The Predictors and Impact of Intensification of Antihyperglycemic Therapy in Type 2 Diabetes: Translating Research into Action for Diabetes (TRIAD)

  1. Laura N. McEwen, PhD (lmattei{at}med.umich.edu)1,
  2. Dori Bilik, MBA1,
  3. Susan L. Johnson, MD, MS1,
  4. Jeffrey B. Halter, MD2,
  5. Andrew J. Karter, PhD3,
  6. Carol M. Mangione, MD4,
  7. Usha Subramanian, MD5,
  8. Beth Waitzfelder, PhD6,
  9. Jesse C. Crosson, PhD7 and
  10. William H. Herman, MD, MPH1,8
  1. 1Department of Internal Medicine/Metabolism, Endocrinology and Diabetes; University of Michigan, Ann Arbor, MI
  2. 2Department of Internal Medicine/Geriatric Medicine; University of Michigan, Ann Arbor, MI
  3. 3Kaiser Permanente, Oakland, CA
  4. 4University of California, Los Angeles, Los Angeles, CA
  5. 5Division of General Internal Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
  6. 6Pacific Health Research Institute, Honolulu, HI
  7. 7Department of Family Medicine, New Jersey Medical School and Research Division, Department of Family Medicine, Robert Wood Johnson Medical School, University of Medicine and Dentistry New Jersey, Somerset, NJ
  8. 8Department of Epidemiology, University of Michigan, Ann Arbor, MI

    Abstract

    Objective: To examine the predictors of intensification of antihyperglycemic therapy in patients with type 2 diabetes; its impact on HbA1c, body weight, symptoms of anxiety/depression, and health status; and patient characteristics associated with improvement in HbA1c.

    Research Design and Methods: We analyzed survey, medical record, and health plan administrative data collected in Translating Research into Action for Diabetes (TRIAD). We examined patients who were using diet/exercise or oral antihyperglycemic medications at baseline, had HbA1c > 7.2%, and stayed on the same therapy or intensified therapy (initiated or increased the number of classes of oral antihyperglycemic medications or began insulin) over 18 months.

    Results: 520 of 1093 patients intensified therapy with oral medications or insulin. Patients intensifying therapy were 58±12 years of age, had diabetes duration of 11±9 years, and HbA1c of 9.1 ± 1.5%. Younger age and higher HbA1c were associated with therapy intensification. Compared to patients who did not intensify therapy, those who intensified therapy experienced a 0.49% reduction in HbA1c (p<0.0001), 3 pound increase in weight (p=0.003), and no change in anxiety/depression (p=0.5) or health status (p=0.2). Among those who intensified therapy, improvement in HbA1c was associated with higher baseline HbA1c, older age, black race/ethnicity, lower income, and more physician visits.

    Conclusion: Treatment intensification improved glycemic control with no worsening of anxiety/depression or health status, especially in elderly, lower income, and minority patients with type 2 diabetes. Interventions are needed to overcome clinical inertia when patients might benefit from treatment intensification and improved glycemic control.

    Footnotes

      • Received October 21, 2008.
      • Accepted February 12, 2009.

    This Article

    1. Published online before print February 19, 2009, doi: 10.2337/dc08-1911
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