DAP-Cat group. Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.
CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain.
Diabetes Obes Metab. 2018 Jan;20(1):103-112. doi: 10.1111/dom.13045. Epub 2017 Jul 28.
To determine the patterns and predictors of treatment intensification in patients with type 2 diabetes on ≥2 non-insulin antidiabetic drugs (NIADs) and inadequate glycaemic control in primary care in Catalonia, Spain.
This was a retrospective analysis using electronic medical records from patients with HbA1c ≥ 7% and a first prescription for a new NIAD or insulin recorded from January 2010 to December 2014. Therapeutic inertia was defined as no intensification if HbA1c was ≥8% at baseline or during follow-up. Time to first intensification was evaluated by time-to-event analysis, and factors predicting intensification through a competing-risk regression model.
Among 23 678 patients with HbA1c ≥ 7%, 26.2% were censored without treatment intensification after a median follow up of 4.2 years. Among the 12 730 patients in the subgroup with HbA1c ≥ 8% at baseline or during follow-up, therapeutic inertia was present in 18.1% of cases. In the overall cohort, mean HbA1c at initiation of insulin and NIAD were 9.4% ± 1.5% and 8.7% ± 1.3%, respectively. Median time to first intensification was 17.1 months in patients with HbA1c 8.0% to 9.9%, and 10.1 months in those with HbA1c > 10%. Variables strongly associated with intensification were HbA1c values 8.0% to 9.9% (subhazard ratio [SHR], 1.7; 95% CI, 1.65-1.78) and >10% (SHR, 2.5; 95% CI, 2.37-2.68); diabetes duration ≥20 years (SHR, 1.25; 95% CI, 1.11-1.41) and, to a lesser extent, female gender, presence of comorbidities, chronic kidney disease and microvascular complications.
Intensification was not undertaken in 1 in 5 patients. Both HbA1c thresholds and time until therapy intensification exceeded current recommendations.
在西班牙加泰罗尼亚的初级保健中，确定患有 2 种或以上非胰岛素降糖药物（NIAD）且血糖控制不佳的 2 型糖尿病患者的治疗强化模式和预测因素。
这是一项回顾性分析，使用了 2010 年 1 月至 2014 年 12 月期间记录的 HbA1c≥7%和首次开具新的 NIAD 或胰岛素处方的患者的电子病历。如果基线或随访期间 HbA1c≥8%，则认为存在治疗惰性。通过时间依赖性分析评估首次强化治疗的时间，通过竞争风险回归模型预测强化治疗的因素。
在 23678 名 HbA1c≥7%的患者中，26.2%的患者在中位随访 4.2 年后未经治疗强化而被排除。在基线或随访期间 HbA1c≥8%的 12730 名患者亚组中，18.1%的患者存在治疗惰性。在整个队列中，起始胰岛素和 NIAD 时的平均 HbA1c 分别为 9.4%±1.5%和 8.7%±1.3%。HbA1c 为 8.0%至 9.9%的患者首次强化治疗的中位时间为 17.1 个月，HbA1c>10%的患者为 10.1 个月。与强化治疗密切相关的变量为 HbA1c 值 8.0%至 9.9%（亚危险比[SHR]，1.7；95%置信区间[CI]，1.65-1.78）和>10%（SHR，2.5；95%CI，2.37-2.68）；糖尿病病程≥20 年（SHR，1.25；95%CI，1.11-1.41），以及在较小程度上的女性、合并症、慢性肾脏病和微血管并发症。
1/5 的患者未进行强化治疗。HbA1c 阈值和开始治疗强化的时间均超过了当前的建议。
