Achieving glycemic goals in type 2 diabetes

There is increasing evidence that the majority of individuals with diabetes are not treated to currently recommended glycemic goals. Rubino et al. (abstract 324) analyzed a U.K. database of 31,289 individuals with type 2 diabetes, of whom 2,501 had not received insulin and had A1C >8% despite treatment with two oral hypoglycemic agents (abstract numbers refer to the ADA Scientific Sessions, Diabetes 55 [Suppl. 1], 2006). After 1.8 years, 25% had started insulin; 4.9 years elapsed before half had started insulin, with similar lack of rapidity of treatment intensification among those diagnosed with retinopathy (18%) or neuropathy (7%). With A1C thresholds of 7 and 9%, half had started insulin at 6.3 and 4.2 years, respectively. Similarly, Nichols et al. (abstract 535) identified 4,365 individuals from the Kaiser Permanente Northwest pharmacy records starting sulfonylurea plus metformin, with a mean A1C 8.4%, and 79 and 51% of patients achieving A1C <8% and <7%, respectively. Sixty-six percent of the former group rose to >8% (after a mean of 16 months), and 75% of the latter group rose to >7% (mean of 11 months), with 73% not receiving insulin over 33 months of follow-up. Those whose A1C initially fell below 7% ultimately receiving insulin had mean A1C 9.2% when this treatment was added, at a mean of 28 months. Riedel and Plauschinat (abstracts 552 and 553) assessed treatment patterns of 9,416 type 2 diabetic individuals initiated on oral …