Journal Article

The Burden of Treatment Failure in Type 2 Diabetes

Andrew Perry, Jonathan B. Brown, Gregory A. Nichols

2004

Overview

The Burden of Treatment Failure in Type 2 Diabetes Jonathan B. Brown , PHD, MPP 1 , Gregory A. Nichols , PHD 1 and Andrew Perry , MA HONS, MSC 2 1 Kaiser Permanente Center for Health Research, Portland, Oregon 2 GlaxoSmithKline Research & Development, Philadelphia, Pennsylvania Address correspondence and reprint requests to Jonathan B. Brown, PhD, Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227-1110. E-mail: jonathan.brown{at}kpchr.org Abstract OBJECTIVE —In type 2 diabetes, therapies to maintain blood glucose control usually fail after several years. We estimated the glycemic burden that accumulates from treatment failure and describe the time course and predictors of failure. RESEARCH DESIGN AND METHODS —A prospective, population-based study using retrospective observational data. We identified all 7,208 complete courses of treatment with nondrug therapy, sulfonylurea monotherapy, metformin monotherapy, and combination oral antihyperglycemic therapy between 1994 and 2002, inclusive, among members of the Kaiser Permanente Northwest Region. We calculated mean cumulative glycemic burden, defined as HbA 1c -months >8.0 or 7.0% for each treatment. We then measured the likelihood that the next HbA 1c would exceed 8.0 and 7.0% after HbA 1c exceeded each of ten hypothetical treatment thresholds. Finally, we estimated multivariate logistic regression models to predict when HbA 1c would continue to deteriorate. RESULTS —In this well-controlled population, the average patient accumulated nearly 5 HbA 1c -years of excess glycemic burden >8.0% from diagnosis until starting insulin and about 10 HbA 1c -years of burden >7.0%. Whenever patients crossed the American Diabetes Association-recommended treatment threshold of 8.0%, their next HbA 1c result was as likely to be <8.0 as >8.0%. Multivariate prediction models had highly statistically significant coefficients, but predicted <10% of the variation in future HbA 1c results. CONCLUSIONS —Clinicians should change glucose-lowering treatments in type 2 diabetes much sooner or use treatments that are less likely to fail. An action point at 7.0% or lower is more likely to prevent additional deterioration than the traditional action point of 8.0%. ADA, American Diabetes Association KPNW, Kaiser Permanente Northwest Footnotes J.B.B. and G.A.N. have received research support from Eli Lilly and Wyeth. A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Accepted April 15, 2004. Received December 31, 2003. DIABETES CARE

• Publisher: American Diabetes Association
• Subject: Analysis / Biological and medical sciences / Blood Glucose - metabolism / Blood sugar / Care and treatment / Control / Diabetes / Diabetes Mellitus, Type 2 - blood / Diabetes Mellitus, Type 2 - therapy / Diabetes therapy / Diabetes. Impaired glucose tolerance / Diet, Diabetic / Endocrine pancreas. Apud cells (diseases) / Endocrinopathies / Etiopathogenesis. Screening. Investigations. Target tissue resistance / Female / Glycated Hemoglobin A - analysis / Health Maintenance Organizations - standards / Humans / Hypoglycemic Agents - therapeutic use / Male / Medical sciences / Medical treatment / Middle Aged / Oregon / Time Factors / Treatment Failure / Type 2 diabetes / Washington