Time to Treatment Intensification After Monotherapy Failure and Its Association With Subsequent Glycemic Control Among 93,515 Patients With Type 2 Diabetes.

Urvi Desai, Noam Y Kirson, Jennifer Kim, Kamlesh Khunti, Sarah King, Erich Trieschman, Michael Hellstern, Phillip R Hunt, Jayanti Mukherjee

REVIEW


28 January 2019

A relevant paper showing that regarding intensification after failure of monotherapy: the earlier, the better


RELEVANCE 5
INNOVATIVENESS 4
APPLICABILITY 5
OVERALL 5

PAPER DETAILS


TITLE

Time to Treatment Intensification After Monotherapy Failure and Its Association With Subsequent Glycemic Control Among 93,515 Patients With Type 2 Diabetes.

ABSTRACT

OBJECTIVE
The goal of this study was to evaluate the association between the timing of treatment intensification and subsequent glycemic control among patients with type 2 diabetes in whom monotherapy fails.

RESEARCH DESIGN AND METHODS
This retrospective analysis of the U.K. Clinical Practice Research Datalink database focused on patients with type 2 diabetes and one or more HbA measurements ≥7% (≥53 mmol/mol) after ≥3 months of metformin or sulfonylurea monotherapy (first measurement meeting these criteria was taken as the study index date). Baseline (6 months before the index date) characteristics were stratified by time from the index date to intensification (early: <12 months; intermediate: 12 to <24 months; late: 24 to <36 months). Intensification was defined as initiating after the index date one or more noninsulin antidiabetes medication in addition to metformin or a sulfonylurea. Association between time to intensification and subsequent glycemic control (first HbA <7% [<53 mmol/mol] after intensification) was evaluated using Kaplan-Meier analyses and Cox proportional hazard models that accounted for baseline differences.

RESULTS
Of the 93,515 patients who met the study criteria (mean age 60 years; ∼59% male; 80% taking metformin), 23,761 (25%) intensified <12 months after the index date; 11,908 (13%) intensified after 12 to <24 months; and 7,146 (8%) intensified after 24 to <36 months. Patients who intensified treatment ≥36 months after the index date ( = 9,638 [10%]) and those with no evidence of treatment intensification during the observable follow-up period ( = 41,062 [44%]) were not included in further analyses. The median times from intensification to control were 20.0, 24.1, and 25.7 months, respectively, for the early, intermediate, and late intensification cohorts. After adjustment for baseline differences, the likelihood of attaining glycemic control was 22% and 28% lower for patients in the intermediate and late intensification groups, respectively, compared with those intensifying early ( < 0.0001).

CONCLUSIONS
Earlier treatment intensification is associated with shorter time to subsequent glycemic control, independent of whether patients initiate first-line treatment with metformin or a sulfonylurea.



AUTHOR(S)

Urvi Desai, Noam Y Kirson, Jennifer Kim, Kamlesh Khunti, Sarah King, Erich Trieschman, Michael Hellstern, Phillip R Hunt, Jayanti Mukherjee,

JOURNAL

Diabetes care

PLACE

United States