Delay in treatment intensification increases the risks of cardiovascular events in patients with type 2 diabetes

Abstract

Background:The aim of the study was to evaluate the effect of delay in treatment intensification (IT; clinical inertia) in conjunction with glycaemic burden on the risk of macrovascular events (CVE) in type 2 diabetes (T2DM) patients. Methods:A retrospective cohort study was carried out using United Kingdom Clinical Practice Research Datalink, including T2DM patients diagnosed from 1990 with follow-up data available until 2012. Results:In the cohort of 105,477 patients mean HbA1c was 8.1% (65 mmol/mol) at diagnosis, 11% had a history of cardiovascular disease, and 7.1% experienced at least one CVE during 5.3 years of median follow-up. In patients with HbA1c consistently above 7/7.5% (53/58 mmol/mol, n = 23,101/11,281) during 2 years post diagnosis, 26/22% never received any IT. Compared to patients with HbA1c <7% (<53 mmol/mol), in patients with HbA1c ≥7% (≥53 mmol/ mol), a 1 year delay in receiving IT was associated with significantly increased risk of MI, stroke, HF and composite CVE by 67% (HR CI: 1.39, 2.01), 51% (HR CI: 1.25, 1.83), 64% (HR CI: 1.40, 1.91) and 62% (HR CI: 1.46, 1.80) respectively. One year delay in IT in interaction with HbA1c above 7.5% (58 mmol/mol) was also associated with similar increased risk of CVE. Conclusions:Among patients with newly diagnosed T2DM, 22% remained under poor glycaemic control over 2 years, and 26% never received IT. Delay in IT by 1 year in conjunction with poor glycaemic control significantly increased the risk of MI, HF, stroke and composite CVE.

Intensification of Diabetes Therapy and Time Until A1C Goal Attainment Among Patients With Newly Diagnosed Type 2 Diabetes Who Fail Metformin Monotherapy Within a Large Integrated Health System

“…Although many of these patients did eventually undergo an intervention to improve glycemia within 2 years of the initial/baseline A1C, this is a longer period than would be desired. A delay in treatment intensification by 1 year, in conjunction with poor glycemic control, has been reported to significantly increase the risk of macrovascular events (15). Patients with type 2 diabetes are often highly motivated near the time of diagnosis, so it would seem important to leverage this motivation and intervene to improve glycemic control early on in the disease process and not allow for time to pass and perhaps risk losing the patient to follow-up.…”

“…Unlike other studies that have evaluated the various concepts of clinical inertia (4,14,15), the current analysis included numerous interventions in the definition of intensification rather than simply defining an intervention as the addition of another antidiabetic agent, which may not always be the modality by which a treatment intensification occurs. Moreover, follow-up A1C information was available on most of the subjects, which allowed an analysis of the effects of an intervention on glycemic control and, more importantly, the timing of that intervention on long-term glycemic goal attainment.…”

Optimizing management of glycaemia

“…Clinical inertia or delay in treatment intensification by 1 year increases the risk of composite CV events, myocardial infarction (MI), stroke and heart failure (47) and is associated with polypharmacy, multi-morbidity, weight gain and/or hypoglycaemia concerns, resource issues, lack of training and education, patient quality of life and treatment burden (35,48) (Table 2). This mostly occurs after triple oral therapy with up to 7 years before insulin is appropriately intensified (49).…”

Data Mining Approach to Estimate the Duration of Drug Therapy from Longitudinal Electronic Medical Records

“…Such real-world analysis provides an extremely valuable means for the understanding of drug utilization patterns, treatment initiation periods following the diagnosis of a disease, the effectiveness of specific therapies on disease-related risk factors, and possible associations of therapies with long-term outcomes [1,6]. These studies warrant appropriate extraction of longitudinal information on prescriptions or medications at individual patient level, inappropriate extraction of the data may result in misleading inferences reported [33 -35].…”