Doctors slow to switch diabetes treatment when drugs don't work

When type 2 diabetes isn’t well controlled with oral medications, doctors are often slow to switch patients to more intensive treatment, a U.S. study suggests.

Researchers found that only about one-third of patients with poorly controlled blood sugar on oral drugs were switched to higher doses, different drugs or insulin within six months.

At the start of the study, all of the patients had been taking two oral diabetes drugs for at least six months. But they still had poorly controlled diabetes based on blood tests showing so-called hemoglobin A1c levels, which reflect average blood sugar levels over about three months. Readings above 6.5 signal diabetes, and everyone in the study had readings of at least 7.

Under U.S. guidelines for managing diabetes, all such patients should be switched to more intense treatment, researchers note in Diabetes Care. But six months after the start of the study, doctors had only prescribed more intense therapy for 37 percent of these patients.

“Generally speaking, if a patient’s A1c is above target, it will either remain there or get worse,” said lead study author Dr. Kevin Pantalone of the Cleveland Clinic in Ohio. “It does not usually get better.”

Globally, about one in 10 adults has diabetes, according to the World Health Organization. Most have type 2 diabetes, which is associated with obesity and aging and occurs when the body can’t make or process enough of the hormone insulin.

Medications as well as lifestyle changes such as improved diet and exercise habits can help manage diabetes and keep symptoms in check. When diabetes isn’t well managed, however, dangerously high blood sugar can eventually lead to blindness, amputations, kidney failure, heart disease and stroke.

Too often, doctors and patients will find reasons not to intensify treatment, making these complications more likely, Pantalone said by email.

“Whether it be the patient saying for the fifth time ‘I will start watching my diet and start exercising,’ or a physician saying ‘the A1c is close to goal and I don’t really want to add yet another medication and copay, we will wait and see what happens in another 3 months,’ the end result is lack of intensification and A1c goal attainment,” Pantalone said.

In the current study, researchers examined electronic health records for 7,389 patients with poorly controlled diabetes who were treated at the Cleveland Clinic between 2005 and 2016.

People with the most poorly controlled blood sugar were more likely to get more intense treatment, the study found.

Among patients with A1c readings from 7 to 7.9, just 28 percent of patients were switched to more intense treatment during the study.

However, about 47 percent of patients with A1c readings from 8 to 8.9 were switched, as were almost 60 percent of patients with A1c readings of 9 or higher.

The study wasn’t a controlled experiment designed to prove whether or how treatment intensification might directly improve blood sugar. Researchers also lacked data to explain why doctors or patients might have decided against a change in therapy. And the study didn’t show whether failure to switch treatment regimens resulted in diabetes complications.

Still, such complications can become more likely the longer patients go with poorly controlled blood sugar, said Dr. Vanessa Arguello of the David Geffen School of Medicine at the University of California, Los Angeles.

“When appropriate, patients need to be involved in escalating their diabetes care to prevent diabetic complications and stay healthy,” Arguello, who wasn’t involved in the study, said by email.

“Patients should empower themselves by checking their blood sugars daily, knowing what their target blood sugar levels should be, and having regular appointments with their doctor,” Arguello added. “If patients are having blood sugars above their target blood sugar levels then this may be a warning sign that they need to talk with their physician on how to take a different approach in managing their diabetes.”