Delays in treatment intensification with oral antidiabetic drugs and risk of microvascular and macrovascular events in patients with poor glycaemic control: An individual patient simulation study

Time to Treatment Intensification to Reduce Diabetes-Related Complications: A Post Hoc Study

Patients with type 2 diabetes mellitus (T2DM) can be affected by clinical inertia, leading to abysmal results. Studies on a suitable timeframe for treatment intensification remain scarce—especially outside of developed countries. This study aimed to explore the association between time to treatment intensification and diabetes-related complications. A database from a tertiary care hospital in Thailand was retrieved in order to conduct a retrospective cohort study for the years 2011–2017. This study comprised outpatients with T2DM presenting an HbA1c of ≥7.0%. Eligible patients were divided into three groups based on the time of treatment intensification: no delayed treatment intensification, treatment intensification within 6 months, and treatment intensification after 6 months. A Cox proportional hazards model was used to investigate the association between time to treatment intensification and diabetes-related complications. A total of 686 patients were included in the final analysis. During 6.5 years of median follow-up, the group with treatment intensification within 6 months was more strongly associated with diabetic nephropathy compared to the group with no delayed treatment intensification (adjusted HR 2.35; 95%CI 1.35–4.09). Our findings reveal that delaying treatment intensification by even 6 months can increase the likelihood of diabetic nephropathy compared to no delayed treatment intensification. We suggest that patients with T2DM whose blood glucose levels are outside the target range promptly receive treatment intensification.

Effect of Clinical Inertia on Diabetes Complications among Individuals with Type 2 Diabetes: A Retrospective Cohort Study

Background and Objectives: Clinical inertia is a key obstacle that leads to suboptimal care in patients with type 2 diabetes mellitus (T2DM). It can occur at any stage of T2DM treatment. However, the effect of clinical inertia on diabetes complications has not been studied sufficiently. This study aimed to evaluate the effect of clinical inertia on the risk of diabetes complications among patients with T2DM. Materials and Methods: A retrospective cohort study was conducted at a tertiary teaching hospital in Thailand between 2011 and 2017. Outpatients with T2DM, aged 40–65 years, presenting an HbA1c greater than 7% were included in this study. Clinical inertia was identified when patients did not get treatment intensification at the index date and a subsequent prescription. The association between clinical inertia and diabetes complications, including a composite of macrovascular complications and a composite of microvascular complications, was determined using a Cox proportional hazard model. Propensity score methods were applied, to control confounding by indication. Results: Of 686 patients with T2DM, 165 (24.0%) experienced clinical inertia. Baseline low-density lipoprotein cholesterol, blood pressure, body mass index, the estimated glomerular filtration rate, and medication between the two groups did not differ significantly. Our study found that clinical inertia was associated with a significantly increased risk of diabetic nephropathy (adjusted HR 1.51, 95% CI 1.01–2.27). The results remained the same as when using propensity score methods. According to the post hoc analysis, lowering the HbA1c levels by 1% results in a significant decrease in the rate of diabetic complications (adjusted HR 0.92, 95% CI 0.86–0.99), the composite of microvascular complications (adjusted HR 0.91, 95% CI 0.84–0.98) and diabetic nephropathy (adjusted HR 0.89, 95% CI 0.80–0.98). Conclusions: Our results demonstrated a significant effect of clinical inertia on diabetic nephropathy. Patients with an HbA1c level over the target range should have their medication intensified to reduce the risk of diabetic nephropathy.

Quality of Diabetes Care in the USA

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the current quality of diabetes care in the USA, discuss barriers to guideline-recommended treatment adherence, and outline strategies for the improvement in care.

RECENT FINDINGS

Current treatment guidelines highlight the importance of glycemic control, use of novel medications with proven cardiovascular efficacy, and multifactorial cardiovascular risk factor intervention for the treatment of diabetes and associated complications. Albeit proven evidence for these guidelines, the vast majority of patients with diabetes remain insufficiently treated. Interventions to improve outcomes require focus on care delivery systems, physician behavior, and patient-centered approaches. De-fragmenting care systems to form collaborative, multi-specialty teams, use of standardized and comprehensive treatment algorithms, development of quality assessment tools, avoiding physician therapeutic inertia, and addressing patient barriers, including lack of perceived benefit, insufficient diabetes education and access to care, and medication costs, represent key objectives to improve diabetes care and outcomes. Clinical research in standardized trials has proven the feasibility to reduce morbidity and mortality associated with diabetes. Implementing models of care to disseminate these encouraging research findings to the wider population and to overcome barriers to achieving guideline-recommended treatment goals should be the objective to improve our current quality of diabetes care in the USA.

A cross-sectional study of the quality of life of patients living with type 1 diabetes treated with insulin glargine and neutral protamine Hagedorn insulin and the implications

Objectives

The study aim was to identify key factors associated with the health-related quality of life (HRQOL) of patients with type 1 diabetes mellitus (T1DM) treated with neutral protamine Hagedorn (NPH) insulin or human insulin analog glargine (IGLA).

Methods

We conducted two cross-sectional studies in Minas Gerais State, Brazil. One with 401 patients treated with IGLA, and the other with 179 T1DM patients treated with NPH. HRQOL was measured by Euroqol (EQ-5D-3L).

Key findings

Most participants were male (51%), aged between 18 and 40 years (47%), non-black (58%) and from the highest economic strata (A1-B2) (74%). Participants perceived their health as good/very good (51%), had one to three medical consultations in the previous year (51%), were not hospitalized in the previous year (74%), did not report angina (96%), diabetic neuropathy (90%), hearing loss (94%) or kidney disease (89%). Non-severe hypoglycaemia episodes in the last 30 days were reported by 17% of participants.

Conclusions

Higher HRQOL was associated with younger age (18–40 years), good/very good health self-perception, having had up to three medical consultations in the last year, not being hospitalized in the last year, having none to three comorbidities, not reporting angina, diabetic neuropathy, hearing loss or kidney disease and having had episodes of non-severe hypoglycaemia. In addition, the findings of our study demonstrated inequalities in access to treatment, which will be the subject of future research projects.

Inspiratory Muscle Training on Glucose Control in Diabetes: A Randomized Clinical Trial

This study evaluated the effects of inspiratory muscle training (IMT) in glucose control and respiratory muscle function in patients with diabetes. It was a randomized clinical trial conducted at the Physiopathology Laboratory of the Hospital de Clínicas de Porto Alegre. Patients with Type 2 diabetes were randomly assigned to IMT or placebo-IMT (P-IMT), performed at 30% and 2% of maximal inspiratory pressure, respectively, every day for 12 weeks. The main outcome measures were HbA1c, glycemia, and respiratory muscle function. Thirty patients were included: 73.3% women, 59.6 ± 10.7 years old, HbA1c 8.7 ± 0.9% (71.6 ± 9.8 mmol/mol), and glycemia 181.8 ± 57.8 mg/dl (10.5 ± 3.2 mmol/L). At the end of the training, HbA1c was 8.2 ±0.3% (66.1 ± 3.3 mmol/mol) and 8.7 ± 0.3% (71.6 ± 3.3 mmol/mol) for the IMT and P-IMT groups, respectively (p = .8). Fasting glycemia decreased in both groups with no difference after training although it was lower in IMT at 8 weeks: 170.0 ± 11.4 mg/dl(9.4 ± 0.6 mmol/L) and 184.4 ± 15.0 mg/dl (10.2 ± 0.8 mmol/L) for IMT and P-IMT, respectively (p < .05). Respiratory endurance time improved in the IMT group (baseline = 325.9 ± 51.1 s and 305.0 ± 37.8 s; after 12 weeks = 441.1 ± 61.7 s and 250.7 ± 39.0 s for the IMT and P-IMT groups, respectively; p < .05). Considering that glucose control did not improve, IMT should not be used as an alternative to other types of exercise in diabetes. Higher exercise intensities or longer training periods might produce better results. The clinical trials identifier is NCT03191435.

Clinical Inertia in Poorly Controlled Type 2 Diabetes Mellitus Patients with Obesity: An Observational Retrospective Study

INTRODUCTION

To evaluate clinical inertia in patients with type 2 diabetes mellitus (T2DM), obesity and poor glycaemic control in routine clinical practice.

METHODS

This was a retrospective, observational study based on the analysis of medical records from the BIG-PAC® database. Subjects who required medical care in 2013 with the following characteristics were enrolled in the study: age ≥ 30 years, diagnosis of T2DM, glycosylated haemoglobin (HbA1c) ≥ 8%, obesity (body mass index [BMI] ≥ 30 kg/m²) and treatment with ≥ 2 oral antidiabetic drugs (OADs). Inertia was evaluated by time (days) to the first intensification during the period while HbA1c levels were ≥ 8% and percentage of patients whose treatment was not intensified at 6 months, 1, 2 and 3 years and the end of follow-up. The minimum length of follow-up was 4 years. Descriptive analyses and Kaplan-Meier survival curves were performed.

RESULTS

A total of 13,824 patients with T2DM receiving ≥ 2 OADs were identified; of these 2709 (19.6%) had HbA1c ≥ 8% and BMI ≥ 30 kg/m², thus fulfilling the inclusion criteria. Of these 2709 patients, the mean age was 65.5 (standard deviation [SD] 12.0) years; 54.9% were male, mean HbA1c level was 9.2% (SD 1.3%); mean BMI was 32.1 (SD 0.9) kg/m²; and mean time from diagnosis was 8.2 (SD 3.0) years. HbA1c remained ≥ 8% for a median of 440 (95% confidence interval [CI] 421-459) days. The median time to first intensification was 456 (95% CI 429-483) days. No intensification had occurred in 77.8, 59.5, 41.5, 28.1 and 22.4% of patients at 6 months, 1, 2, 3 years and the end of follow-up, respectively.

CONCLUSIONS

The patients with T2DM analysed in this study had a mean HbA1c of 9.2% at baseline, and this remained at ≥ 8% for > 1 year. The time to the first treatment intensification was longer than that recommended by guidelines. Treatment was not intensified in a large percentage of patients, with almost 60% of patients not receiving intensification at 1 year of follow-up.

Evaluation of the Clinical and Economic Burden of Poor Glycemic Control Associated with Therapeutic Inertia in Patients with Type 2 Diabetes in the United States

Introduction

Therapeutic inertia refers to the failure to initiate or intensify treatment in a timely manner and is widespread in type 2 diabetes (T2D) despite the well-established importance of maintaining good glycemic control. The aim of this analysis was to quantify the clinical and economic burden associated with poor glycemic control due to therapeutic inertia in patients with T2D in the USA.

Methods

The IQVIA CORE Diabetes Model was used to simulate life expectancy, costs associated with diabetes-related complications, and lost workplace productivity in US patients. Baseline glycated hemoglobin (HbA1c) levels were 7.0% (53 mmol/mol), 9.0% (75 mmol/mol), 11.0% (97 mmol/mol) 13.0% (119 mmol/mol), or 15.0% (140 mmol/mol), with targets of 6.5% (48 mmol/mol), 7.0% (53 mmol/mol), 8.0% (64 mmol/mol), or 9.0% (75 mmol/mol) depending on baseline HbA1c, across several delayed intensification scenarios (values above target were defined as poor control). The burden associated with intensification delays of 1, 2, 3, 5, and 7 years was estimated over time horizons of 1–30 years. Future costs and clinical benefits were discounted at 3% annually.

Results

In a population of 13.4 million patients with T2D and baseline HbA1c of 9.0% (75 mmol/mol), delaying intensification of therapy by 1 year was associated with a loss of approximately 13,390 life-years and increased total costs of US dollars (USD) 7.3 billion (1-year time horizon). Longer delays in intensification were associated with a greater economic burden. Delaying intensification by 7 years was projected to cost approximately 3 million life-years and USD 223 billion over a 30-year time horizon.

Conclusion

Therapeutic inertia is common in routine clinical practice and makes a substantial contribution to the burden associated with type 2 diabetes in the USA. Initiatives and interventions aimed at preventing therapeutic inertia are needed to improve clinical outcomes and avoid excess costs.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-019-01199-8) contains supplementary material, which is available to authorized users.

Factors associated with clinical inertia in type 2 diabetes mellitus patients treated with metformin monotherapy

Aims: To assess demographic and clinical characteristics associated with clinical inertia in a real-world cohort of type 2 diabetes mellitus patients not at hemoglobin A1c goal (<7%) on metformin monotherapy.Methods: Adult (≥18 years) type 2 diabetes mellitus patients who received care at Massachusetts General Hospital/Brigham and Women's Hospital and received a new metformin prescription between 1992 and 2010 were included in the analysis. Clinical inertia was defined as two consecutive hemoglobin A1c measures ≥7% ≥3 months apart while remaining on metformin monotherapy (i.e. without add-on therapy). The association between clinical inertia and demographic and clinical characteristics was examined via logistic regression.Results: Of 2848 eligible patients, 43% did not achieve a hemoglobin A1c goal of <7% 3 months after metformin monotherapy initiation. A sub-group of 1533 patients was included in the clinical inertia analysis, of which 36% experienced clinical inertia. Asian race was associated with an increased likelihood of clinical inertia (OR = 2.43; 95% CI = 1.48-3.96), while congestive heart failure had a decreased likelihood (OR = 0.58; 95% CI = 0.32-0.98). Chronic kidney disease and cardiovascular/cerebrovascular disease had weaker associations but were directionally similar to congestive heart failure.Conclusions: Asian patients were at an increased risk of clinical inertia, whereas patients with comorbidities appeared to have their treatment more appropriately intensified. A better understanding of these factors may inform efforts to decrease the likelihood for clinical inertia.

Treatment patterns of drug-naive patients with type 2 diabetes mellitus: a retrospective cohort study using a Japanese hospital database

BACKGROUND

Guidelines for Type 2 diabetes mellitus (T2DM) management in Japan provide physicians the discretion to select treatment options based on patient pathophysiology of the disease. There exists a wide variation of preference for initial antidiabetes drugs (AD). The current database analysis aimed to understand the real world treatment patterns in drug-naive patients with T2DM in Japan.

METHODS

We analyzed data of patients (≥ 18 years) diagnosed with T2DM between October 2012 and September 2016 from the Medical Data Vision, a Diagnosis Procedure Combination database. The primary objective was to determine the proportion of T2DM patients receiving each type of treatment as first-line therapy among the drug-naive cohort.

RESULTS

Of the 436,546 drug-naive patients, 224,761 received their first-line T2DM treatment in the outpatient setting. The mean age of the patient population was 65.6 years at index date. Dipeptidyl peptidase-4 (DPP-4) inhibitor was the most prescribed (56.8%) outpatient AD monotherapy, followed by metformin (15.4%). DPP-4 inhibitors were prescribed over metformin in patients with renal disease (odds ratio [OR]: 4.20; p < 0.0001), coronary heart disease and stroke (OR: 2.22; p < 0.0001). Male (OR: 1.03; p = 0.0026), presence of diabetic complications [retinopathy (OR: 1.33; p < 0.0001), neuropathy (OR: 1.05; p = 0.0037), nephropathy (OR: 1.08; p < 0.0001)] and a high baseline HbA1c (OR: 1.45; p < 0.0001) received treatment intensification during 180 days.

CONCLUSION

DPP-4 inhibitors were the most prevalent first-line T2DM treatment followed by metformin in Japan. The findings from this retrospective analysis also support the previously published web survey results and can help understand the real world utilization of T2DM treatment.Trial registration Retrospectively registered.

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

OBJECTIVE

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.

RESEARCH DESIGN AND METHODS

This retrospective analysis of the U.K. Clinical Practice Research Datalink database focused on patients with type 2 diabetes and one or more HbA_1c 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 medication in addition to metformin or a sulfonylurea. Association between time to intensification and subsequent glycemic control (first HbA_1c <7% [<53 mmol/mol] after intensification) was evaluated using Kaplan-Meier analyses and Cox proportional hazard models that accounted for baseline differences.

RESULTS

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 (P < 0.0001).

CONCLUSIONS

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.

Assessment of the relationship between diabetes treatment intensification and quality measure performance using electronic medical records

AIMS

Assess the relationship between timely treatment intensification and hemoglobin A1C (HbA1C) control quality-of-care performance measures, i.e., HbA1C levels, among patients with uncontrolled type 2 diabetes.

MATERIALS AND METHODS

Electronic medical records and diabetes registry data from a large, accountable care organization (ACO) were used to isolate a sample of adult patients with type 2 diabetes who received at least one oral antidiabetes agent and had at least one HbA1C level measurement ≥8.0% (64 mmol/mol; i.e., uncontrolled diabetes) between 7/1/2011 and 6/30/2015. Treatment intensification status was evaluated for each patient during a 120-day treatment intensification window following the index HbA1c measure. Two-level hierarchical generalized linear models, with patients aggregated at the physician level, were used to assess the association between treatment intensification and achieving HbA1C quality performance measures.

RESULTS

547 patients met study selection criteria and 480 patients had at least one HbA1C test after the treatment intensification window and were used for the statistical analyses. About 40% of patients who had uncontrolled diabetes received treatment intensification during the 120-day window. Greater index HbA1C, greater patient body mass index, and fewer unique pre-index oral antidiabetes agents were significantly associated with greater likelihood of receiving timely treatment intensification. The odds of receiving treatment intensification were about 1.8 times higher (P = 0.0027) among patients with poor index HbA1C control (HbA1c level >9.0% [75 mmol/mol]) compared to other patients (index HbA1c 8.0% - 9.0%). Hispanic patients (compared to White patients) were significantly more likely to exhibit poor control after treatment intensification (odds ratio [OR] 2.91, P = 0.0304), underscoring the difficulty of controlling diabetes in this vulnerable group. In contrast, being male and being treated primarily by an internist (compared to primary treatment by a family medicine specialist) were both significantly associated with achieving superior control (HbA1c level <8.0%) after treatment intensification (OR 0.53 [P = 0.0165]; OR 0.41 [P = 0.0275], respectively).

CONCLUSIONS

Timely treatment intensification was significantly associated with greater likelihood of patients achieving superior HbA1C control (<8.0%) and better HbA1C control quality performance for the practice. Even in an ACO with resources dedicated to diabetes control, it is incumbent upon clinicians to readily identify and open dialogues with patients who may benefit from closely supervised, individualized attention.

Diabetes and dyslipidemia: characterizing lipoprotein metabolism

Premature atherosclerosis in diabetes accounts for much of the decreased life span. New treatments have reduced this risk considerably. This review explores the relationship among the disturbances in glucose, lipid, and bile salt metabolic pathways that occur in diabetes. In particular, excess nutrient intake and starvation have major metabolic effects, which have allowed us new insights into the disturbance that occurs in diabetes. Metabolic regulators such as the forkhead transcription factors, the farnesyl X transcription factors, and the fibroblast growth factors have become important players in our understanding of the dysregulation of metabolism in diabetes and overnutrition. The disturbed regulation of lipoprotein metabolism in both the intestine and the liver has been more clearly defined over the past few years, and the atherogenicity of the triglyceride-rich lipoproteins, and - in tandem - low levels of high-density lipoproteins, is seen now as very important. New information on the apolipoproteins that control lipoprotein lipase activity has been obtained. This is an exciting time in the battle to defeat diabetic atherosclerosis.