Diabetes Treatment Intensification May Be Warranted in Some Populations

Results of a recent study indicate that therapeutic inertia occurs in approximately 1 in 5 patients with type 2 diabetes who have hemoglobin A1C (HbA1C) levels higher than 8% and currently take 2 or more non-insulin antidiabetic drugs (NIADs). However, many patients who meet these criteria tend to need treatment intensification.

Additionally, patients who are women and/or have comorbidities, chronic kidney disease (CKD), or microvascular complications face an increased risk of intensification, although to a lesser extent.
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Between January 2010 and December 2014, the researchers analyzed the electronic medical records of 23,678 participants taking 2 or more NIADs. All participants had HbA1c levels of 7% or higher and a record of a first prescription for a new NIAD. Of these 23,678 participants, 12,730 were categorized into a subgroup of participants with HbA1c levels of 8% or higher at baseline or during follow-up. Median follow-up was 4.2 years.

Therapeutic inertia was defined as no intensification of treatment if HbA1c levels were 8% or higher at baseline or during follow-up. Time-to-event analysis was used to assess time to first intensification, and a completing-risk regression model was used to evaluate factors predicting intensification.

Of all participants included in the study, 26.2% were censored without treatment intensification after follow-up. Of the 12,730 participants with HbA1c levels of 8% or higher at baseline or during follow-up, 18.1% were classified with therapeutic.

The mean HbA1c among all participants was 9.4% at initiation of insulin and 8.7% at initiation of NIAD. The median time to first intensification was 17.1 months in participants with HbA1c levels between 8.0% and 9.9%, and 10.1 months in those with HbA1c levels higher than 10%.

Factors strongly associated with intensification of treatment were HbA1c levels higher than 8% and a diabetes duration of 20 years or longer. Participants who were female and/or had comorbidities, CKD, or microvascular complications also faced a greater risk of treatment intensification, although to a lesser extent.

“Lack of intensification was present in 1 in 5 patients. Both the HbA1c thresholds and the time until therapy intensification exceeded current recommendations,” the researchers concluded.

—Christina Vogt

Reference:

Mata-cases M, Franch-Nadal J, Real J, et al. Therapeutic inertia in patients treated with two or more antidiabetics in primary care: factors predicting intensification of treatment [Published online June 28, 2017]. Diabetes Obes Metab. doi:10.1111/dom.13045.