Study Finds Delays in Diabetes Treatment Intensification

Miriam E. Tucker

August 02, 2013

Delays in treatment intensification are common among patients with type 2 diabetes, despite suboptimal glycemic control, a large retrospective cohort study shows.

The results were published online July 22 in Diabetes Care by Kamlesh Khuni, MD, from the Diabetes Research Unit, Leicester Diabetes Centre, University of Leicester, United Kingdom, and colleagues.

"Patients remain in poor control for too long, and there is a reluctance on behalf of the healthcare professional to intensify therapy," principal investigator Melanie J. Davies, MD, professor of diabetes medicine at the Leicester Diabetes Centre, told Medscape Medical News.

Guidelines from the American Diabetes Association, the European Association for the Study of Diabetes, and the United Kingdom's National Institute for Health and Clinical Excellence recommend intensification of diabetes treatment for patients with HbA1c values exceeding 6.5% to 7%.

Long Delays

Prescription data were analyzed for 50,476 type 2 diabetes patients from the Clinical Practice Research Datalink (CPRD), which includes primary-care records for over 13 million UK patients. People who were started on an oral antidiabetes drug (OAD) during January 2004 through December 2006 were followed until April 2011.

At baseline, all 50,476 people were taking at least 1 OAD, 25,600 were taking 2 OADs, and 5677 were taking 3. Average baseline HbA1c levels for those 3 groups were 8.4%, 8.8%, and 9.0%, respectively.

The frequency of HbA1c testing was greater among those in poorer control, ranging from between-test intervals of 4.7 months for those with baseline HbA1c values of 8% and above to 5.3 months for those with HbA1c 7% or higher. Testing frequency did not differ significantly by the number of OADs.

Among the total 35,988 patients with HbA1c levels of 7% or higher, the median time to intensification of treatment with 1 additional OAD was 2.9 years and median time to insulin intensification was more than 7.2 years. Time to insulin use was similar regardless of the number of OADs the patient was taking.

Among those taking 1 OAD, time to use of a second or third OAD was 1.9 years for those with an HbA1c at or above 7.5% and 1.6 years for an HbA1c 8.0% or greater. However, time to insulin use for those taking 1 or 2 OADs at baseline was more than 6.9 to 7.2 years regardless of baseline HbA1c.

Time to insulin use was slightly lower but still more than 6 years among patients with HbA1c levels of 7.5% or above, despite taking 3 OADs. By the end of follow-up, insulin had been initiated in just 1 in 5 people who had HbA1c levels of 7.5% or higher, despite taking 3 OADs.

At the time of treatment intensification with either an additional OAD or insulin, mean HbA1c was 8.7% for those taking 1 OAD at baseline, 9.1% for those taking 2 OADs, and 9.7% for those taking 3 OADs.

"This analysis shows that there is a delay in intensifying treatment in people with type 2 diabetes with suboptimal glycemic control, with patients remaining in poor glycemic control for [more than] 7 years before intensification of treatment with insulin… Despite having HbA1c levels for which diabetes guidelines recommend treatment intensification, few people appeared to undergo intensification," the authors write. "Consequently, these people experienced prolonged periods in poor glycemic control, which is detrimental to long-term outcomes," they add.

Inertia on Several Levels

Both patient and physician factors play a role in the delay to treatment, with a particular reluctance to initiate insulin on both sides, the authors note.

"Inertia surrounding insulin initiation is a specific problem. Physicians may be reluctant to initiate insulin owing to a belief about patient risk, including risks in people with comorbidities, excess weight gain, hypoglycemia, impaired quality of life, beliefs about patient competence, and resource issues. Patient factors, such as fear of hypoglycemia or weight gain, also contribute to clinical inertia when initiating insulin," they write.

And, they add, recent studies finding a lack of cardiovascular benefit and possible harm with tight glucose control have caused people to question the approach in type 2 diabetes management.

Possible approaches to help overcome clinical inertia include use of guidelines and recommendations, motivation and support of patient self-management, and education for both physicians and people with diabetes.

Use of electronic medical records to assist clinical decision-making has also been proposed but is not yet supported with strong evidence, the authors note.

Novo Nordisk contributed to the study design, statistical analyses, data interpretation, manuscript preparation, and the decision to submit the manuscript for publication. The authors received editorial support for this study from Watermeadow Medical, which was funded by Novo Nordisk. Dr. Khuni is the recipient of the Anglo-Danish-Dutch Study of Intensive Treatment in People With Screen-Detected Diabetes in Primary Care grant from the UK National Health Service Research and Development department for the submitted work and has been an advisory board member, received research funding, and been a paid speaker on behalf of Novo Nordisk in the previous 3 years. Dr. Davies has been an advisory board member, received research funding, been a paid speaker, been paid to develop educational programs, and been compensated for travel/accommodation/meeting expenses on behalf of Novo Nordisk in the previous 3 years. Disclosures for the coauthors are listed in the article.

Diabetes Care. Published online July 22, 2013. Abstract


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