High-Risk Medication Use to Achieve Tight Glycemic Control among U.S. Adults with Serious Chronic Conditions

Abstract

For patients with serious comorbidities, diabetes management guidelines recommend more relaxed glycemic targets (glycosylated hemoglobin [HbA1c] <8-8.5% rather than <7%) and cautious use of agents known to cause hypoglycemia. We examined glycemic control and use of insulin and/or sulfonylureas among commercially insured and Medicare Advantage beneficiaries with serious comorbidities. Using OptumLabs Data Warehouse, we identified adults ≥18 years with diabetes and ≥1 of the following conditions (all identified by the guidelines) in 2014: dementia, end stage renal disease (ESRD), stages 3-4 chronic kidney disease (CKD), myocardial infarction (MI), heart failure (HF), cerebrovascular disease (CVD), chronic obstructive pulmonary disease (COPD), cancer, arthritis, urinary incontinence, falls, depression, hypertension, cirrhosis, proliferative retinopathy, peripheral neuropathy, and recent emergency department or hospital visit for hypoglycemia. We then identified their last available HbA1c in 2015 and the medications filled within 100 days of this HbA1c. There were 216,839 adults (mean age 65.5 years, 50.5% women, 58.6% white) with diabetes included in the study. The proportion of patients with HbA1c <7% was lowest among patients with retinopathy (28.9%), hypoglycemia (33.4%), and neuropathy (48.4%); it was highest among patients with dementia (59.1%). The majority (between 51.5% and 58.6%) of patients with the remaining conditions also had HbA1c <7%. The plurality of patients in each disease cohort was treated insulin and/or sulfonylurea, including 66.9% of patients with hypoglycemia, 54.4% with ESRD, 51.9% with CKD, 51.1% with cirrhosis, 46.8% with MI, 48% with HF, and 43% with dementia. Sulfonylureas were used in combination with insulin by nearly 6% of patients with ESRD, CKD, and cirrhosis. Thus, despite efforts to individualize therapy, the majority of patients with chronic conditions achieve HbA1c <7% and the plurality do so using high risk drugs. Disclosure R.G. McCoy: None. H. Van Houten: None. K.J. Lipska: Other Relationship; Self; Centers for Medicare and Medicaid Services. Research Support; Self; National Institutes of Health. N. Shah: None.