The American Diabetes Association 72nd Scientific Sessions:

Patients Who Fail Multiple OADs: Add a Third Agent or Suggest Insulin?

Type 2 diabetes patients may encounter this challenge:  they may not achieve the blood glucose goals they would like with multiple oral antidiabetic agents (OADs).  At that point, practitioners have a choice for how to continue treating.  They can add a third OAD, use a GLP-1 agonist, or prescribe insulin.

In order to look at how this challenge is being dealt with in the clinical setting, a recent study examined data from IMPACT ® (a managed care claim database).  This research was presented at the American Diabetes Association 72nd Scientific Sessions in a poster called “Treatment Patterns and A1c Reduction After Adding a 3rd Agent to 2 Oral Antidiabetic Drugs (OADs).”1

Data from 200o to 2011 were analyzed.  The index drug was the third agent added, and the patients were grouped by index drug added:  third OAD (3OAD), GLP-1 agonist (+GLP1), and insulin (+ins).  There were 51,771 patients, and they fell into the following groups:

  • 3OAD: 79.3%
  • +ins:  17.3%  (This group had the highest A1c levels, and they were the oldest.)
  • +GLP1:  7.4% (This group had the lowest baseline A1c levels, and they were the youngest.)

One-year and two-year follow-up persistence (no switching or discontinuing the index drug) and A1c results were noted.

Third Oral Antidiabetic Agent Results

  • Persistent at 1-year but switched before 2-year:  8.9%
  • Persistent at 1-year and 2-years:  72%
  • Switched before 1-year:  8.8%
  • Total 2-year A1c reduction (for all 3OAD patients, regardless of persistence):  -0.64 ± 1.65

Insulin Results

  • Persistent at 1-year but switched before 2-year:  9.0%
  • Persistent at 1-year and 2-years:  57.1%
  • Switched before 1-year:  24.7
  • Total 2-year A1c reduction (for all +ins patients, regardless of persistence):  -0.88 ± 1.92

GLP-1 Agonist Results

  • Persistent at 1-year but switched before 2-year:  17.3%
  • Persistent at 1-year and 2-years:  35.6%
  • Switched before 1-year:  39.8%
  • Total 2-year A1c reduction (for all +GLP1 patients, regardless of persistence):  -0.33 ± 1.52

What the Results Mean
This database analysis showed that most type 2 diabetes patients choose to go on a third oral antidiabetic agent after failing 2 other OADs. 

For patients who added insulin after failing 2 OADs showed the biggest reduction in A1c over 2 years (for the persistent patients).

This data shows the need for prescribing insulin to type 2 diabetes patients who have failed 2 oral antidiabetic agents—and then encouraging them to stay on insulin.

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