Predictors and Impact of Intensification of Antihyperglycemic Therapy in Type 2 Diabetes: Translating Research into Action for Diabetes (TRIAD)

OBJECTIVE

The purpose of this study was to examine the predictors of intensification of antihyperglycemic therapy in patients with type 2 diabetes; its impact on A1C, body weight, symptoms of anxiety/depression, and health status; and patient characteristics associated with improvement in A1C.

RESEARCH DESIGN AND METHODS

We analyzed survey, medical record, and health plan administrative data collected in Translating Research into Action for Diabetes (TRIAD). We examined patients who were using diet/exercise or oral antihyperglycemic medications at baseline, had A1C >7.2%, and stayed with the same therapy or intensified therapy (initiated or increased the number of classes of oral antihyperglycemic medications or began insulin) over 18 months.

RESULTS

Of 1,093 patients, 520 intensified therapy with oral medications or insulin. Patients intensifying therapy were aged 58 ± 12 years, had diabetes duration of 11 ± 9 years, and had A1C of 9.1 ± 1.5%. Younger age and higher A1C were associated with therapy intensification. Compared with patients who did not intensify therapy, those who intensified therapy experienced a 0.49% reduction in A1C (P < 0.0001), a 3-pound increase in weight (P = 0.003), and no change in anxiety/depression (P = 0.5) or health status (P = 0.2). Among those who intensified therapy, improvement in A1C was associated with higher baseline A1C, older age, black race/ethnicity, lower income, and more physician visits.

CONCLUSIONS

Treatment intensification improved glycemic control with no worsening of anxiety/depression or health status, especially in elderly, lower-income, and minority patients with type 2 diabetes. Interventions are needed to overcome clinical inertia when patients might benefit from treatment intensification and improved glycemic control.Over the past decade, the number of therapies available for the management of type 2 diabetes has increased dramatically. Much of the evidence demonstrating the efficacy of these therapies has come from randomized, controlled, clinical trials (1,2). The effectiveness of these therapies in real-world clinical settings has not been studied as thoroughly.Clinical inertia, defined as the failure of health care providers to appropriately intensify medical management (3), and patient nonadherence, defined as the failure of patients to initiate or continuephysician-recommended changes in management, contribute to suboptimal glycemic control (4–6). A previous study of patients with poorly controlled diabetes showed that older patients and those of nonwhite race/ethnicity were less likely to have their treatment intensified than younger, white individuals (7). Physicians cite concerns about hypoglycemia, weight gain, and patient preferences as reasons for not intensifying therapy, and patients often express concerns about injections and the negative impact on quality of life as reasons for not intensifying therapy. Ideally, diabetes treatment regimens should be individually designed to prevent complications and comorbidities while respecting patient preferences and optimizing quality of life.The current analyses were designed to assess the impact of changes in antihyperglycemic therapies on health outcomes in managed care patients with type 2 diabetes. Specifically, we assessed the predictors of intensification of antihyperglycemic therapy, its impact on A1C, body weight, symptoms of anxiety/depression, and health status, and patient characteristics associated with improvement in A1C.