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Author Notes:

Correspondence: Richard M. Abaniel, richard.abaniel@abbott.com

Acknowledgements: The authors thank William Perlman, PhD, CMPP, for his editorial assistance in developing this article.

Author contributions: J.R.G. contributed to the concept and design of the study, provided data regarding health disparities, participated in writing the initial draft, and provided critical revision of the manuscript. R.M.A. contributed to the acquisition of data, analysis and interpretation of data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. N.S.V. participated in the acquisition of the data, analysis and interpretation of data, and drafting of the manuscript and provided administrative, technical, or logistic support and supervision. All authors reviewed the manuscript and approved its submission. J.R.G. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Competing interests: J.R.G. has served on advisory boards and/or speaker bureaus for Abbott Diabetes Care, Boehringer Ingelheim, Medtronic, and Novo Nordisk. R.M.A. and N.S.V. are employees of Abbott Diabetes Care. No other potential conflicts of interest relevant to this article were reported.

Subject:

Research Funding:

This study was funded by Abbott Diabetes Care, Alameda, CA.

Keywords:

  • insulin initiation
  • heart failure
  • myocardial infarction
  • stroke

Therapeutic Inertia and Delays in Insulin Intensification in Type 2 Diabetes: A Literature Review

Tools:

Journal Title:

Diabetes Specturm

Volume:

Volume 36, Number 4

Publisher:

, Pages 379-384

Type of Work:

Article | Final Publisher PDF

Abstract:

Background Therapeutic inertia leading to delays in insulin initiation or intensification is a major contributor to lack of optimal diabetes care. This report reviews the literature summarizing data on therapeutic inertia and delays in insulin intensification in the management of type 2 diabetes. Methods A literature search was conducted of the Allied & Complementary Medicine, BIOSIS Previews, Embase, EMCare, International Pharmaceutical Abstracts, MEDLINE, and ToxFile databases for clinical studies, observational research, and meta-analyses from 2012 to 2022 using search terms for type 2 diabetes and delay in initiating/intensifying insulin. Twenty-two studies met inclusion criteria. Results Time until insulin initiation among patients on two to three antihyperglycemic agents was at least 5 years, and mean A1C ranged from 8.7 to 9.8%. Early insulin intensification was linked with reduced A1C by 1.4%, reduction of severe hypoglycemic events from 4 to <1 per 100 person-years, and diminution in risk of heart failure (HF) by 18%, myocardial infarction (MI) by 23%, and stroke by 28%. In contrast, delayed insulin intensification was associated with increased risk of HF (64%), MI (67%), and stroke (51%) and a higher incidence of diabetic retinopathy. In the views of both patients and providers, hypoglycemia was identified as a primary driver of therapeutic inertia; 75.5% of physicians reported that they would treat more aggressively if not for concerns about hypoglycemia. Conclusion Long delays before insulin initiation and intensification in clinically eligible patients are largely driven by concerns over hypoglycemia. New diabetes technology that provides continuous glucose monitoring may reduce occurrences of hypoglycemia and help overcome therapeutic inertia associated with insulin initiation and intensification.

Copyright information:

© 2023 by the American Diabetes Association

This is an Open Access work distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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