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Clinical inertia in intensifying therapy in people with type 2 diabetes treated with basal insulin

Commentary by Professor Khunti

Type 2 diabetes is a progressive disease requiring stepwise intensification of therapy, with the majority of the patients eventually requiring insulin therapy to achieve good glycaemic control. There is now good evidence that tight glycaemic control, particularly from onset and diagnosis, leads to significant reductions in microvascular and macrovascular complications. Despite this evidence many people fail to reach appropriate glycaemic targets, with one reason being the delay in treatment intensification (both for oral and insulin therapy) also known as “clinical inertia”. In addition to this “clinical inertia”, the SOLVE study has shown that there was an “insulin intensification inertia” once patients had been initiated on basal insulin. The current study is the first to show inertia following basal insulin therapy. Conducted using the UK clinical practice research data link and including more than 11,000 patients, the study showed that for those patients who were eligible for intensification (people with an HbA1c of greater than 7.5% [58mmols/mol]) the median time to intensification was 3.7 years from the start of basal insulin. However, within this period only one-third of participants were intensified. Clinical inertia was shown to be more likely in people who were older, had longer duration of diabetes, or had more co-morbidities. Intuitively one would expect this to be the case, as the ADA/EASD algorithm states that these are the key factors that need to be taken into consideration when intensifying therapy. However, this study has significant impact in terms of clinical practice, as any delay in intensification (but particularly one in the first years following a diagnosis) has been shown to be associated with a significantly increased risk of cardiovascular outcomes. Efforts therefore need to be made to not only initiate appropriate patients on insulin, but also to titrate and intensify appropriate patients with overall aim of reducing long-term microvascular and macrovascular complications and mortality.  

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