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Type 2 Diabetes Treatment Intensifies

Mar 19, 2016

Patients with greater disease burden more likely to receive therapy  increase.

Type 2 diabetes is a growing concern in the United States. The number of adults in the United States with type 2 diabetes has been growing at an alarming rate. According to the Center for Disease Control and Prevention, the number of adults with type 2 diabetes has quadrupled from 1980 to 2014, going from 5.5 million to 21.9 million adults.


Individuals with diabetes have high blood glucose levels, also known as hyperglycemia. Individuals are usually started on metformin if lifestyle modifications are not sufficient, but due to the progressive nature of diabetes, most patients eventually require the addition of other medication. As their disease state progresses, a patient’s therapy must be intensified in a timely manner to avoid greater risk of complications. There are many different factors that could delay treatment intensifications such as nonadherence, financial burden, or polypharmacy. Healthcare providers could also be facing competing clinical demands or lack of awareness that could hinder their intervention and practices.

However, recent studies reveal that the percentage of diabetic patients in the United States meeting glycemic goals has increased. The increase could be attributed to the increased public focus on diabetes.

A large retrospective secondary data analysis of adults 18 years and older with type 2 diabetes looked at diabetes therapy intensification in 75,069 treatment naïve adults between 2002 and 2007. The study participants’ mean age was 60 years old, 49.7% were women, and 63.1% were non-hispanic white. The study found that diabetes therapy was intensified in 26,169 individuals (34.6%). After adjusting for significant confounders including sex, income level, education, and comorbidity burden, the study found that individuals were more likely to have therapy intensification over time than compared to the cohorts from 2002 to 2003. The study found that sulfonylureas were the most commonly used second-line agents. Over time, sulfonylurea and thiazolidinedione use have decreased while incretin use has increased. The study found that patients with greater disease burden were more likely to receive increase in therapy contradicting current guideline recommendations for a more cautious and less intensive therapeutic approach. The reason for increased therapy in greater disease-burdened patients could be that they are more likely to see healthcare providers more often, which increases their opportunities for therapy increase.

The choice of second-line therapy changed with time over the course of the study. While metformin is the most used drug as first-line therapy, there is no clear consensus on second-line therapy. The decrease in sulfonylurea use as a second-line therapy could be attributed to a loss in market share to newer agents that are better marketed, with potentially less side effects. The study also saw a significant decline in thiazolidinedione use with time. The decrease in thiazolidinedione could be attributed to rosiglitazone being linked to increased risk of cardiovascular events, while pioglitazone increased risk of fractures and bladder cancer. The increase in incretin use may be due to their low risk of hypoglycemia and weight gain. The study could not determine if the type of pharmacy benefit each patient had could affect the patient’s adherence as well as provider treatment options. The study did not include patients covered by public health plans; thus the study is not a complete representation of the population. Overall, the study found a steady increase in diabetes therapy intensification. However, the study could not assess the long term outcomes for patients as well as see how the increase in therapy affects the patients’ quality of life.

Practice Pearls:

  • Data looking at 2 years cohorts from 2002 to 2010 showed that patients are more likely to receive diabetes treatment intensification over time.
  • Sulfonylureas are the most commonly used second-line therapy, however, introduction of newer agents may have resulted in their loss of market share.
  • The use of thiazolidinedione has been decreasing over time as rosiglitazone has been linked to increased cardiovascular disease and pioglitazone has increased risk of fractures and bladder cancer. Incretin use has been steadily climbing with time.

Researched and prepared by Jimmy Tran, Doctor of Pharmacy Candidate LECOM reviewed by Dave Joffe, BSPharm, CDE
Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: US Department of Health and Human Services; 2014.

McCoy, Rozalina G., et al. “Changing trends in type 2 diabetes mellitus treatment intensification, 2002-2010.” Am J Manag Care 21.5 (2015): e288-e296.

American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033-1046.