P 31: Medication intensification strategies and outcomes in patients with type 2 diabetes (T2DM) who have A1C ≥ %7 on ≤ 2 oral anti-diabetes agents (OAD)

Abstract

Type 2 diabetes (T2D) is a chronic metabolic disorder requiring vigilant glycemic monitoring to guide treatment intensification strategies. Current algorithms recommend addition of basal insulin, glucagon-like peptide-1(GLP-1) agonist, or oral anti-diabetic drugs(OAD) in a different class for patients not achieving A1C<7% on 1 or 2 OADs. There is little information available on implementation of these recommendations in clinical practice. We queried a large electronic medical record (EMR) to identify patients with T2D with an A1C>7% on 1 or 2 OAD between June 2005 and November 2011. Patients were grouped according to intensification strategy: insulin (Group 1 n=421); GLP-1(Group 2 n=56); OAD (Group 3 n=1413); or no additional therapy (Group 4 n=2660). Efficacy of therapy intensification was defined according to changes in A1C, the percentage of patients achieving A1C<7%, and the percentage of patients who achieved ≥0.5% reductions in A1C in each group. The majority of patients received OAD for therapy intensification. Patients who did not receive intensification were older (66.3±13.0 years vs Group 1: 61.5±14.2, Group 2: 55.4±13.0, Group 3: 62.7±12.5; P<0.0001) and had lower A1C at baseline (7.55±0.96 vs Group 1: 9.32±2.05, Group 2: 8.24±1.14, Group 3: 8.28±1.30; P<0.0001). Reductions in A1C levels were observed in all groups (Group 1: -1.21±2.15, Group 2: -0.84±1.31, Group 3: -0.71±1.40, Group 4: -0.33±1.11). The greatest absolute A1C reduction was observed in Group 1, who was also more likely to achieve A1C reductions of ≥0.5% (60.3% vs Group 2: 50.0% vs Group 3: 55.1%). Despite this, <25% of these patients achieved A1C<7% as compared to 41.1%, 36.1%, and 48.6% in the other groups respectively. GLP-1 patients, who were younger and more obese, were more likely than insulin or OAD patients to achieve A1C<7% as well as a decrease in BMI. The difference in percentage of patients achieving an A1C<7% remained significant after adjusting for baseline differences in A1C (P=0.0345). Using a health system database, we are able to identify treatment patterns in clinical practice. These results demonstrate that OADs remain the most frequently used intensification strategy for patients with uncontrolled T2DM and suggest that intensification may be delayed. Further investigations into reasons for the observed treatment intensification patterns and delay in therapeutic intensification are planned.