Therapeutic Inertia and the Legacy of Dysglycemia on the Microvascular and Macrovascular Complications of Diabetes

Abstract

Type 2 diabetes is characterized by a continuous decline in β‐cell function with the resultant progressive loss of glycemic control over time (1). The hyperglycemic burden is associated with longer-term microvascular and macrovascular complications. Early diagnosis and intensive glycemic control has conclusively demonstrated a reduction in microvascular complications (2,3) and possibly macrovascular complications over a long period of observation (4), the so-called legacy effect (5). Even though there have been improvements in survival from cardiovascular disease in the general population, people with type 2 diabetes remain at increased risk of cardiovascular mortality compared with matched population control subjects (6). A very high proportion of patients fail to reach the recommended glycemic targets for a considerable period of time after the diagnosis of diabetes (7–9), thus leading to the complications. Guidelines for the treatment of patients with type 2 diabetes suggest that tight glycemic control (defined as glycated hemoglobin [HbA1c] <7.0% [53 mmol/mol]) should be maintained from diagnosis through active titration of combinations of antihyperglycemic medications and lifestyle modification, as appropriate (10). Modeling studies suggest that when this is done through an individualized approach, it leads to reduced costs and increased quality of life (11).\n\nBesides patient-level characteristics such as multimorbidity and poor adherence to treatment recommendations, clinical inertia has been suggested as one key reason for not achieving glucose targets. The term “clinical inertia” in most instances has been used in relation to failure to advance therapy when appropriate to do so (12). However, the definition of therapeutic inertia is now also accepted to reflect the failure to de-intensify treatment when appropriate to do so (12). A number of studies have shown that therapeutic inertia is associated with worse microvascular and macrovascular outcomes. In a cohort study of 105,477 patients, mean HbA1c …