Posted Jan 21 , 2019 02:43 AM

Time to Treatment Intensification After Monotherapy Failure and Its Association with Subsequent Glycemic Control Among 93,515 Patients With Type 2 Diabetes

Desai U, et al. Diabetes Care 2018;41:2096

What were the findings (excerpted from the Abstract)?

The goal of this study was to evaluate the association between the timing of treatment intensification and subsequent glycemic control among patients with type 2 diabetes in whom monotherapy fails. This study is a retrospective analysis of the U.K. Clinical Practice Research Datalink database focused on patients with type 2 diabetes and one or more HbA1c measurements ≥7% (≥53 mmol/mol) after ≥3 months of metformin or sulfonylurea monotherapy (first measurement meeting these criteria was taken as the study index date). Baseline (6 months before the index date) characteristics were stratified by time from the index date to intensification (early: <12 months; intermediate: 12 to <24 months; late: 24 to <36 months). Intensification was defined as initiating after the index date one or more noninsulin antidiabetes medications in addition to metformin or a sulfonylurea. Association between time to intensification and subsequent glycemic control (first HbA1c <7% [<53 mmol/mol] after intensification) was evaluated using Kaplan-Meier analyses and Cox proportional hazard models that accounted for baseline differences. Of the 93,515 patients who met the study criteria (mean age 60 years; ∼59% male; 80% taking metformin), 23,761 (25%) intensified <12 months after the index date; 11,908 (13%) intensified after 12 to <24 months; and 7,146 (8%) intensified after 24 to <36 months. Patients who intensified treatment ≤36 months after the index date (n = 9,638 [10%]) and those with no evidence of treatment intensification during the observable follow-up period (n = 41,062 [44%]) were not included in further analyses. The median times from intensification to control were 20.0, 24.1, and 25.7 months, respectively, for the early, intermediate, and late intensification cohorts. After adjustment for baseline differences, the likelihood of attaining glycemic control was 22% and 28% lower for patients in the intermediate and late intensification groups, respectively, compared with those intensifying early.

Why is this important?

Earlier treatment intensification is associated with shorter time to subsequent glycemic control, independent of whether patients initiate first-line treatment with metformin or a sulfonylurea. That said, one of the most problematic issues noted in this study was that 44% of individuals had no intensification of therapy despite not meeting glucose management standards for at least the 3 years of this observation. Clearly, despite nationally recognized standards for glucose management and reimbursement based on achieving those standards [such as HEDIS standards] the fact remains that we need to redouble our efforts to regularly review and update therapy for all of our patients with diabetes. What percentage of your patients have A1C values above 7%...8%...(?) What mechanism do you have to call out those patients and review and update their medications?

Read the Abstract: