Abstract
BackgroundTo describe common type 2 diabetes treatment intensification regimens, patients’ characteristics and changes in glycated hemoglobin (HbA1c) and body mass index (BMI).MethodsWe constructed a national retrospective cohort of veterans initially treated for diabetes with either metformin or sulfonylurea from 2001 through 2008, using Veterans Health Administration (VHA) and Medicare data. Patients were followed through September, 2011 to identify common diabetes treatment intensification regimens. We evaluated changes in HbA1c and BMI post-intensification for metformin-based regimens.ResultsWe identified 323,857 veterans who initiated diabetes treatment. Of these, 55 % initiated metformin, 43 % sulfonylurea and 2 % other regimens. Fifty percent (N = 89,057) of metformin initiators remained on metformin monotherapy over a median follow-up 58 months (interquartile range [IQR] 35, 74). Among 80,725 patients who intensified metformin monotherapy, the four most common regimens were addition of sulfonylurea (79 %), thiazolidinedione [TZD] (6 %), or insulin (8 %), and switch to insulin monotherapy (2 %). Across these regimens, median HbA1c values declined from a range of 7.0–7.8 % (53–62 mmol/mol) at intensification to 6.6–7.0 % (49–53 mmol/mol) at 1 year, and remained stable up to 3 years afterwards. Median BMI ranged between 30.5 and 32 kg/m2 at intensification and increased very modestly in those who intensified with oral regimens, but 1–2 kg/m2 over 3 years among those who intensified with insulin-based regimens.ConclusionsBy 1 year post-intensification of metformin monotherapy, HbA1c declined in all four common intensification regimens, and remained close to 7 % in subsequent follow-up. BMI increased substantially for those on insulin-based regimens.Electronic supplementary materialThe online version of this article (doi:10.1186/s12902-016-0101-2) contains supplementary material, which is available to authorized users.
Highlights
To describe common type 2 diabetes treatment intensification regimens, patients’ characteristics and changes in glycated hemoglobin (HbA1c) and body mass index (BMI)
Study design and data sources We assembled a retrospective cohort of patients seen in Veterans Health Administration (VHA) facilities who had a new hypoglycemic prescription between October 1, 2001 and September 30, 2008 [15, 16]
Fifty percent (N = 89,057) of metformin initiators remained on metformin therapy over a median follow-up 58 months
Summary
To describe common type 2 diabetes treatment intensification regimens, patients’ characteristics and changes in glycated hemoglobin (HbA1c) and body mass index (BMI). A biguanide approved and marketed in the U.S since 1995, is the preferred oral hypoglycemic medication for initial management of type 2 diabetes [1,2,3,4]. Despite consensus on initial diabetes treatment, when to intensify and the preferred specific treatment regimen remains highly patient specific. Roumie et al BMC Endocrine Disorders (2016) 16:32 guidelines have advocated for a shared approach between provider and patient when choosing both the treatment goals and regimen for intensification [7]. A number of factors influence providers to recommend a medication for intensification including medication costs, side effects, their own knowledge and beliefs about future treatment benefits, such as prevention or delay of macrovascular and microvascular disease [8]. Because of the potential microvascular benefit to patients with tighter glycemic control, there has been a fairly substantial increase in the use of insulin over time [14]
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