Clinical Inertia in the Management of Type 2 Diabetes Mellitus: A Systematic Review

Evidence-based SGLT2 inhibitor and GLP-1 receptor agonist use by race in the VA healthcare system

Importance

Adoption of novel therapeutics often lags for Black versus non-Hispanic White patients. Seminal clinical trials established the cardiovascular efficacy of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) in patients with type 2 diabetes (T2D) and established atherosclerotic cardiovascular disease. However, it is uncertain whether race influences the evidence-based prescription of these agents.

Objective

To determine whether evidence-based prescription of SGLT2i or GLP-1RA differs by Black versus White race in the Veterans Affairs (VA) healthcare system.

Design Setting and Participants

Retrospective cohort study of US Veterans with T2D and angiographically confirmed coronary artery disease (CAD) at 84 VA medical centers over the period 2015-2023. Data from the VA Clinical Assessment, Reporting, and Tracking Program were used to construct cohorts eligible for SGLT2i or GLP-1RA treatment based on eligibility criteria for the seminal Empagliflozin, Cardiovascular Outcomes, and Mortality in T2D (EMPA-REG OUTCOME) or the Liraglutide Effect and Action in Diabetes (LEADER) trial, respectively. Multivariable logistic regression estimated adjusted odds of trial-concordant SGLT2i or GLP-1RA prescription by race.

Exposures

Self-identified race.

Main Outcomes and Measures

SGLT2i or GLP-1RA prescription among those with an evidence-based (trial-concordant) indication.

Results

Of 63,561 Veterans with T2D and CAD, 3527 Black and 18,668 White patients met criteria for trial-concordant SGLT2i treatment and 2020 Black and 10,103 White patients for GLP1-RA treatment. Trial-concordant prescription of both classes increased over time for both races but reached only 42 % for SGLT2i and 15 % for GLP1-RA in 2023. Black versus White race was not associated with evidence-based SGLT2i prescription (adjusted odds ratio [OR] 0.96, 95 % CI 0.89-1.04, P = 0.32). However, Black Veterans were less likely than White to be provided with a trial-concordant GLP1-RA prescription (adjusted OR 0.85, 95 % CI 0.74-0.98, P = 0.025).

Conclusions and Relevance

Among patients with T2D and CAD in the VA healthcare system, evidence-based SGLT2i and GLP1-RA prescription increased over time, but many eligible patients remained untreated. Although SGLT2i prescription did not differ by race, Black versus White Veterans were less likely to receive evidence-based GLP1-RA prescription. Racial disparities in evidence-based cardiovascular drug prescription exist even in a healthcare system with few economic barriers and may be drug class-specific.

Personalized therapeutic approaches for improved glycemic outcomes in type 2 diabetes

Managing type 2 diabetes mellitus remains a significant challenge, particularly for individuals with persistently poor glycemic control. Although inadequate glycemic regulation is a well-established public health concern and a major contributor to diabetes-related complications, evidence on the effectiveness of intensive and supportive interventions across diverse patient subgroups is scarce. This editorial examines findings from a prospective study evaluating the influence of glycemic history on treatment outcomes in poorly controlled diabetes. The study highlights that personalized care models outperform generalized approaches by addressing the unique trajectories of glycemic deterioration. Newly diagnosed patients demonstrated the most favorable response to intervention, while those with consistently elevated glycated hemoglobin (≥ 10%) faced the greatest challenges in achieving glycemic control. These findings underscore the limitations of a one-size-fits-all strategy, reinforcing the need for patient-centered care that integrates individualized monitoring and timely intervention. Diabetes management requires prioritizing personalized treatment strategies that mitigate therapeutic inertia and ensure equitable, effective care for all patients.

Therapeutic Inertia Quantification in Diabetes Care: A Narrative Review and Synthesis

PURPOSE

Therapeutic inertia, which refers to the failure to adjust therapy despite suboptimal glycemic control, is a growing concern. This phenomenon is associated with significant adverse health consequences and reflects the gap between population health goals and patient outcomes. Current research lacks harmonized and effective ways to measure therapeutic inertia, posing significant challenges to addressing this issue in diabetes care. This review aimed to summarize the approaches used to quantify therapeutic inertia in diabetes care, with the goal of improving clinical management and patient outcomes.

METHODS

A narrative review was conducted to identify relevant articles through a search of MEDLINE (PubMed), Embase, and Web of Science databases from their inception until August 2024, employing search terms related to therapeutic inertia, quantification, and diabetes care. We included all articles that focused on quantifying therapeutic inertia in diabetes care. Quantification methods were summarized with respect to key aspects of formula, scoring, validation, advantages, and limitations.

FINDINGS

Four approaches for quantifying therapeutic inertia were identified from the retrieved articles. However, these methods have several limitations that have led to the development of a therapeutic inertia index. The primary goal of the index as a quality measure is to describe healthcare providers' practices and establish a connection between the implemented process measures and key glycemic outcomes. Three commonly used therapeutic inertia indices have been reported in the literature: the norm-based method, standard-based method (SBM), and American Diabetes Association method.

IMPLICATIONS

There is a need to standardize therapeutic inertia measurement approaches and develop comprehensive interventions to enhance the management of diabetes.

Analysis of Factors Influencing Clinical Inertia in the Treatment of Type 2 Diabetes Mellitus Patients With Metformin

Aims/Background Medication therapy is a crucial measure for type 2 diabetes mellitus (T2DM). However, approximately 50% of diabetes patients in China fail to achieve their blood glucose control targets despite receiving hypoglycemic treatment. Studies have indicated that clinical inertia is often a key factor contributing to poor long-term blood glucose control in most patients. This study aims to investigate the factors influencing clinical inertia in the treatment process of patients using metformin. Methods A retrospective study method was adopted, and 86 T2DM patients treated with metformin who have clinical inertia between June 2021 and June 2023 at Zhejiang Hospital were treated as the inertia group. Additionally, 87 patients who received the same medication treatment and follow-up evaluation without clinical inertia during the same period were selected as the control group. By comparing general data, family and economic situations, lifestyle, and diabetes conditions between the two groups, a logistic multivariate analysis model was used to analyze the factors influencing clinical inertia in the treatment process of T2DM patients using metformin. Results The proportion of male patients and those with an elementary education or below was significantly higher in the inertia group compared to the control group (p < 0.05). Additionally, the proportion of patients without commercial insurance was significantly higher in the inertia group (p < 0.05). The proportion of patients practicing dietary control was lower in the inertia group compared to the control group (p < 0.05). Furthermore, the inertia group had a lower proportion of patients with initial glycated hemoglobin levels ≥8.0%, those conducting home blood glucose monitoring, patients with diabetes-related complications, and those receiving diabetes health education compared to the control group (p < 0.05). Male gender (odds ratio (OR) = 3.487, p = 0.001), elementary education or below (OR = 2.362, p = 0.027), lack of commercial insurance (OR = 3.783, p = 0.005), absence of home blood glucose monitoring (OR = 3.127, p = 0.007), absence of diabetes-related complications (OR = 2.995, p = 0.006), and lack of chronic disease health education (OR = 2.753, p = 0.017) were identified as risk factors for clinical inertia in the treatment of T2DM patients using metformin (p < 0.05). Conclusion The risk of clinical inertia during metformin treatment in T2DM patients is relatively high and is associated with various factors. Targeted intervention measures should be implemented for high-risk populations to reduce the risk of clinical inertia.

The Effectiveness of an Electronic Decision Support Algorithm to Optimize Recommendations of SGLT2i and GLP-1RA in Patients with Type 2 Diabetes upon Discharge from Internal Medicine Wards

Background/Objectives: Despite the established cardiovascular benefit of sodium-glucose cotransporter-2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs), these medications are under-prescribed in patients with type 2 diabetes. Our study aims to examine the effectiveness of a clinical decision support system (CDSS) in improving the recommendation rate of SGLT2i and GLP-1RA upon discharge. Methods: We developed an algorithm to automatically recommend SGLT2is and GLP-1RAs for eligible patients with type 2 diabetes upon discharge, based on current guidelines. Data were collected from electronic medical records of all eligible patients ≥18 years old hospitalized in one of five internal medicine wards at Beilinson Hospital. The primary outcome was to evaluate the rate of physician recommendation of SGLT2is and GLP-1RAs at discharge, before and after algorithm implementation. Results: Our study included 1318 patients in the pre-algorithm group and 970 in the post-algorithm group. The recommendation rate of SGLT2is and GLP-1RAs was 8.5% in the pre-algorithm group and 22.7% in the post-algorithm. The odds ratio (OR) of recommendation in the post- vs. pre-algorithm group was 3.151 (95% CI: 2.467-4.025, p < 0.0001). Recommendation rates increased in all subgroups analyzed, notably in patients hospitalized due to heart failure (recommendation rate pre-algorithm: 14.6% vs. post-algorithm: 49.02%). Conclusions: This study demonstrates the benefit of a CDSS in improving the recommendation rate of SGLT2is and GLP-1RAs in patients with type 2 diabetes upon discharge from hospitalization. Future studies should assess the impact of the algorithm on recommendation rates in other wards, medication utilization, and long-term outcomes.

Clinical inertia and treatment intensification among patients with type ii diabetes mellitus at Debre Tabor comprehensive specialized hospital, Ethiopia: an institutional-based cross-sectional study

Background

People with type 2 diabetes mellitus who have clinical inertia often struggle to control their blood sugar levels and do not receive timely treatment intensification. Strict glycemic control has advantages, but many patients with diabetes are unable to reach their target blood sugar levels. The study's main objective was to determine the prevalence of clinical inertia in patients with type 2 diabetes at Debre Tabor Comprehensive Specialized Hospital(DTCSH) in Ethiopia.

Methods

An institutional based, cross-sectional research design was used at Debre Tabor Comprehensive Specialized Hospital from November 20/2023 to January 30/2024. A structured questionnaire modified from various medical records and literatures were used to gather data. A logistic regression model was also employed after the Hosmer-Lemeshow goodness-of-fit test was checked to find contributing variables to clinical inertia. A threshold of p < 0.05 was considered statistically significant.

Result

In total, 287 samples were included in the research. The occurrences of clinical inertia 31.4% (95%CI: 25.9 - 36.8) were obtained from 90 patients. Aged patients (AOR = 1.103; 95% CI, 1.034 - 1.176; P = 0.003), medication fee (AOR = 4.955; 95% CI, 1.284 - 14.127; P = 0.020), medication nonadherence (AOR = 4.345; 95% CI, 2.457 - 15.537; P = 0.001), increase number of medication (AOR = 4.205; 95% CI, 2.657- 6.655; P ≤ 0.001), poor glycemic control (AOR = 2.253; 95% CI, 1.673 - 3.033; P ≤ 0.001) were more likely to have clinical inertia.

Conclusion

One-third of patients experienced clinical inertia. Age, glycemic control, medication non-adherence, treatment fee, and number of medications were found to be strongly correlated with clinical inertia. More precise knowledge of the clinical inertia and the associated therapies is necessary to tackle this issue more effectively.

Glucagon-like Peptide-1 Receptor Agonist Use in Hospital: A Multicentre Observational Study

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are effective medications for type 2 diabetes mellitus (T2DM) and obesity, yet their uptake among individuals most likely to benefit has been slow.

METHODS

We conducted a cross-sectional analysis of medication exposure in adults hospitalized at 16 hospitals in Ontario, Canada, between 2015 and 2022. We estimated the proportions of those with T2DM, obesity, and cardiovascular disease. We identified the frequency of GLP-1RA use and conducted multivariable logistic regression to identify factors associated with their use.

RESULTS

Across 1,278,863 hospitalizations, 396,084 (31%) patients had T2DM and approximately 327,844 (26%) had obesity. GLP-1RA use (n=1,274) was low among those with a diagnosis of T2DM (0.3%) or obesity (0.7%), despite a high prevalence of cardiovascular disease (36%). In contrast, the use of diabetes medications lacking cardiovascular benefit was high during inpatient hospitalizations related to diabetes: 60% (n=236,612) received insulin and 14% (n=54,885) received a sulfonylurea. Apart from T2DM (odds ratio [OR]=29.6, 95% confidence interval [CI] 23.5 to 37.2), characteristics associated with greater odds of receiving a GLP-1RA were seen in those 50 to 70 years of age (OR=1.71, 95% CI 1.38 to 2.11) compared with those <50 years of age, glycated hemoglobin >9% (OR=1.83, 95% CI 1.36 to 2.47) compared with <6.5%, and highest income quintile (OR=1.73, 95% CI 1.45 to 2.07) compared with lowest income quintile.

CONCLUSION

Knowledge translation interventions are needed to address the low adoption of GLP-1RAs among hospitalized patients with T2DM and obesity, who are the most likely to benefit from this treatment.

The rise of weekly insulins: addressing the challenges of type 2 diabetes care in Brazil

BACKGROUND

Type 2 diabetes mellitus (T2D) is a global health concern with a rising prevalence, particularly in Brazil. Insulin therapy plays a crucial role in managing T2D, helping to maintain glucose and energy homeostasis. Moreover, early initiation of insulin is crucial for hyperglycemic control and prevention of chronic complications. Clinical guidelines recommend initiating insulin when other treatments fail. However, several barriers may delay its initiation, contributing to therapeutic inertia and patients' non-adherence. These barriers include fear of hypoglycemia, lack of adherence, the need for glucose monitoring, the injection method of insulin administration, social rejection associated with the stigma of injections, fear of weight gain, a sense of therapeutic failure at initiation, and lack of experience among some healthcare professionals. : In this context, the development of once-weekly insulin formulations could improve initial acceptance, adherence, treatment satisfaction, and consequently, the quality of life for patients. Currently, two once-weekly insulin treatments, insulin icodec and efsitora alfa, have shown promise in clinical trials, demonstrating efficacy and safety profiles similar or better than those of daily insulin therapies.

SHORT CONCLUSION

These once-weekly insulins have the potential to emerge as landmark achievements in the evolution of insulin therapy. This narrative review aims to evaluate the role of weekly insulins in managing T2D, providing insights into the potential benefits, challenges, and opportunities associated with a new weekly insulin therapy, specially within the Brazilian context.

Clinical inertia in onychomycosis treatment: results from the Illuminating Dialogues and Insights in Onychomycosis Management (IDIOM) survey

Onychomycosis is a fungal infection of the nail that can serve as a reservoir for tinea infections in other parts of the body and can be transmitted to other individuals. As the disease progresses, it can lead to functional impairment, such as difficulties in walking, and negatively impact the psychosocial aspects of quality of life. Onychomycosis treatment, especially topical, is long-term, and adequate follow-up is essential for cure. However, the realities and issues of patient-physician communication after treatment initiation, including patients' perception of efficacy, treatment satisfaction, and reconsideration of the treatment approach, remain unclear. Therefore, this study aimed to examine the realities and issues associated with onychomycosis treatment, focusing on topical therapies, through a web-based survey of patients with onychomycosis and dermatologists. The duration of topical treatment was prolonged, with 30.5% of patients undergoing topical therapy for more than 2 years. Of these, 54.5% had not perceived clear efficacy. In addition, 93.7% of all patients with onychomycosis expressed a desire to change their treatment if it was ineffective. However, only 29.9% of patients receiving topical treatment discussed changing their treatment with their physicians, and only 7.3% ultimately changed their treatment. These findings indicate that the review of treatment strategies was insufficient. Furthermore, the satisfaction rate among patients treated with oral medications was higher than that of patients treated with topical medication. Despite dermatologists' awareness of low patient satisfaction with topical treatments, approximately 40% recommended alternative topical therapies when the initial topical treatment was ineffective. These results suggest clinical inertia in the treatment of onychomycosis stemming from a lack of appropriate intensification of treatment. In managing onychomycosis, the patient and dermatologist must share a common understanding of the importance of regular evaluation and the optimization of treatment regimens during treatment and must work side by side toward a cure.

Potassium inwardly-rectifying channel subfamily J member 11 (KCNJ11) gene polymorphism in Egyptian type 2 diabetic patients: a single-center study

BACKGROUND

The KCNJ11 gene belongs to the potassium channel gene family. It has a major role in the secretion of insulin. Genetic variations in KCNJ11 are possibly responsible for the progression of type 2 diabetes mellitus (T2DM). In this study, we investigated the possible correlation between KCNJ11 (rs5210) gene polymorphism and T2DM.

SUBJECTS AND METHOD

This study included 92 individuals divided into two groups. Group 1 included 46 type 2 diabetic patients. Group 2 (control group) included 46 healthy participants. A complete history was taken and a full physical examination was performed. Anthropometric data were measured. Laboratory investigations included fasting blood glucose (FBG), two hours post-prandial blood glucose (2HPPBG), glycated hemoglobin (HbA1c), and fasting lipid profile. KCNJ11 (rs5210) single nucleotide polymorphism was detected by polymerase chain reaction restriction-fragment length polymorphism (PCR-RFLP).

RESULTS

Both AG and GG genotypes were associated with increased risk for T2DM (OR 5.2, 95% CI 1.32-20.5, P = 0.01 for AG; and OR 18.2, 95% CI 2.99-31.7, P = 0.002 for GG). Also, the frequency of the G allele was significantly higher in type 2 diabetic patients compared to healthy controls (50% versus 23.9%, respectively). The G allele of rs5210 in KCNJ11 contributed to an increased risk of T2DM (OR 3.18, 95% CI 1.31-7.75, P = 0.01). There was a statistically significant association between increased 2HPPBG and HbA1c levels and the carrier of AG and GG genotypes (P = 0.01 and 0.007, respectively). There was a statistically significant association between total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-c), and high-density lipoprotein-cholesterol (HDL-c) levels and the carrier of AG and GG genotypes (P < 0.001, 0.02, and 0.007, respectively). Regression analysis detected that body mass index (BMI), 2HPPBG, TC, triglycerides (TG), and the G allele of rs5210 in KCNJ11 gene showed a significant association with T2DM (P = 0.004, 0.042, 0.003, 0.006, and 0.01, respectively) while no association was observed with FBG, HbA1c, LDL-c or HDL-c (P = 0.099, 0.123, 0.522, and 0.765, respectively).

CONCLUSION

KCNJ11 rs5210 genetic polymorphism may raise the risk for the occurrence of T2DM among Egyptians.

Efficacy, adherence and persistence of various glucagon-like peptide-1 agonists: nationwide real-life data

AIM

The management of type 2 diabetes mellitus has advanced in the last two decades since the introduction of glucagon-like peptide-1 receptor agonists (GLP-1RAs). However, multiple factors may interfere with achieving better glycaemic control. This study evaluated the differences between various GLP-1RAs in efficacy, adherence and persistence.

MATERIALS AND METHODS

We conducted a retrospective cohort study using the electronic medical database from Clalit Health Services. Adults with type 2 diabetes mellitus who purchased any GLP-1RA between 2009 and 2021 were included. The Index Date was defined as the date of the first purchase of any GLP-1RA. We evaluated the adherence, persistence and glycaemic control after GLP-1RAs initiation. Baseline glycaemic and post-treatment glycaemic controls were analysed.

RESULTS

In total, 70 654 patients were included. The mean age was 11.7 ± 60.4, and 51% were females. A significant reduction in glycated haemoglobin (HbA1c) was observed in all patients who received GLP-1RAs. However, the percentage of changes in the HbA1c was higher among weekly GLP-1RA than daily initiators (14.6% vs. 10.2%, p < 0.001). The proportion of subjects with any decrease in HbA1c was higher among the once-weekly compared with the daily dose (82.4% vs. 74.7%) and mainly patients initiated semaglutide or dulaglutide, with 16.0% and 14.7% reduction. The frequency of good adherence (the proportion of days covered ≥80%) was significantly higher among the weekly group odds ratio = 1.25 (95% confidence interval 1.21-1.28). Good adherence was reported in older age, female gender, Jewish ethnicity and high socio-economic status (p < 0.001).

CONCLUSIONS

Weekly GLP-1RAs initiators were more adherent, persistent to therapy and achieved better glycaemic control. Epidemiological variables might play a role in achieving this goal.

Exploring disparities: A comparative analysis of insulin-naïve, regular users, and inertia patients among type 2 diabetes mellitus outpatients in India

Introduction

Insulin utilization pattern varies greatly in type 2 diabetes mellitus (T2DM) patients. Clinical inertia in treatment intensification hinders glycemic control in T2DM management. This study investigated insulin prescription trends and various predictors among insulin naive, user, and insulin inertia (II) patients in T2DM.

Methodology

A retrospective analysis of T2DM patient records from the diabetes clinic at a tertiary care center was conducted. Data on socio-demographics, anthropometry, disease characteristics, comorbidities, adherence, and medication prescribing patterns were collected. Analysis was done using tests of significance, odds ratio (OR), and multivariate logistic regression.

Results

A total of 950 records were analyzed, with 17.3% of patients identified as insulin users (IU), 70.9% being insulin-naïve (IN), and 11.8% having II. IUs had significantly higher glycemic levels including HbA1c, fasting, postprandial, and random blood sugars compared to the other groups. Higher HbA1c levels were associated with significantly increased odds of insulin usage (OR: 3.46, confidence interval (CI): 1.94-6.16), while individuals taking sulfonylureas had lower odds of insulin usage (OR: 0.27, CI: 0.08-0.91). A significant association was also seen with the total number of oral antidiabetic drugs prescribed (four drugs; OR: 15.6, and five drugs; OR: 9.1). Other factors did not show a significant association. The regression model showed HbA1c level as low as 7.9% could indicate a future insulin requirement in 22% of patients.

Conclusion

The study outlines differences in characteristics and parameters among T2DM patients who require or do not require insulin and highlights the challenges in insulin initiation in Indian T2DM patients. Findings on II underscore the need for timely treatment intensification.

Open questions on basal insulin therapy in T2D: a Delphi consensus

AIMS

The revolution in the therapeutic approach to type 2 diabetes (T2D) requires a rethinking of the positioning of basal insulin (BI) therapy. Given the considerable number of open questions, a group of experts was convened with the aim of providing, through a Delphi consensus method, practical guidance for doctors.

METHODS

A group of 6 experts developed a series of 29 statements on: the role of metabolic control in light of the most recent guidelines; BI intensification strategies: (1) add-on versus switch; (2) inertia in starting and titrating; (3) free versus fixed ratio combination; basal-bolus intensification and de-intensification strategies; second generation analogues of BI (2BI). A panel of 31 diabetologists, by accessing a dedicated website, assigned each statement a relevance score on a 9-point scale. The RAND/UCLA Appropriateness Method was adopted to assess the existence of disagreement among participants.

RESULTS

Panelists showed agreement for all 29 statements, of which 26 were considered relevant, one was considered not relevant and two were of uncertain relevance. Panelists agreed that the availability of new classes of drugs often allows the postponement of BI and the simplification of therapy. It remains essential to promptly initiate and titrate BI when required. BI should always, unless contraindicated, be started in addition to, and not as a replacement, for ongoing treatments with cardiorenal benefits. 2BIs should be preferred for their pharmacological profile, greater ease of self-titration and flexibility of administration.

CONCLUSION

In a continuously evolving scenario, BI therapy still represents an important option in the management of T2D patients.

Temporal trends in the starting of insulin therapy in type 2 diabetes in Italy: data from the AMD Annals initiative

AIMS

Opportunities and needs for starting insulin therapy in Type 2 diabetes (T2D) have changed overtime. We evaluated clinical characteristics of T2D subjects undergoing the first insulin prescription during a 15-year-observation period in the large cohort of the AMD Annals Initiative in Italy.

METHODS

Data on clinical and laboratory variables, complications and concomitant therapies and the effects on glucose control after 12 months were evaluated in T2D patients starting basal insulin as add-on to oral/non-insulin injectable agents, and in those starting fast-acting in add-on to basal insulin therapy in three 5-year periods (2005-2019).

RESULTS

We evaluated data from 171.688 T2D subjects who intensified therapy with basal insulin and 137.225 T2D patients who started fast-acting insulin. Overall, intensification with insulin occurred progressively earlier over time in subjects with shorter disease duration. Moreover, the percentage of subjects with HbA1c levels > 8% at the time of basal insulin initiation progressively decreased. The same trend was observed for fast-acting formulations. Clinical characteristics of subjects starting insulin did not change in the three study-periods, although all major risk factors improved overtime. After 12 months from the starting of basal or fast-acting insulin therapy, mean HbA1c levels decreased in all the three investigated time-periods, although mean HbA1c levels remained above the recommended target.

CONCLUSIONS

In this large cohort of T2D subjects, a progressively earlier start of insulin treatment was observed during a long observation period, suggesting a more proactive prescriptive approach. However, after 12 months from insulin prescription, in many patients, HbA1c levels were still out-of-target.

Insulin Inertia Among People With Type 2 Diabetes Mellitus in Qatar: The INERT-Q Study

BACKGROUND

Achieving and maintaining adequate glycaemic control is critical to reduce diabetes-related complications. Therapeutic inertia is one of the leading causes of suboptimal glycaemic control.

AIM

To assess the degree of inertia in insulin initiation and intensification in people with Type 2 diabetes mellitus (DM-2).

METHODS

We performed a retrospective longitudinal cohort study and followed DM-2 2 years before and 2 years after the start of insulin. The primary outcome was the proportion of patients who achieved glycaemic targets (HBA1c ≤ 7.5%) at 6th month, 1st year and 2nd year.

RESULTS

We included 374 predominantly male subjects (62%). The mean age was 55.3 ± 11.3 years, the mean duration of DM-2 was 12.0 ± 7.3 years, 64.4% were obese, 47.6% had a microvascular disease, and 24.3% had a macrovascular disease. The mean HBA1c at -2nd year and -1st year was 9.2 ± 2.1% and 9.3 ± 2.0%, respectively. The mean HbA1C at the time of insulin initiation was 10.4 ± 2.1%. The mean HBA1c at 6th month, 12th month and 2nd year was 8.5 ± 1.8%, 8.4 ± 1.8% and 8.5 ± 1.7%, respectively. The proportion of subjects who achieved HBA1c targets at 6th month, 12th month and 2nd year was 32.9%, 31.0% and 32.9%, respectively. Multivariate logistic regression analysis showed that achieving HBA1c targets at 6th month and 1st year increases the odds of achieving HBA1c targets at 2nd year (OR 4.87 [2.4-9.6] p < 0.001) and (OR 6.2 [3.2-12.0], p < 0.001), respectively.

CONCLUSION

In people with DM-2, there was an alarming delay in starting and titrating insulin. The reduction in HBA1c plateaued at 6th month. Earlier initiation and intensification of insulin therapy are critical to achieving glycaemic targets. More studies are needed to examine the causes of therapeutic inertia from physicians', patients' and systems' points of view.

SGLT2 Inhibitors - The New Standard of Care for Cardiovascular, Renal and Metabolic Protection in Type 2 Diabetes: A Narrative Review

A substantial evidence base supports the use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in the treatment of type 2 diabetes mellitus (T2DM). This class of medicines has demonstrated important benefits that extend beyond glucose-lowering efficacy to protective mechanisms capable of slowing or preventing the onset of long-term cardiovascular, renal and metabolic (CVRM) complications, making their use highly applicable for organ protection and the maintenance of long-term health outcomes. SGLT2is have shown cost-effectiveness in T2DM management and economic savings over other glucose-lowering therapies due to reduced incidence of cardiovascular and renal events. National and international guidelines advocate SGLT2i use early in the T2DM management pathway, based upon a plethora of supporting data from large-scale cardiovascular outcome trials, renal outcomes trials and real-world studies. While most people with T2DM would benefit from CVRM protection through SGLT2i use, prescribing hesitancy remains, potentially due to confusion concerning their place in the complex therapeutic paradigm, variation in licensed indications or safety perceptions/misunderstandings associated with historical data that have since been superseded by robust clinical evidence and long-term pharmacovigilance reporting. This latest narrative review developed by the Improving Diabetes Steering Committee (IDSC) outlines the place of SGLT2is within current evidence-informed guidelines, examines their potential as the standard of care for the majority of newly diagnosed people with T2DM and sets into context the perceived risks and proven advantages of SGLT2is in terms of sustained health outcomes. The authors discuss the cost-effectiveness case for SGLT2is and provide user-friendly tools to support healthcare professionals in the correct application of these medicines in T2DM management. The previously published IDSC SGLT2i Prescribing Tool for T2DM Management has undergone updates and reformatting and is now available as a Decision Tool in an interactive pdf format as well as an abbreviated printable A4 poster/wall chart.

Burden of Illness of Type 2 Diabetes Mellitus in the Kingdom of Saudi Arabia: A Five-Year Longitudinal Study

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is associated with huge clinical and economic burden in the Kingdom of Saudi Arabia (KSA) which can be curtailed by efficacious treatment. In order to achieve this, current treatment pathways for T2DM and associated costs need to be assessed.

METHODS

A longitudinal cohort review was conducted to collect country-specific and patient-specific clinical data, over a minimum observation period of 5 years in the KSA. Patient demographics, clinical characteristics and treatment patterns were recorded. The IQVIA Core Diabetes Model (CDM) version 9.5 Plus was used to assess the burden of illness, which included long-term projections of clinical (life expectancy [LE], quality-adjusted life-years [QALYs], event rates of diabetes-related complications) and direct medical cost (per-patient annual or lifelong [50 years]) outcomes of the most commonly used first-line (1st-line) regimens for T2DM from a payer perspective in the KSA.

RESULTS

Data were collected from a subpopulation of 638 patients from 15 participating centres. There was an equal gender representation with a majority of the patients belonging to Arabian/Saudi ethnicity (71.0%). Biguanides (81.5%), sulfonylureas (51.6%), dipeptidyl peptidase 4 (DPP4) inhibitors (26.2%) and fast-acting insulins (17.2%) were the most prescribed 1st-line agents. The most frequently used 1st-line regimens resulted in an estimated LE of 25-28 years, QALYs of 18-21 years and lifelong total cost of illness of 201,377-437,371 Saudi Arabian riyal (53,700-116,632 US dollars).

CONCLUSION

Our study addresses gaps in the current research by providing a complete landscape of baseline demographic, clinical characteristics and treatment patterns from a heterogeneous group of patients with T2DM in the KSA. Additionally, the burden of illness analysis using CDM showed substantially higher cost of T2DM care from a payer perspective in the KSA.

Investigation of the causal relationship between inflammatory bowel disease and type 2 diabetes mellitus: a Mendelian randomization study

Background: Type 2 diabetes mellitus (T2DM) and inflammatory bowel disease (IBD) have been associated, according to various epidemiological research. This study uses Mendelian randomization (MR) to investigate the causal link between T2DM and IBD. Methods: To investigate the causal relationship between IBD and T2DM risk using European population data from the genome-wide association study (GWAS) summary datasets, we constructed a two-sample MR study to evaluate the genetically predicted impacts of liability towards IBD outcomes on T2DM risk. As instrumental variables (IVs), we chose 26 single nucleotide polymorphisms (SNPs) associated with IBD exposure data. The European T2DM GWAS data was obtained from the IEU OpenGWAS Project database, which contains 298,957 cases as the outcome data. The causal relationship between T2DM and IBD using a reverse MR analysis was also performed. Results: The two-sample MR analysis, with the Bonferroni adjustment for multiple testing, revealed that T2DM risk in Europeans is unaffected by their IBD liability (odds ratio (OR): 0.950-1.066, 95% confidence interval (CI): 0.885-1.019, p = 0.152-0.926). The effects of liability to T2DM on IBD were not supported by the reverse MR analysis either (OR: 0.739-1.131, 95% confidence interval (CI): 0.651-1.100, p = 0.058-0.832). MR analysis of IBS on T2DM also have no significant causal relationship (OR: 0.003-1.007, 95% confidence interval (CI): 1.013-5.791, p = 0.069-0.790). FUMA precisely mapped 22 protein-coding genes utilizing significant SNPs of T2DM acquired from GWAS. Conclusion: The MR study showed that the existing evidence did not support the significant causal effect of IBD on T2DM, nor did it support the causal impact of T2DM on IBD.

Comparison of Type 2 Diabetes Mellitus Control at Home Healthcare and Hospital Clinic Care at King Salman Armed Forces Hospital (2021-2022): A Retrospective Cohort Study

BACKGROUND

Home healthcare represents a great necessity for patients with diabetes mellitus (DM). Although there are numerous studies on geriatric diabetic patients, there are few studies on diabetic home care versus hospital care.

AIM

This study aimed to compare the effect of home healthcare services to hospital care for controlling type 2 diabetes mellitus (T2DM) at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia.

METHODS

This retrospective cohort study included patients with type 2 diabetes mellitus at King Salman Armed Forces Hospital. The home healthcare group included 128 participants who received frequent follow-up visits at home. The hospital care group included 128 participants from the primary care clinic. Glycosylated hemoglobin (HbA1c) was used to measure glycemic control. Logistic regression analysis was done to detect factors related to achieving glycemic control.

RESULTS

Home healthcare care had a greater impact on the reduction of baseline glycosylated hemoglobin levels (p=0.0053). The target glycosylated hemoglobin was achieved by patients who received home healthcare (p=0.020). Using the multivariate regression analysis, home healthcare, married patients, those who can do full daily life activities without assistance, and those who were treated with only insulin had significant correlations to meet the target glycosylated hemoglobin level (odds ratio: 0.814, 0.541, 0.448, and 0.144; 95% confidence intervals: 0.72-0.94, 0.30-0.99, 0.31-0.65, and 0.08-0.25, respectively).

CONCLUSIONS

Home care strategy for patients suffering from type 2 diabetes mellitus provides better glycemic control compared to hospital care. Home care, marriage, doing full daily activities, and insulin treatment are important factors affecting glycemic control.