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Delay Of Insulin Addition To Oral Combination Therapy Despite Inadequate Glycemic Control

Delay of Insulin Therapy

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Abstract

BACKGROUND

Patients and providers may be reluctant to escalate to insulin therapy despite inadequate glycemic control.

OBJECTIVES

To determine the proportion of patients attaining and maintaining glycemic targets after initiating sulfonylurea and metformin oral combination therapy (SU/MET); to assess insulin initiation among patients failing SU/MET; and to estimate the glycemic burden incurred, stratified by whether HbA1c goal was attained and maintained.

DESIGN

Longitudinal observational cohort study.

SUBJECTS

Type 2 diabetes patients, 3,891, who newly initiated SU/MET between 1 January 1996 and 31 December 2000.

MEASUREMENTS

Subjects were followed until insulin was added, health plan disenrolment, or until 31 December 2005. We calculated the number of months subjects continued SU/MET therapy alone, in total, and during periods of inadequate glycemic control; the A1C reached during those time periods; and total glycemic burden, defined as the estimated cumulative monthly difference between measured A1C and 8%.

RESULTS

During a mean follow-up of 54.6 ± 28.6 months, 41.9% of the subjects added insulin, and 11.8% received maximal doses of both oral agents. Over half of SU/MET patients attained but failed to maintain A1C of 8%, yet continued SU/MET therapy for an average of nearly 3 years, sustaining glycemic burden equivalent to nearly 32 months of A1C levels of 9%. Another 18% of patients never attained the 8% goal with SU/MET, yet continued that therapy for an average of 30 months, reaching mean A1C levels of 10%.

CONCLUSIONS

Despite inadequate glycemic control, a minority of patients added insulin or maximized oral agent doses, thus, incurring substantial glycemic burden on SU/MET. Additional studies are needed to examine the benefits of rapid titration to maximum doses and earlier initiation of insulin therapy.

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Acknowledgments

The authors wish to thank Jennifer Coury, for her editing suggestions, and James Hartnett, for his helpful review and comments. This work was supported by funding from Pfizer, Inc. and by the Kaiser Permanente Center for Health Research.

Conflict of Interest Statement

Within the past 3 years, Gregory A. Nichols has received grant support from Pfizer, Inc.; GlaxoSmithKline, Inc; Merck & Co., Inc.; Eli Lilly and Co.; Sanofi-Aventis; and Bristol-Myers Squibb. Sonali N. Shah and Yuri Koo are employed by and hold stock in Pfizer, Inc.

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Authors and Affiliations

  1. Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227-1098, USA

    Gregory A. Nichols PhD

  2. US Outcomes Research, Pfizer, Inc., New York, NY, USA

    Yuri H. Koo JD, MPH & Sonali N. Shah RPh, MBA, MPH

Authors
  1. Gregory A. Nichols PhD
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  2. Yuri H. Koo JD, MPH
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  3. Sonali N. Shah RPh, MBA, MPH
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Corresponding author

Correspondence to Gregory A. Nichols PhD.

Additional information

Supported by a research grant from Pfizer, Inc.

Presented in poster form at the American Diabetes Association 66th Annual Meetings, June, 2006.

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Nichols, G.A., Koo, Y.H. & Shah, S.N. Delay Of Insulin Addition To Oral Combination Therapy Despite Inadequate Glycemic Control. J GEN INTERN MED 22, 453–458 (2007). https://doi.org/10.1007/s11606-007-0139-y

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  • DOI: https://doi.org/10.1007/s11606-007-0139-y

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