Association Between Therapeutic Inertia and Future Hypoglycemia Among Patients with Type 2 Diabetes

Therapeutic inertia (TI), the failure to adjust therapy when HbA1c remains above- target, is a barrier to optimal glycemic control in type 2 diabetes (T2D). This study examined the association between TI and subsequent-year hypoglycemia visit, and whether continuous glucose monitoring (CGM) modifies this relationship.

We analyzed electronic health records (2017-2023) from two Midwest US healthcare systems, including adults with T2D, at least one above-target HbA1c (>7% for ages 18-64; >8% for ages ≥65), and glucose-lowering prescriptions. TI was calculated annually as the percentage of above-target HbA1c results without prescription changes within 30 days. We fitted logistic regression models to examine whether high TI (>50%) was associated with subsequent-year hypoglycemia visits. An interaction term tested whether this association differed between those who used vs. did not use CGM.

Among 65,983 participants (mean age 56, 51% male, 75% White), mean HbA1c at last follow-up was 8.1% (ages 18-64) and 8.0% (ages ≥ 65). High TI was associated with 31% increased odds of hypoglycemia visit (OR=1.74; 95% CI: 1.61-1.88; p<0.001). Insulin users had threefold higher odds (OR=2.95; p<0.001). Medicare beneficiaries had 31% higher odds than Medicaid beneficiaries. Adults aged 18-44 years had more hypoglycemia visits compared to other age groups. Low CGM use (7%) limited the interpretation of interaction effects (95% CI: 0.47-1.1, p=0.12).

In this cohort, high TI predicted hypoglycemia-visit. Further research is needed to understand TI drivers and how to balance improving glycemic control without increasing the risk of hypoglycemia.