Clinical Inertia in Type 2 Diabetes Mellitus: Time in Poor Glycaemic Control Until Treatment Intensification in Patients on DPP-4I And/Or SGLT-2I Treatment

OBJECTIVES: Failure to intensify treatment in patients with type 2 diabetes (T2D) in a timely manner is common. If newer oral antidiabetic drugs (OAD) such as dipep-tidyl peptidase-4 inhibitors (DPP-4i) and sodium/glucose cotransporter 2 inhibitors (SGLT-2i) do not achieve metabolic control, injectable therapy like insulin or glucagon-like Peptide 1 (GLP-1) analogues are required. We investigated the time in poor glycaemic control (PGC, HbAlc >7%) in adult patients with T2D treated with DPP-4i or SGLT-2i until treatment intensification. METHODS: T2D patients >18 years treated with DPP-4i and/or SGLT-2i who have been switched to injectable therapy after a period of PGC from the German-Austrian diabetes follow-up registry (DPV) were studied. Patients were divided into three groups based on OAD therapy prior to injectable therapy: DPP-4i only, SGLT-2i only, combination (DPP-4i+SGLT-2i). PGC was defined as the time from the first HbAlc measurement >7%, with no improvement thereafter, until treatment intensification. RESULTS: We identified 16,591 patients (documented until March 2017) treated with DPP-4i and/or SGLT-2i, of these 2,434 (14.7%) patients with HbAlc continuously >7% were not initiated and 1,130 (6.8%) were initiated on an injectable therapy Mean diabetes duration was 9.1 years, age was 64.5 years on average and mean HbAlc was 8.5% during period of PGC. Most of the patients were treated with DPP-4i only (91.8%), 4.9% had a combination of DPP-4i+SGLT-2i and 3.3% were treated with SGLT-2i only before intensification. Average time on DPP-4i/SGLT-2i therapy was 2.9 years. Mean time in PGC until intensification with injectable therapy was 1.2 years, corresponding to 41% of time on the previous therapy. CONCLUSIONS: Even with newer OAD, not all T2D patients achieve treatment targets for good metabolic control. In real-life care, time interval until treatment intensification with injectable therapy seems long. This may be due to individualized target setting for HbAlc, or reluctance of patients towards injectable therapy.