Antihyperglycemics in Patients With Newly Diagnosed T2DM
Antihyperglycemics in Patients With Newly Diagnosed T2DM
The present study assessed the time to antihyperglycaemic medication initiation in a UK cohort of patients with newly diagnosed type 2 diabetes and found that the proportion of patients who had antihyperglycaemic therapy initiated after 2 years of follow up was 51%, with lower rates of treatment initiation observed in older compared to younger individuals. This percentage is less than the 75% of Dutch patients with type 2 diabetes who initiated oral antihyperglycaemic therapy within 2 years of diagnosis. In a Danish cohort, 70% of newly diagnosed diabetic patients received antihyperglycaemic therapy after nearly 6 years of follow up, despite a mean baseline HbA1c level of 10.2%. Glycaemic control has been shown to deteriorate over time in patients with newly diagnosed type 2 diabetes, specifically those untreated with antihyperglycaemic medication (i.e., receiving only diet and lifestyle intervention). Therefore, given that the mean HbA1c was ~8.0% around the time of diagnosis for those with measurements and in the absence of other factors, more patients should have been initiated on antihyperglycaemic medications over the 2-year period than the 51% observed in the present study.
Although various algorithms for treatment of type 2 diabetes were in place or introduced during the time period assessed for our study (2003–2007), the recommendations are generally similar for patients with newly diagnosed type 2 diabetes. The recommendations include language stating that lifestyle modifications should be initiated with follow-up assessment of glycaemic control (i.e., fasting glucose and HbA1c) within a 3 to 6 month period. If HbA1c targets are not achieved with lifestyle modifications, initiation of antihyperglycaemic medication should be considered along with continuation of lifestyle changes. Despite such recommendations, this study demonstrated that 2 years after initial diagnosis of type 2 diabetes, a large proportion of patients remain untreated. The proportion of untreated patients was inversely related to the HbA1c values with a greater proportion of patients receiving treatment as HbA1c increased. However, 30% of patients with an HbA1c value ≥ 7.5% at the end of follow up had not yet received treatment, despite the apparent need for treatment based on guidelines.
Management of type 2 diabetes is related to a myriad of patient-, physician, and systematic-related factors. Patient age may affect treatment initiation or intensification and limit treatment choices because of the increased likelihood of co-morbidities and frailty in older patients. In the present study older patients were more likely to have pre-existing, co-morbid conditions. After adjusting for these differences, increasing age was still associated with a decreased likelihood of physician prescribing of antihyperglycaemic medication. Similar findings were found with a US cohort of patient with newly diagnosed type 2 diabetes. Conversely, higher HbA1c values near the time of diagnosis increased the likelihood of a physician initiating antihyperglycaemic medication. Younger patients had higher HbA1c at diagnosis, which account for part of the higher rates of treatment initiation relative to older patients. When controlling for HbA1c values at diagnosis, older patients were less likely to initiate treatment than younger patients. However, a significant interaction was observed between age and HbA1c values ≥ 7.5% at diagnosis, suggesting that the influence of age on non-treatment with antihyperglycaemic medication was reduced as HbA1c increased above 7.5%. Similar trends were observed when HbA1c at the end of follow up was used in the analysis. It is apparent that older patients in this study were not treated as frequently with antihyperglycaemic therapy as younger patients with the same HbA1c level. A recent survey study evaluated the reasons UK general practitioners do not treat their newly diagnosed type 2 diabetes patients with antihyperglycaemic medications. Reasons cited by the general practitioners were those related to adequate glycaemic control for both younger and older patients. However, issues related to safety of antihyperglycaemic agents, burden to the patients, or cognitive or physical function of the patient were selected more often by GPs for not treating their older patients. Collectively, the present findings are consistent with the less stringent, glycaemic target recommendations for older adults, especially those with pre-existing, co-morbid conditions.
In addition, the development or treatment of co-morbid conditions during the follow-up period was positively associated with initiating antihyperglycaemic treatment. The new conditions may have prompted the physician to evaluate glycaemic control in the context of increased risk factors for cardiovascular disease, as recommended by treatment guidelines. Of the patients who initiated treatment, median time to start treatment was approximately 2 months. This is consistent with clinical guidelines in place at the time (2003–2007) that suggested initiating antihyperglycaemic treatment if inadequate glycaemic control was present after a short period (3 to 6 months) of lifestyle intervention.
These limitations should be considered when interpreting the present results. HbA1c measures around the time of diagnosis were available for only 55% of the patients. Thus, the HbA1c results may not reflect the true baseline value at the time of diagnosis for the entire cohort. The study had only a 2-year follow-up period. If one more year of follow up was added, the patient count would have been reduced by 15–30%. Although eligible patients had to be at least 30 years old and were identified using ICD-10 codes for type 2 diabetes, some patients with type 1 diabetes may have been incorrectly indentified as having type 2 diabetes, although the number is likely to have been small.
In summary, in this UK cohort of patients with newly diagnosed type 2 diabetes, only 51% had antihyperglycaemic medication initiated over a 2-year period following diagnosis, with older patients significantly less likely to have been prescribed medication by their physicians. Elevated HbA1c was the strongest factor associated with initiating antihyperglycaemic medication in these patients. These results highlight the under-treatment of older adults with type 2 diabetes. Further research is needed to better understand the reasons for the observed differences between younger and older patients with type 2 diabetes.
Discussion
The present study assessed the time to antihyperglycaemic medication initiation in a UK cohort of patients with newly diagnosed type 2 diabetes and found that the proportion of patients who had antihyperglycaemic therapy initiated after 2 years of follow up was 51%, with lower rates of treatment initiation observed in older compared to younger individuals. This percentage is less than the 75% of Dutch patients with type 2 diabetes who initiated oral antihyperglycaemic therapy within 2 years of diagnosis. In a Danish cohort, 70% of newly diagnosed diabetic patients received antihyperglycaemic therapy after nearly 6 years of follow up, despite a mean baseline HbA1c level of 10.2%. Glycaemic control has been shown to deteriorate over time in patients with newly diagnosed type 2 diabetes, specifically those untreated with antihyperglycaemic medication (i.e., receiving only diet and lifestyle intervention). Therefore, given that the mean HbA1c was ~8.0% around the time of diagnosis for those with measurements and in the absence of other factors, more patients should have been initiated on antihyperglycaemic medications over the 2-year period than the 51% observed in the present study.
Although various algorithms for treatment of type 2 diabetes were in place or introduced during the time period assessed for our study (2003–2007), the recommendations are generally similar for patients with newly diagnosed type 2 diabetes. The recommendations include language stating that lifestyle modifications should be initiated with follow-up assessment of glycaemic control (i.e., fasting glucose and HbA1c) within a 3 to 6 month period. If HbA1c targets are not achieved with lifestyle modifications, initiation of antihyperglycaemic medication should be considered along with continuation of lifestyle changes. Despite such recommendations, this study demonstrated that 2 years after initial diagnosis of type 2 diabetes, a large proportion of patients remain untreated. The proportion of untreated patients was inversely related to the HbA1c values with a greater proportion of patients receiving treatment as HbA1c increased. However, 30% of patients with an HbA1c value ≥ 7.5% at the end of follow up had not yet received treatment, despite the apparent need for treatment based on guidelines.
Management of type 2 diabetes is related to a myriad of patient-, physician, and systematic-related factors. Patient age may affect treatment initiation or intensification and limit treatment choices because of the increased likelihood of co-morbidities and frailty in older patients. In the present study older patients were more likely to have pre-existing, co-morbid conditions. After adjusting for these differences, increasing age was still associated with a decreased likelihood of physician prescribing of antihyperglycaemic medication. Similar findings were found with a US cohort of patient with newly diagnosed type 2 diabetes. Conversely, higher HbA1c values near the time of diagnosis increased the likelihood of a physician initiating antihyperglycaemic medication. Younger patients had higher HbA1c at diagnosis, which account for part of the higher rates of treatment initiation relative to older patients. When controlling for HbA1c values at diagnosis, older patients were less likely to initiate treatment than younger patients. However, a significant interaction was observed between age and HbA1c values ≥ 7.5% at diagnosis, suggesting that the influence of age on non-treatment with antihyperglycaemic medication was reduced as HbA1c increased above 7.5%. Similar trends were observed when HbA1c at the end of follow up was used in the analysis. It is apparent that older patients in this study were not treated as frequently with antihyperglycaemic therapy as younger patients with the same HbA1c level. A recent survey study evaluated the reasons UK general practitioners do not treat their newly diagnosed type 2 diabetes patients with antihyperglycaemic medications. Reasons cited by the general practitioners were those related to adequate glycaemic control for both younger and older patients. However, issues related to safety of antihyperglycaemic agents, burden to the patients, or cognitive or physical function of the patient were selected more often by GPs for not treating their older patients. Collectively, the present findings are consistent with the less stringent, glycaemic target recommendations for older adults, especially those with pre-existing, co-morbid conditions.
In addition, the development or treatment of co-morbid conditions during the follow-up period was positively associated with initiating antihyperglycaemic treatment. The new conditions may have prompted the physician to evaluate glycaemic control in the context of increased risk factors for cardiovascular disease, as recommended by treatment guidelines. Of the patients who initiated treatment, median time to start treatment was approximately 2 months. This is consistent with clinical guidelines in place at the time (2003–2007) that suggested initiating antihyperglycaemic treatment if inadequate glycaemic control was present after a short period (3 to 6 months) of lifestyle intervention.
These limitations should be considered when interpreting the present results. HbA1c measures around the time of diagnosis were available for only 55% of the patients. Thus, the HbA1c results may not reflect the true baseline value at the time of diagnosis for the entire cohort. The study had only a 2-year follow-up period. If one more year of follow up was added, the patient count would have been reduced by 15–30%. Although eligible patients had to be at least 30 years old and were identified using ICD-10 codes for type 2 diabetes, some patients with type 1 diabetes may have been incorrectly indentified as having type 2 diabetes, although the number is likely to have been small.
In summary, in this UK cohort of patients with newly diagnosed type 2 diabetes, only 51% had antihyperglycaemic medication initiated over a 2-year period following diagnosis, with older patients significantly less likely to have been prescribed medication by their physicians. Elevated HbA1c was the strongest factor associated with initiating antihyperglycaemic medication in these patients. These results highlight the under-treatment of older adults with type 2 diabetes. Further research is needed to better understand the reasons for the observed differences between younger and older patients with type 2 diabetes.
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