Texas Diabetes Institute and the University of Texas Health Science Center at San Antonio, San Antonio, TX 78207, USA.
Am J Manag Care. 2010 Aug;16(7 Suppl):S195-200.
As demonstrated by suboptimal levels of therapeutic goal achievement, there exists significant room for improvement in type 2 diabetes management. Despite widespread disease awareness and high rates of risk-factor testing in managed care, effective metabolic control in patients with type 2 diabetes is lacking and points toward a phenomenon known as clinical inertia. Clinical inertia, defined as a failure to initiate or advance therapy in a patient who is not at the evidence-based goal, is a key contributing factor in the suboptimal rates of therapeutic target achievement for type 2 diabetes. The causes of clinical inertia are multifactorial and interactive, arising among patients, providers, and health systems and from specific characteristics of available treatments. Therapeutic nonadherence is perhaps the most significant factor contributing to clinical inertia, with recent analyses demonstrating that providers are more likely to prescribe a dose escalation in patients who are adherent to therapy compared with those who are not. While the concept may be counterintuitive, antihyperglycemic agents also have the potential to cause or contribute to the phenomenon of clinical inertia. This often occurs via factors inherent to the drugs themselves, such as treatment-related adverse effects (eg, hypoglycemia, weight gain, edema, gastrointestinal symptoms), perception of long-term safety profiles, and the complexity of the treatment regimen. Often not considered, but equally important, is the durability of an antihyperglycemic agent to maintain glycosylated hemoglobin (A1C) level goals. Because no monotherapy exists to arrest the pancreatic beta-cell failure of type 2 diabetes, early combination therapy with thiazolidinediones and glucagon-like protein-1 agonists that is associated with sustained A1C level reduction is the only hope to change the progressive nature of type 2 diabetes mellitus.
尽管在管理式医疗中普遍存在疾病意识和高风险因素检测率，但 2 型糖尿病的管理仍有很大的改进空间，这表明治疗目标的达标率并不理想。在 2 型糖尿病患者中，有效的代谢控制仍然缺乏，这表明存在一种被称为临床惰性的现象。临床惰性是指在未达到基于证据的目标的患者中，未能启动或推进治疗，这是 2 型糖尿病治疗目标达标率不理想的一个关键因素。临床惰性的原因是多因素和相互作用的，涉及患者、提供者和医疗系统，以及可用治疗方法的具体特征。治疗不依从性可能是导致临床惰性的最重要因素，最近的分析表明，与不依从治疗的患者相比，提供者更有可能为依从治疗的患者开更高剂量的药物。虽然这一概念可能有违直觉，但抗高血糖药物也有可能导致或促成临床惰性现象。这通常是由于药物本身固有的因素引起的，如与治疗相关的不良反应（如低血糖、体重增加、水肿、胃肠道症状）、对长期安全性的看法，以及治疗方案的复杂性。通常不被考虑，但同样重要的是，抗高血糖药物维持糖化血红蛋白（A1C）水平目标的持久性。由于没有单一的疗法可以阻止 2 型糖尿病的胰岛β细胞衰竭，因此早期联合使用噻唑烷二酮类和胰高血糖素样肽-1 激动剂的治疗方案，与持续降低 A1C 水平相关，这是改变 2 型糖尿病进行性性质的唯一希望。
