Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus

Abstract

Many people with type 2 diabetes mellitus (T2DM) fail to achieve glycaemic control promptly after diagnosis and do not receive timely treatment intensification. This may be in part due to 'clinical inertia', defined as the failure of healthcare providers to initiate or intensify therapy when indicated. Physician-, patient- and healthcare-system-related factors all contribute to clinical inertia. However, decisions that appear to be clinical inertia may, in fact, be only 'apparent' clinical inertia and may reflect good clinical practice on behalf of the physician for a specific patient. Delay in treatment intensification can happen at all stages of treatment for people with T2DM, including prescription of lifestyle changes after diagnosis, introduction of pharmacological therapy, use of combination therapy where needed and initiation of insulin. Clinical inertia may contribute to people with T2DM living with suboptimal glycaemic control for many years, with dramatic consequences for the patient in terms of quality of life, morbidity and mortality, and for public health because of the huge costs associated with uncontrolled T2DM. Because multiple factors can lead to clinical inertia, potential solutions most likely require a combination of approaches involving fundamental changes in medical care. These could include the adoption of a person-centred model of care to account for the complex considerations influencing treatment decisions by patients and physicians. Better patient education about the progressive nature of T2DM and the risks inherent in long-term poor glycaemic control may also reinforce the need for regular treatment reviews, with intensification when required.

Triple therapy with low‐dose dapagliflozin plus saxagliptin versus dual therapy with each monocomponent, all added to metformin, in uncontrolled type 2 diabetes

“…Clinical inertia, defined as failure to intensify anti‐hyperglycaemic therapy in a timely manner, has been proposed as one explanation for these findings when sequential therapy is used. Although many factors contribute to clinical inertia, this traditional sequential treatment paradigm for type 2 diabetes, comprising stepwise addition of anti‐hyperglycaemic agents to initial metformin monotherapy in response to increased glycated haemoglobin (HbA1c) levels, may be a major reason why some patients experience delays in reaching their glycaemic goals …”

“…clinical inertia, 4 this traditional sequential treatment paradigm for type 2 diabetes, comprising stepwise addition of anti-hyperglycaemic agents to initial metformin monotherapy in response to increased glycated haemoglobin (HbA1c) levels, may be a major reason why some patients experience delays in reaching their glycaemic goals. [5][6][7] An alternative approach to type 2 diabetes treatment is simultaneous combination therapy with anti-hyperglycaemic agents that have complementary mechanisms of action, and therefore target multiple physiological defects.…”

Efficacy and safety of lixisenatide as add‐on therapy to basal insulin in older adults with type 2 diabetes in the GetGoal‐O Study

“…Despite these recommendations, clinical inertia, defined as the failure to intensify treatment when required, is common in clinical practice in patients with T2D . In a UK study of patients treated with basal insulin who were clinically eligible for treatment intensification, only 31% had their treatment intensified, with a median time to intensification of 3.7 years .…”

“…7 Despite these recommendations, clinical inertia, defined as the failure to intensify treatment when required, is common in clinical practice in patients with T2D. [10][11][12][13][14][15][16][17] In a UK study of patients treated with basal insulin who were clinically eligible for treatment intensification, only 31% had their treatment intensified, with a median time to intensification of 3.7 years. 11 Delay in treatment intensification in patients with uncontrolled T2D has been shown to have a number of clinical consequences, including a significantly increased risk of myocardial infarction, heart failure, stroke, and a composite endpoint of cardiovascular events, 18 as well as a higher incidence of (and significantly shorter median time to) progression of diabetic retinopathy.…”

Real-World Adequacy of Glycaemic Control in Treatment-Naïve Greek Patients with Type 2 Diabetes Mellitus Initiating Treatment with Metformin Monotherapy at the Maximum Tolerated Dose: The Reload Study

“…Despite the recommendations for strict glucose control, numerous studies have shown that increased HbA 1c levels may persist for long periods of time in patients with T2DM [8,9]; these findings likely reflect the progressive nature of the disease but are also attributed to 'clinical inertia' which is defined as a failure to 'intensify therapy when indicated, or a failure to act despite recognition of the problem' [10]. Clinical inertia in the management of patients with T2DM may result in suboptimal glycaemic control, which is associated with increased incidence of cardiovascular events [11].…”