The purpose of this K01 proposal is to provide Dr. Jinnie Rhee with the protected time and resources to allow her to pursue the training needed to reach her long-term goal of becoming an independent investigator in patient-centered clinical research, and an expert in diabetes epidemiology. Type 2 diabetes mellitus (T2DM) management in chronic kidney disease (CKD) remains a challenge due to the complexity of multiple medication regimens that are often needed, and the required pharmacological dose adjustments and contraindications of several conventional antidiabetic medications. Barriers to achieving optimal T2DM management in CKD may include low patient adherence, and conservative provider prescription decision- making, resulting from lack of long-term data on the safety and effectiveness regarding benefits and harms of certain medication classes over others in patients with CKD, particularly for newer medications with which there has been little clinical experience in the CKD population. The objective of the proposed research is to better understand the comparative safety and effectiveness of various strategies aimed to manage T2DM in CKD, and to understand factors that currently influence patient and provider choice of these strategies through a series of quantitative and qualitative studies.
In Aim 1, Dr. Rhee will conduct a descriptive study to quantify patterns of conventional and newer antidiabetic medication use across different stages of CKD, and examine proportions of each medication prescribed by an endocrinologist, nephrologist, or primary care physician.
In Aim 2, Dr. Rhee will use a detailed administrative database to compare the safety and effectiveness of DPP-4 inhibitors and GLP-1 agonists versus conventional antidiabetic medications by examining associations with cardiovascular outcomes, glycemic control, weight gain, and hypoglycemia-related ED visits and hospitalizations. Effect modification by CKD stage will also be examined.
In Aim 3, Dr. Rhee will conduct a qualitative study to understand: (1) the perspectives of patients on the use of antidiabetic drugs, including newer agents, and uncover perceived barriers to, and facilitators of, adherence; and (2) providers? perspectives on prescribing conventional and newer antidiabetic medications, and examine both clinical and nonclinical factors that influence their prescription decision-making. This award will allow Dr. Rhee to transition into a clinically-minded epidemiologist whose work goes beyond quantitative research. It will help her fill critical training gaps in the areas of advanced pharmacoepidemiology, health services research, and qualitative research. The detailed training plan includes formal coursework at Stanford University as well as seminars, meetings, research apprenticeships, directed readings, and attendance at national/international conferences. The proposed work has high potential to make a significant public health and clinical impact. The sum of experiences acquired through this K01 will help Dr. Rhee to successfully transition toward an independent clinical research career.
Despite a wide variety of antidiabetic medications that are currently available, little is known about how to optimize diabetes care in persons with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD), who are at very high risk of cardiovascular disease and other adverse health outcomes. Factors that contribute to difficult T2DM management in CKD may include low patient adherence, and conservative provider prescription decision-making, resulting from lack of long-term data on potential benefits and harms of certain medications over others in CKD as well as from little clinical experience with newer drugs. The proposed research aims to understand the comparative safety and effectiveness of various strategies aimed to manage T2DM in CKD, and to understand factors that currently influence patient and provider choice of these strategies.