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Delay of insulin addition to oral combination therapy despite inadequate glycemic control: delay of insulin therapy

Gregory A Nichols1, Yuri H Koo, Sonali N Shah

  • 1Kaiser Permanente Center for Health Research, Portland, OR 97227-1098, USA. greg.nichols@kpchr.org

Journal of General Internal Medicine
|March 21, 2007
PubMed
Abstract

Insights

Many type 2 diabetes patients on sulfonylurea and metformin (SU/MET) therapy experience prolonged inadequate glycemic control. This leads to significant health burdens, highlighting the need for earlier insulin initiation.

Area of Science:

  • Endocrinology
  • Pharmacology
  • Clinical Medicine

Background:

  • Patients and healthcare providers exhibit reluctance in escalating to insulin therapy, even with suboptimal glycemic control.
  • Type 2 diabetes management often involves a delay in intensifying treatment regimens.

Purpose of the Study:

  • To assess the proportion of patients achieving and sustaining glycemic targets with sulfonylurea and metformin oral combination therapy (SU/MET).
  • To evaluate the rate of insulin initiation in patients who do not respond adequately to SU/MET.
  • To quantify the glycemic burden experienced by patients, considering whether glycemic goals were met.

Main Methods:

  • A longitudinal observational cohort study involving 3,891 patients with type 2 diabetes initiating SU/MET.
  • Patients were followed from their initiation date (1996-2000) until insulin initiation, disenrollment, or December 2005.
  • Key metrics included duration of SU/MET use, HbA1c levels, and estimated cumulative glycemic burden.

Main Results:

  • Over a mean follow-up of 54.6 months, 41.9% of patients initiated insulin, and 11.8% reached maximal oral agent doses.
  • More than half of patients attained but failed to maintain an HbA1c below 8%, continuing SU/MET for an average of 3 years and accumulating significant glycemic burden.
  • Approximately 18% of patients never reached the 8% HbA1c goal with SU/MET, continuing therapy for 30 months with mean HbA1c levels around 10%.

Conclusions:

  • A significant proportion of patients on SU/MET experience prolonged hyperglycemia, incurring substantial glycemic burden due to delayed treatment intensification.
  • The findings suggest a clinical inertia in escalating therapy, underscoring the need for further research into the benefits of earlier insulin initiation.
  • Further investigation is warranted to explore strategies for optimizing treatment titration and timely insulin therapy in type 2 diabetes management.

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