Delays in treatment intensification with oral antidiabetic drugs and risk of microvascular and macrovascular events in patients with poor glycaemic control: An individual patient simulation study

• Published in: Diabetes, obesity & metabolism obesity & metabolism, 2017-07, Vol.19 (7), p.1006-1013
• Main Authors: Folse, Henry J., Mukherjee, Jayanti, Sheehan, John J., Ward, Alexandra J., Pelkey, Ryan L., Dinh, Tuan A., Qin, Lei, Kim, Jennifer
• Format: Article
• Language: English
• Subjects: Administration, Oral; antidiabetic drug; Antidiabetics; Cohort Studies; Diabetes Mellitus, Type 2 - blood; Diabetes Mellitus, Type 2 - complications; Diabetes Mellitus, Type 2 - drug therapy; Diabetic Angiopathies - epidemiology; Diabetic Angiopathies - physiopathology; Diabetic Angiopathies - prevention & control; Dipeptidyl-peptidase IV; DPP‐4 inhibitor; Drug Monitoring; Drug Resistance; Drug Therapy, Combination - adverse effects; Female; Glycated Hemoglobin A - analysis; Hemoglobin; Humans; Hyperglycemia - prevention & control; Hypoglycemia; Hypoglycemia - chemically induced; Hypoglycemia - prevention & control; Hypoglycemic Agents - administration & dosage; Hypoglycemic Agents - adverse effects; Hypoglycemic Agents - therapeutic use; macrovascular disease; Male; Middle Aged; Models, Cardiovascular; Patient Simulation; Patients; Practice Guidelines as Topic; Retrospective Studies; Risk Factors; Severity of Illness Index; sulphonylureas; thiazolidinediones; Time-to-Treatment
• ISSN: 1462-8902; 1463-1326
• DOI: 10.1111/dom.12913

Aims To use the Archimedes model to estimate the consequences of delays in oral antidiabetic drug (OAD) treatment intensification on glycaemic control and long‐term outcomes at 5 and 20 years. Materials and methods Using real‐world data, we modelled a cohort of hypothetical patients with glycated haemoglobin (HbA1c) ≥8%, on metformin, with no history of insulin use. The cohort included 3 strata based on the number of OADs taken at baseline. The first add‐on in the intensification sequence was a sulphonylurea, next was a dipeptidyl peptidase‐4 inhibitor, and last, a thiazolidinedione. The scenarios included either no delay or delay, based on observed and extrapolated times to intensification. Results At 1 year, HbA1c was 6.8% for patients intensifying without delay, and 8.2% for those delaying intensification. For no delay vs delay, risks of major adverse cardiac events, myocardial infarction, heart failure and amputations were reduced by 18.0%, 25.0%, 13.7%, and 20.4%, respectively, at 5 years; severe hypoglycaemia risk, however, increased to 19% for the no delay scenario vs 12.5% for delay. At 20 years, the results showed similar trends to those at 5 years. Conclusions Timing of intensification of OAD therapy according to guideline recommendations led to greater reductions in HbA1c and lower risks of complications, but higher risks of hypoglycaemia than delaying intensification. These results highlight the potential impact of timely treatment intensification on long‐term outcomes.