'A Bad Result': A1c Targets Missed in Most With Type 1 Diabetes

Miriam E. Tucker

September 25, 2019

Dr Eric M. Renard

BARCELONA — Worldwide, only a small proportion of adults with type 1 diabetes are achieving optimal glucose control, new research indicates.

Findings from the multinational, observational Study of Adults' Glycemia in TID (SAGE) were presented September 17 here at the European Association for the Study of Diabetes (EASD) 2019 Annual Meeting.

Overall data were presented by Eric M. Renard, MD, PhD, Medical School of the University of Montpellier and Lapeyronie University Hospital, Montpellier, France. Region-specific data were presented by Jochen Seufert, MD, PhD, University Hospital of Freiburg and University of Freiburg, Germany.

The study included nearly 4000 adults aged 26 years and older with type 1 diabetes from 17 countries in Western Europe, Eastern Europe, Latin America, Asia, and the Middle East. (North America and Africa weren't included.) 

Overall, only a quarter to a fifth of patients were achieving A1c levels < 7% (< 53 mmol/mol) or individualized targets set by their clinician. Better control was achieved in Western Europe compared with other regions, and the least amount of patients met A1c goals in the Middle East.

"Unfortunately, it is a bad result for most people...There is really a need for education because what we see is that technology is not improving results so much," Renard told Medscape Medical News in an interview.

"It's not only the tools but also the people who live with [type 1] diabetes understanding the goal of therapy. It's how you feel with this disease and live with it, and being able to see the future. Clinicians should spend more time with their patients explaining why these numbers are important. What does [an A1c of] 7% mean?" he said.

Diabetes technology use was uncommon, patients were often not titrating their own insulin doses, and in some regions human NPH and Regular insulins were still being used by sizable minorities of patients. 

Renard also noted that although the United States wasn't included in SAGE, the results are very similar to those seen in the American T1D Exchange.  

Asked to comment, Peter Lommer Kristensen, PhD, Nordsjællands Hospital, Hillerød, Denmark, told Medscape Medical News, "We now have new insulins, pumps, and sensors, but it's common that new pump users don't benefit from it. So what is happening there?

"I believe it's psychosocial factors, among other things. If that's true you have to talk to patients about these things. And of course, there are a lot of cultural differences across regions."

 "A Bad Result for Most People"

The study was a single-visit, cross-sectional, noninvasive analysis of data from 3858 adults aged 26 years and older with type 1 diabetes of at least a year's duration.

By region, 30% were from Western Europe, 26% Eastern Europe, 20% Asia, 13% Latin America, and 11% the Middle East. By age, 45% were 26-44 years old, 39% were 45-64 years old, and 16% were 65 years and older. 

The overall average A1c was 7.95% and didn't vary significantly by age or region, ranging from 7.7% in Western Europe to 8.2% in the Middle East.

The primary endpoint, the percentage of people with A1c < 7%, was 24.3% overall, 27.6% for those aged 26-44 years, 21.0% for those aged 45-64 years, and 22.8% for those aged 65 years and older.

Of concern, 43.4% had an A1c ≥ 8% and 20.1% had an A1c ≥ 9%.

Even when considering individualized targets set by the physician — more than half of which were A1c 7.0-7.5% even in the youngest group — just a fifth (20.9%) of patients overall met them.

And in those aged 65 years and older, for whom 27.2% were given A1c targets of 7.5%-8.0%, just 26.2% even met these less-stringent levels.

By region, the proportions achieving A1c < 7% ranged from 27.0% in Western Europe to just 18.9% in the Middle East. For individualized targets, the range was 23.9% in Western Europe to 14.4% in the Middle East.

Severe hypoglycemic episodes in the past 3 months were experienced by 11.9% of patients overall, with little difference by age. Proportions of patients with severe hypoglycemia didn't differ by region, but the Middle East had lower rates of symptomatic hypoglycemia than other regions, corresponding with their higher overall A1c levels, Seufert noted.

Severe hyperglycemia leading to diabetic ketoacidosis in the past 6 months occurred in 4.2% of participants overall and was highest in the 26-44 year age group (4.8%). Across regions, the range was 6.7% in Western Europe to 2.3% in Asia.

Technology Use Low, Many Patients Wait to Be Told What to Do

Insulin pumps were only used by a fifth (19.9%) of patients globally, ranging from 24.0% of the youngest age group to just 10.6% of the oldest, and from 43.3% in Western Europe to just 3.2% in the Middle East.

Although most patients were using insulin analogs, 9.9% overall were still using intermediate-acting NPH insulin and 5.6% were still using premixed insulin. Use of both was highest in those aged 65 years and older. Use of NPH ranged from 21.8% in Eastern Europe to 1.3% in Western Europe. Use of premixed insulin ranged from 16.7% in the Middle East to 1.0% in Western Europe.

Surprisingly, 43.0% of patients used physician-driven insulin titration and 57.0% self-titrated.

"It's a bit surprising to see that 43% of these type 1 diabetes patients are waiting for their physician to tell them the dose they should use. It's quite unexpected in type 1 diabetes patients," Renard commented.

Those proportions also varied significantly by region, with 69.0% and 71.3% using self-titration in Western and Eastern Europe, respectively, whereas physician-led titration was more common in Latin America (53.1%), the Middle East (72.7%), and Asia (56.3%). 

Use of continuous glucose monitoring (CGM) was 23.2% overall, with slightly higher use among the younger group. As with insulin pumps, CGM use was far greater in Western Europe (46.4%) compared with just 2.5% in the Middle East, 4.7% in Eastern Europe, 21.1% in Latin America, and 25.5% in Asia.

"There is really a lot to do to try to improve control," Renard commented.   

According to Kristensen, "Sometimes clinicians think that the A1c has to go lower but the patients aren't interested.

"That's probably the key question we have to talk with our patients about. What is actually the goal? We always talk about glucose and A1c. I think we have to go further with patients who don't reach their goals. You have to talk with them, not only about glucose and insulin but about their problems and fears. I think it's the only way to go further."

The SAGE trial was funded by Sanofi. Renard has reported being a consultant to and/or has received research support from Abbott, Air Liquide, Becton Dickinson, Cellnovo, Dexcom, Eli Lilly, Insulet, Johnson & Johnson, Medtronic, Novo Nordisk, Sanofi-Aventis, Roche, and Tandem. Seufert has reported serving on advisory panels for, receiving research support from, and/or being a speaker for Abbott, AstraZeneca, Boehringer Ingelheim, GI-Dynamics, Janssen, LifeScan, Mundipharma, Novartis, Novo Nordisk, Sanofi Aventis, Bristol-Myers Squibb, Intarcia, Ipsen, Ypsomed, Berlin-Chemie, Lilly, MSD, Medscape, Novartis, and OmniaMed. Kristensen has reported no relevant financial relationships.

EASD 2019 Annual Meeting. Presented September 17, 2019. Abstract OP 03.

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