from Turkey, revealed that glycated hemoglobin (HbA1c) had increased from 7.7% during the pre-lockdown period to 8.1% during the lockdown period, while fasting glucose had risen from 158 to 163 mg/dl [6] . In contrast, a study of 380 type 2 diabetes individuals from Greece found a decrease in HbA1c, body mass index, and total cholesterol values during the lockdown in this country [7] . In Germany, the first lockdown has had little impact on HbA1c, fasting glucose and several other metabolic parameters (e.g., blood J o u r n a l P r e -p r o o f pressure, cholesterol and triglycerides) in the type 2 diabetes population [4] . In addition to this scientific debate, only a few studies have compared the prescription of insulin in patients with diabetes between the pre-COVID-19 and the COVID-19 era [8, 9] . Although these studies have advanced the field, they were based on data exclusively collected in 2020, and little is known on how COVID-19 impacted insulin consumption in the diabetes population in 2021. Therefore, this study aimed to investigate the prescription of insulin in Germany between 2017 and 2021. This retrospective study used data from the longitudinal prescription LRx database (IQVIA). The LRx database contains data on approximately 80% of prescriptions reimbursed by statutory health insurance funds in Germany. For each prescription, information is available on brand, substance, package size, product form, and dispensed date. Besides, age and sex of patients are documented in the database. All data are anonymized in accordance with German data privacy laws, Finally, the LRx database has already been used in previous studies focusing on the prescription of insulin [10, 11] . The present study included all patients with at least one prescription for insulin separately. CDD was defined as follows: (package size * number of packages) / number of days between two consecutive prescriptions. Mean CDD was obtained for each patient and, because data were not normally distributed, median (interquartile range) CDD was estimated for each year. The three types of insulin (i.e., basal, short-acting, and mix insulin) were studied separately, and analyses were stratified by age (i.e., 0-<18, 18-40, 41-50, 51-60, 61-70, 71-80, and >80 years) and sex (i.e., male and female). This study was of a descriptive nature, and no hypotheses were tested. All analyses were carried out using SAS version 9.4 (SAS institute, Cary, USA). The characteristics of the population are displayed in Table 1 This retrospective study using data collected in 2017-2021 showed that COVID-19 had no effects on the prescription of insulin in Germany. The prescription of basal insulin was relatively stable between 2017 and 2021, while there was a slight and steady decrease in CDD for both short-acting and mix insulin during the study period. To the best of the authors' knowledge, this is the first study to have investigated the impact of the COVID-19 on the prescription of insulin not only in 2020 but also in 2021. These findings are partially in line with the literature. As a matter of fact, the mean number of prescriptions of insulin has been found to decrease in the United States in 2020 [9] . Other data from Germany have indicated that the number of individuals receiving insulin prescriptions increased by 18% during the first quarter of 2020 [8] . In contrast, one German study of 32,399 patients with type 2 diabetes found a 0.04% increase in HbA1c values between June -November 2019 and the same period in 2020, while there was no substantial change in weight and metabolic control [4] . The present results corroborate the findings of this last study, as there was no apparent increase in CDD of insulin in this country during the COVID-19 pandemic. The lack of substantial effects of the COVID-19 on the prescription of insulin may be explained by healthier behaviors in 2020 and 2021, such as increased physical activity, healthier diets, and decreased stress levels. Nonetheless, more data on the J o u r n a l P r e -p r o o f impact of this health crisis on lifestyle behaviors are needed, as most studies on this topic have been conducted early during the COVID-19 pandemic, and as this impact has likely changed over time. The strengths of this study are the large sample size and the use of data collected between 2017 and 2021. However, the study results should be interpreted in light of two limitations. First, CDD may overestimate prescribed insulin doses [12] , and this may have biased the analyses. Second, only prescriptions reimbursed by statutory health insurance funds are documented in the LRx database, and the findings may not be generalized to Germany. Overall, COVID-19 had no substantial effects on insulin prescription in Germany. Further data are warranted to corroborate or refute these findings in other settings and countries. German law allows the use of anonymous electronic medical records for research purposes under certain conditions. According to this legislation, it is not necessary to obtain informed consent from patients or approval from a medical ethics committee for this type of observational study that contains no directly identifiable data. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. None. Louis Jacob contributed to the design of the study, managed the literature searches, wrote the first draft of the manuscript, and corrected the manuscript. Karel Kostev contributed to the design of the study, and corrected the manuscript. Balaji Yakkali and Mahir Parekh performed the statistical analyses. All authors contributed to and have approved the final manuscript. The authors declare no conflicts of interest. World Health Organization. WHO Coronavirus (COVID-19) Dashboard Are overwhelmed health systems an inevitable consequence of covid-19? Experiences from China Short-term impact of COVID-19 lockdown on metabolic control of patients with well-controlled type 2 diabetes: a single-centre observational study Effects of the COVID-19 lockdown on primary health care for persons with type 2 diabetes -Results from the German Disease Analyzer database Effects of COVID-19 Lockdown on Glucose Control: Continuous Glucose Monitoring Data From People With Diabetes on Intensive Insulin Therapy. 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