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Are prescribing patterns of antidiabetic medications influenced by fears of litigation?

Nature Clinical Practice Endocrinology & Metabolism volume 4, pages 440–441 (2008)Cite this article

In the US, 90% of doctors admit to practicing 'defensive medicine'—the act of performing diagnostic or therapeutic measures in order to avoid the possibility of future litigation rather than to provide actual benefit to the patient. The costs of this practice are thought to exceed US$100 billion annually in the form of unnecessary tests, prescriptions and follow-up.1

Less well-described, but seemingly pervasive and potentially as costly, is the discontinuation or avoidance of effective therapies by either prescribers or patients. As a diabetes specialist, I feel that the most disturbing example of this practice is the sizeable number of patients whose treatment with statins has been stopped because of modest and/or intermittent elevations of liver function tests.2 Monitoring of liver function is recommended in the prescribing information of all statins; however, the incidence of statin-therapy-related acute liver failure is less than 1 per million patient-years, which is approximately equivalent to the background rate of idiopathic acute liver failure detected in the general population. Furthermore, there is no evidence that liver function testing represents an effective strategy to reduce the incidence of acute liver failure in patients treated with statins. These agents have been estimated to provide roughly a 0.5% absolute risk reduction of cardiovascular disease in high-risk populations; therefore, a net harm from defensive monitoring and discontinuation of statins seems highly likely in patients with diabetes mellitus.

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  1. Division of Endocrinology, University of North Carolina School of Medicine, CB #7172, 8027 Burnett-Womack Building, Chapel Hill, NC 27599-7172, USA jbuse@med.unc.edu

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  1. JB Buse is a Professor of Medicine and Chief of the Division of Endocrinology at the University of North Carolina School of Medicine, Chapel Hill, NC, USA.,

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Competing interests

John B Buse is an investigator, consultant and/or speaker for Amylin, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, MannKind, Merck, Novartis, Novo Nordisk, Pfizer, and Sanofi-Aventis. These relationships are managed under contracts between the companies and the University of North Carolina and do not provide direct financial benefit to Dr Buse.

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Buse, J. Are prescribing patterns of antidiabetic medications influenced by fears of litigation?. Nat Rev Endocrinol 4, 440–441 (2008). https://doi.org/10.1038/ncpendmet0869

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