Overcoming Therapeutic Inertia in Type 2 Diabetes Care-Timing, Context, and Appropriateness of Treatment Intensification.

Abstract

Timely, evidence-based, and safe control of hyperglycemia is foundational to the management of type 2 diabetes and is essential for preventing acute and chronic complications of this common and serious disease. There are 2 main reasons for suboptimal glycemic control: the patient’s inability, for whatever reason, to adhere to prescribed medication(s) and the clinician’s failure to initiate or intensify glucose-lowering therapy when it is clinically appropriate to do so (ie, therapeutic inertia). Therapeutic inertia is common, affecting as many as 50% of patients with type 2 diabetes,1 and is driven by a wide range of barriers at the clinician, patient, and health system levels.2 Addressing therapeutic inertia is a priority viewed as central to reducing the burden of diabetes and its complications.2 Nearly 30% of adults aged 65 years and older are living with diabetes.3 Glycemic control among older adults is generally better than among younger patients; recent population-based estimates revealed that 24% of older adults without diabetes complications had glycated hemoglobin (HbA1c) levels of 7.5% or greater (ie, the commonly accepted upper threshold for healthier older adults [to convert to proportion of total hemoglobin, multiply by 0.01]), while 20% of older adults with diabetes complications had HbA1c levels of 8.0% or greater 3 (ie, the recommended upper threshold for more clinically complex patients), suggesting that there is an opportunity to improve glycemic management and reduce the burden of diabetes complications. Hospitalization may be viewed as an opportunity to address therapeutic inertia and improve glycemic control. However, as demonstrated by Anderson et al4 elsewhere in JAMA Network Open, intensification of glucose-lowering therapy upon hospital discharge does not appear to improve glycemic control but exposes patients to risk of preventable harm due to severe hypoglycemia in the immediate postdischarge period. As observed by Anderson et al4 in a large retrospective cohort study of patients with non–insulin-treated type 2 diabetes aged 65 years or older who were admitted to US Veterans Health Administration hospitals for a wide range of routine medical problems unrelated to diabetes, having glucose-lowering medications intensified at or before hospital discharge was associated with a 2-fold increase in the rate of severe hypoglycemic events requiring emergency department or hospital care during the initial 30-day period after hospital discharge. There was, however, also a significant reduction in 30-day all-cause mortality (hazard ratio, 0.55; 95% CI, 0.33-0.92), which the authors attribute to unmeasured confounding and lower perceived risk of death among patients who were deemed eligible for treatment intensification. This mortality benefit was limited to patients with preadmission HbA1c levels greater than 7.5% (ie, uncontrolled diabetes) and was no longer apparent after 1 year of follow-up. Indeed, after 1 year, there was no association between glucose-lowering medication intensification and severe hypoglycemic or hyperglycemic events, HbA1c level, all-cause hospitalizations, or mortality. Depending on one’s perspective, several conclusions can be drawn from this study. On the one hand, treatment intensification at transitions of care appears to be ill advised. Intensification of glucose-lowering medications during hospitalization for causes unrelated to diabetes—the condition whose treatment is being intensified—does not improve glucose control as measured by HbA1c level. Concurrently, it transiently doubles the risk of severe hypoglycemia as patients begin to take their newly prescribed medications, nearly all of which in this study were associated with heightened hypoglycemia risk (ie, insulin and sulfonylurea). On the other hand, treatment intensification may be + Related article