T2DM Management Priorities: Time to Align

Advances in diabetes technology and treatment over the past decade have failed to yield desired glycemic management outcomes in many patients with T2DM.

A recently published study evaluated if a disconnect between patients’ and physicians’ beliefs and perceptions about T2DM management could be contributing to suboptimal glycemic outcomes.

Studies have shown that only 30 percent of patients with type 2 diabetes treated with basal insulin achieved an A1C< 7.0 percent. The likelihood of reaching this A1C target is reduced if not achieved within one year of starting insulin.¹ In patients unable to achieve A1C goals on oral medications, an injectable such as basal insulin is recommended, and the dose is titrated up or down to reach desired glycemic outcomes.² A “ceiling effect” has been observed with basal insulin doses as low as 0.3 units/kg/day.¹ In a post hoc analysis of insulin glargine, a plateau effect was observed with doses > 0.5 units/kg/day.³ This analysis concluded that physicians should consider treatment intensification when basal insulin doses exceed 0.5 units/kg/day.³ Failure to intensify insulin when appropriate is referred to as therapeutic inertia.¹ In a recently published article, Edelman et al. present findings from their study that measured similarities and differences between patients’ and providers’ beliefs and perceptions about diabetes management, and the impact any disconnect may have on therapeutic inertia and patient frustration.⁴

A total of 240 U.S. physicians, and 305 patients with T2DM who were on basal insulin with uncontrolled A1C goals, were included in this double-blind industry-sponsored survey study. Patients ≥18 years, with a confirmed diagnosis of T2DM on basal insulin for ≥12 months, were recruited from a national consumer research panel. Specially designed surveys for physicians and patients were used to capture beliefs and perceptions about insulin therapy; all responses and study sponsor remained anonymous.⁴

Most patients in the study were female (57 percent) and white (77 percent), while 39% were ≥60 years of age. Physicians were from urban, suburban, and rural primary care or endocrinology offices, with practice durations ranging from 2-35 years. When asked about diabetes management priorities, the most frequent response, selected by 62 percent of patients, was “Maintaining your A1C goal over the long term,” compared to 45 percent of physicians. Among physicians, “Avoiding side effects (hypoglycemia)” was the most common priority response selected by 55 percent of physicians, compared to 27 percent of patients.

Most physicians (85 percent) and patients (77 percent) reported setting/receiving A1C goals when basal insulin was started. In patients who received an A1C goal, 63 percent of physicians and 43 percent of patients reported that they discussed how long it would take to achieve this goal. A similar proportion of physicians and patients reported that they expected this goal to be achieved in 6-12 months. In patients who reached their A1C goal (≈50 percent), 3-6 months was the most frequent time frame reported by physicians and patients. Greater than 60 percent of patients indicated that they wanted to reach A1C goals sooner. When patients were asked if they would do more to achieve A1C goals, 93 percent responded that they were willing to do more, double what physicians perceived. More than 60 percent of patients responded that they were frustrated about their suboptimal A1C, compared to 36 percent of physicians who believed that patients felt this way. When patients were asked about the adverse effects of not achieving their A1C goals on emotion, well-being, and happiness, 66 percent responded that treatment failure negatively impacted them. ⁴

Patients may not have been assigned to the physicians in the study, and physicians may not see the types of patients enrolled in the survey, so these are limitations worth noting when evaluating these findings.

Therapeutic inertia in T2DM is complex and dependent on many factors, which may include a disconnect between patient and provider beliefs and perceptions about treatment. Whatever the underlying cause, this inertia can negatively impact a patient’s quality of life and result in patient frustration. More patients than physicians realized reported that they were willing to do more to reach A1C goals. Early and improved communication around insulin use and T2DM management between patients and providers is one way to align the disconnect observed in this study.

Practice Pearls:

• More patients with T2DM are frustrated with their suboptimal glycemic control than physicians realize.
• Many patients with T2DM are willing to do more to achieve their glycemic goals than physicians believe.
• Better communication at the beginning of insulin therapy, to align patient’s and physician’s treatment priorities, expectations, and T2DM management goals, may help minimize therapeutic inertia and patient frustration.

1. Kowart, Kevin. “Overbasalization: Addressing Hesitancy in Treatment Intensification Beyond Basal Insulin.” Clinical Diabetes, vol. 38,3 (2020): 304-310. https://doi.org/10.2337/cd19-0061
2. American Diabetes Association. “Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2020.” Diabetes Care vol. 43 (Supplement 1) (2020): S98-S110. https://doi.org/10.2337/dc20-S009
3. Umpierrez, Guillermo, et al. “When basal insulin is not enough: A dose-response relationship between insulin glargine 100 units/mL and glycaemic control.” Diabetes Obes Metab. vol. 21 (2019):1305-1310. https://doi.org/10.1111/dom.13653
4. Edelman, Steven. “Patients With Type 2 Diabetes Are Willing to Do More to Overcome Therapeutic Inertia: Results From a Double-Blind Survey”. Clin Diabetes vol.38,1 (2020):222-229. https://doi.org/10.2337/cd19-0067

Louise Brown, PharmD Candidate, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences

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