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J Gen Intern Med. 2007 Apr;22(4):453-8.

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

Author information

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

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 HbA(1c) 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 disenrollment, 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.

PMID:
17372792
PMCID:
PMC1829438
DOI:
10.1007/s11606-007-0139-y
[Indexed for MEDLINE]
Free PMC Article

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