Cumulative Delays in Treatment Intensification over Three Typical Stages of Antihyperglycemic Treatment

Although delays in treatment intensification (TI) have been documented for anti-hyperglycemic medications, cumulative delays over the life course of diabetes treatment have not been reported. We combined 2005-2016 data from the Northwest and Mid-Atlantic regions of Kaiser Permanente to identify 248 patients who: (1) initiated metformin (MET); (2) then added a sulfonylurea (SU) to existing MET; and (3) initiated insulin (INS) after MET or SU. We used the date of the initiation of each stage of therapy to calculate time between A1C ≥7% and TI, pre-TI A1C, post-TI A1C, and achievement of A1C goal ≤7% within one year of TI. We also measured time to intensification within 6 months prior to TI. Mean or median cumulative measures were summed across the three TI stages. Among patients who experienced each stage of MET, SU, and INS intensification, the mean A1C percentage points outside of goal summed to 5.9 (Table). These patients accrued a median of 191 days of TI delays in the 3 6-month periods preceding TI. Although A1C was lowered after each stage of TI, a minority of patients achieved A1C goals of ≤7% resulting in accumulation of a mean of 3.3 excess A1C percentage points over the 3 one year periods after TI of MET, SU, and INS. TI delays occur at every stage of diabetes therapy. Glycemic burden accumulates over the life course of diabetes and may result in differential complication risks. However, further study is needed.