Intensification of therapy for patients with type 2 diabetes who have suboptimal glucose control is often delayed….

Kamlesh Khunti, MD, of the University of Leicester in England, and colleagues reported that, in a retrospective study, patients who had an HbA1c of 7% at baseline had a median time to intensification with one additional oral anti-diabetic drug of 2.9 years.

The mean HbA1c at intensification with one additional oral diabetes drug in this population was 8.7%, they found.

"A substantial proportion of people remain in poor glycemic control for several years before intensification with oral anti-diabetes drugs and insulin," they wrote.

Since type 2 diabetes is a progressive disease, it typically requires intensification of treatment in order to maintain good glycemic control. However, some have suggested that clinicians often fail to intensify treatment in a timely manner.

To assess time to treatment intensification, Khunti and colleagues conducted a retrospective cohort study using data from 81,573 patients with type 2 diabetes in the U.K. Clinical Practice Research Datalink between January 2004 and December 2006. Patients were followed until April 2011.

The baseline HbA1c for patients taking one, two, or three oral anti-diabetic drugs was 8.4%, 8.8%, and 9%, respectively. The researchers found that among patients with an HbA1c of 7% or higher who were taking one oral diabetes drug at baseline, the median time to intensification with one additional oral drug was 2.9 years, and the time to intensification with insulin was more than 7.2 years.

The median time to insulin intensification for those with an HbA1c of 7% or higher who were taking two or three oral diabetes drugs at baseline was more than 7.2 and 7.1 years, respectively.

For patients with an HbA1c of more than 7.5% or more than 8% who were taking one oral diabetes drug at baseline, the median time to intensification was 1.9 or 1.6 years, respectively. The median time to intensification with insulin was more than 7.1 years or 6.9 years, respectively, for these patients.

In these HbA1c ranges for patients taking three oral diabetes drugs at baseline, the median time to insulin intensification was more than 6.1 years and 6 years, respectively.

The researchers also found that in the overall population taking one oral anti-diabetes drug, the probability of intensification with one additional oral medication or insulin was 23.9% after 1 year, increasing to 48.7% by the end of follow-up. For those taking two oral drugs, the probability of an additional oral drug or insulin was 11.4% after 1 year, rising to 30.1% after 2 years.

And for those taking three oral drugs at baseline, the probability of an additional oral drug or initiation of insulin was 5.7% after 1 year, rising to 12% by the end of follow-up.

Overall, the mean HbA1c at time of intensification for those already on one drug was 8.7% for those who received one additional oral anti-diabetic and 9.4% for those intensified with insulin. Mean HbA1c at intensification for those taking two oral drugs was 8.8% among those intensified with an additional oral drug and 9.8% among those intensified to insulin, the researchers reported.

For those starting out on three oral drugs, the mean HbA1c at intensification with insulin was 9.7%, they added.

Khunti and colleagues cautioned that a "protracted period of poor control can have adverse effects; the follow-up data from the UK Prospective Diabetes Study (UKPDS) have demonstrated the beneficial legacy effect of good glycemic control early in the course of type 2 diabetes, potentially conferring protection against, or delaying, long-term diabetes complications."

They called for a greater effort to "motivate both people with diabetes and physicians to improve diabetes management, and that motivation needs to be translated into action by striving for the recommended treatment goals in a timely manner."

Practice Pearls:

• Medical professionals often wait for long periods of time before appropriately intensifying treatment in patients with type 2 diabetes.
• Be aware that the time to intensification with insulin was markedly longer than the time to intensification with other drugs.

Source reference: Khunti K, et al "Clinical inertia in people with type 2 diabetes" Diabetes Care 2013; DOI: 10.2337/dc13-0331.