Division of Endocrinology and Metabolic Diseases, Università della Campania L. Vanvitelli, Piazza L. Miraglia, 2, 80138, Naples, Italy.
Diabetes Unit, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, Università della Campania L. Vanvitelli, Naples, Italy.
J Endocrinol Invest. 2019 May;42(5):495-503. doi: 10.1007/s40618-018-0951-8. Epub 2018 Oct 6.
Clinical inertia and medication non-adherence are thought to contribute largely to the suboptimal glycemic control in many patients with type 2 diabetes. The present review explores the relations between A1C targets, clinical inertia and medication non-adherence in type 2 diabetes.
We searched PubMed for English-language studies published from 2001 through June 1, 2018. We also manually searched the references of selected articles, reviews, meta-analyses, and practice guidelines. Selected articles were mutually agreed upon by the authors.
Clinical inertia is the failure of clinicians to initiate or intensify therapy when indicated, while medication non-adherence is the failure of patients to start or continue therapy that a clinician has recommended. Although clinical inertia may occur at all stages of diabetes treatment, the longest delays were reported for initiation or intensification of insulin. Medication non-adherence to antidiabetic drugs may range from 53 to 65% at 1 year and may be responsible for uncontrolled A1C in about 23% of cases. Reverse clinical inertia can be acknowledged as the failure to reduce or change therapy when no longer needed or indicated. Clinical inertia and medication non-adherence are difficult to address: clinician-and patient-targeted educational programs, more connected communications between clinicians and patients, the help of other health professional figures (nurse, pharmacist) have been explored with mixed results.
Both clinical inertia and medication non-adherence remain significant barriers to optimal glycemic targets in type 2 diabetes. Moreover, part of clinical inertia may be a way through which clinicians face current uncertainty in medicine, including some dissonance among therapeutic guidelines. Scientific associations should find an agreement about how to measure and report clinical inertia in clinical practice and should exhort clinicians to consider reverse clinical inertia as a cause of persisting inappropriate therapy in vulnerable patients.
临床惰性和药物依从性差被认为是导致许多 2 型糖尿病患者血糖控制不佳的主要原因。本综述探讨了 2 型糖尿病患者的糖化血红蛋白目标、临床惰性和药物不依从性之间的关系。
我们在 PubMed 上搜索了 2001 年至 2018 年 6 月 1 日发表的英文研究。我们还手动搜索了选定文章、综述、荟萃分析和实践指南的参考文献。选定的文章由作者共同商定。
临床惰性是指临床医生在需要时未能启动或加强治疗，而药物不依从性是指患者未能开始或继续接受临床医生建议的治疗。虽然临床惰性可能发生在糖尿病治疗的所有阶段，但胰岛素的起始或强化治疗的延迟最长。抗糖尿病药物的药物不依从性在 1 年内可能高达 53%至 65%，并且可能导致约 23%的病例无法控制糖化血红蛋白。当不再需要或不适合时，未能减少或改变治疗可被认为是反向临床惰性。临床惰性和药物不依从性难以解决：针对临床医生和患者的教育计划、临床医生和患者之间更紧密的沟通、其他健康专业人士（护士、药剂师）的帮助都进行了探索，但结果喜忧参半。
临床惰性和药物不依从性仍然是 2 型糖尿病实现最佳血糖目标的重要障碍。此外，部分临床惰性可能是临床医生面对当前医学不确定性的一种方式，包括治疗指南之间的一些不和谐。科学协会应就如何在临床实践中衡量和报告临床惰性达成一致，并敦促临床医生将反向临床惰性视为导致脆弱患者持续不适当治疗的原因。
