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What to do with diabetes therapies when HbA1c lowering is inadequate: add, switch, or continue? A MASTERMIND study
Andrew P McGovern1, John M Dennis2, Beverley M Shields3
1University of Exeter Medical School, The Institute of Clinical and Biological Sciences, University of Exeter, Exeter, UK. a.mcgovern@exeter.ac.uk.
Background:
It is unclear what to do when people with type 2 diabetes have had no or a limited glycemic response to a recently introduced medication. Intra-individual HbA1c variability can obscure true response. Some guidelines suggest stopping apparently ineffective therapy, but no studies have addressed this issue.
Methods:
In a retrospective cohort analysis using the UK Clinical Practice Research Datalink (CPRD), we assessed the outcome of 55,530 patients with type 2 diabetes starting their second or third non-insulin glucose-lowering medication, with a baseline HbA1c > 58 mmol/mol (7.5%). For those with no HbA1c improvement or a limited response at 6 months (HbA1c fall < 5.5 mmol/mol [0.5%]), we compared HbA1c 12 months later in those who continued their treatment unchanged, switched to new treatment, or added new treatment.
Results:
An increase or a limited reduction in HbA1c was common, occurring in 21.9% (12,168/55,230), who had a mean HbA1c increase of 2.5 mmol/mol (0.2%). After this limited response, continuing therapy was more frequent (n = 9308; 74%) than switching (n = 1177; 9%) or adding (n = 2163; 17%). Twelve months later, in those who switched medication, HbA1c fell (- 6.8 mmol/mol [- 0.6%], 95%CI - 7.7, - 6.0) only slightly more than those who continued unchanged (- 5.1 mmol/mol [- 0.5%], 95%CI - 5.5, - 4.8). Adding another new therapy was associated with a substantially better reduction (- 12.4 mmol/mol [- 1.1%], 95%CI - 13.1, - 11.7). Propensity score-matched subgroups demonstrated similar results.
Conclusions:
Where glucose-lowering therapy does not appear effective on initial HbA1c testing, changing agents does not improve glycemic control. The initial agent should be continued with another therapy added.
Insights
For type 2 diabetes patients with limited response to medication, switching treatments did not improve glycemic control. Adding new therapy to the existing medication is recommended for better HbA1c reduction.
Area of Science:
- Endocrinology
- Metabolic Diseases
- Pharmacotherapy
Background:
- Limited understanding exists regarding optimal management for type 2 diabetes patients with inadequate glycemic response to new medications.
- Intra-individual HbA1c variability can complicate the assessment of true treatment efficacy.
- Current guidelines offer no definitive guidance on discontinuing apparently ineffective therapies.
Purpose of the Study:
- To investigate the outcomes of continuing, switching, or adding glucose-lowering therapy in type 2 diabetes patients with a limited initial response.
- To provide evidence-based recommendations for managing suboptimal glycemic control in type 2 diabetes.
Main Methods:
- Retrospective cohort analysis of 55,530 patients with type 2 diabetes from the UK Clinical Practice Research Datalink (CPRD).
- Inclusion criteria: baseline HbA1c > 58 mmol/mol (7.5%) starting second or third non-insulin glucose-lowering medication.
- Comparison of HbA1c levels at 12 months for patients with limited response (<5.5 mmol/mol fall) at 6 months, based on treatment strategy: continued, switched, or added therapy.
Main Results:
- A significant proportion (21.9%) of patients experienced no or limited HbA1c improvement (mean increase of 2.5 mmol/mol).
- Continuing therapy was the most frequent strategy (74%) after limited response.
- Switching medication showed only a marginal improvement in HbA1c compared to continuing therapy (-6.8 vs -5.1 mmol/mol).
- Adding new therapy resulted in a substantially greater HbA1c reduction (-12.4 mmol/mol) compared to continuing or switching.
Conclusions:
- Changing glucose-lowering agents is ineffective for improving glycemic control when initial response is limited.
- For patients with type 2 diabetes showing an inadequate response to a medication, continuing the current agent and adding a new therapy is the recommended approach.
- This strategy offers superior HbA1c reduction compared to switching the existing medication.
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