We read with interest the article by Khunti et al. (1) reporting delays in treatment intensification in people with type 2 diabetes, approaching 6.9 years (median) in those with a starting HbA1c level ≥8% (64 mmol/mol) and taking two oral antidiabetes drugs. Moreover, median time to intensification with insulin was 7.1, 6.1, or 6.0 years for those taking one, two, or three oral antidiabetes drugs, respectively. Although their findings support current knowledge about the protracted failure for intensification of treatment despite suboptimal glycemic control, and despite some limitations inherent to this type of analysis, the large patient population of this retrospective cohort study based on 81,573 people with type 2 diabetes in the U.K. provides a good clinical picture of the state of diabetes control in the real world of routine practice. This article also highlights one main reason for the little improvement in glycemic control that occurred in the U.K. between 1997 and 2007 among type 2 diabetic patients (2).
Despite the rapid progress in drug development for type 2 diabetes, it is still challenging to achieve good glycemic control in a substantial population, even when multiple antidiabetes treatments are applied. The analysis of data for adults with self-reported diabetes from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System over the 1999–2010 period (3) shows that 52% of survey participants achieved the HbA1c target <7% from 2007 through 2010 (a slight decrease from the 56% of the previous period 2003–2006). As 77.9% of participants succeeded in achieving HbA1c <8%, this distribution may also reflect a physician’s choice of personalized targets (as also reflected by the individualized targets according to risk profile).
Failure to treat to target or prescribing that is not concordant with guidelines is being referred to as clinical inertia. Clinical inertia is usually limited to disorders in which abnormal values may be the only manifestation of the disease, including diabetes. As not everyone benefits from aggressive glucose management, clinical inertia has been suggested as a clinical safeguard through which physicians acknowledge the uncertainty in some current practice guidelines, thus adopting less aggressive approaches (4); nonetheless, clinical inertia still remains a major obstacle for reaching the HbA1c target. The exhortation of Khunti et al. (1) for a greater effort to motivate physicians to improve diabetes management is sound. Ultimately, physician feeling and conviction about the willingness to reach the HbA1c target (now tailored on the patient) remain paramount to reduce unnecessary clinical inertia (5). As for other common companions of type 2 diabetes, including dyslipidemia and hypertension, the distance from the target (i.e., the difference between the current value of the patient and the individualized target) may be useful. Ironically, among the many antidiabetes drugs added to previous treatments, insulin has the best chance to reach the prefixed HbA1c target.
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Duality of Interest. No potential conflicts of interest relevant to this article were reported.
