Treatment Intensification in Type 2 Diabetes: A Real-World Study of 2-OAD Regimens, GLP-1 RAs, or Basal Insulin

Abstract

Introduction: Treatment guidelines recommend a stepwise approach to glycemia management in patients with type 2 diabetes (T2D), but this may result in uncontrolled glycated hemoglobin A1c (HbA1c) between steps. This retrospective analysis compared clinical and economic outcomes among patients with uncontrolled T2D initiating two oral antidiabetes drugs (OADs), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), or basal insulin in a real-world setting.

Methods: Adults with T2D on OAD monotherapy were identified in the MarketScan claims database (2007-2014). Those initiating two OADs (simultaneously or sequentially), GLP-1 RAs, or basal insulin were selected (date of initiation was termed the 'index date'); patients were required to have HbA1c > 7.0% in the 6 months pre-index date. HbA1c was compared from 6 months pre- to 1-year post-index. Annual all-cause healthcare utilization and costs were reported over the 1-year follow-up period.

Results: Data for 6054 patients were analyzed (2-OAD, n = 4442; GLP-1 RA, n = 361; basal insulin, n = 1251). Baseline HbA1c was high in all cohorts, but highest in the basal-insulin cohort. Treatment initiation resulted in reductions in HbA1c in all cohorts, which was generally maintained throughout the follow-up period. Average HbA1c reductions from the 6 months pre- to 1 year post-index date were -1.2% for GLP-1 RA, -1.6% for OADs, and -1.8% for basal insulin. HbA1c < 7.0% at 1 year occurred in 32.6%, 47.5%, and 41.1% of patients, respectively. Annual healthcare costs (mean [SD]) were lowest for OAD (US$10,074 [$22,276]) followed by GLP-1 RA (US$14,052 [$23,829]) and basal insulin (US$18,813 [$37,332]).

Conclusion: Despite robust HbA1c lowering following treatment initiation, many patients did not achieve HbA1c < 7.0%. Basal insulin, generally prescribed for patients with high baseline HbA1c, was associated with a large reduction in HbA1c and with higher costs. Therapy intensification at an appropriate time could lead to clinical and economic benefits and should be investigated further.

Funding: Sanofi U.S., Inc.

Keywords: Basal insulin; Clinical inertia; GLP-1 RA; Oral antidiabetes drugs; Treatment intensification; Type 2 diabetes.

Fig. 1

Database timeline for patient selection. ^aMarketScan database not designed to capture clinical outcomes

Fig. 2

Flow chart showing selection of patients for this analysis. Percentages do not add up to 100% because of rounding. ^aA total of 3897 (74.8%) patients had HbA1c values recorded in the 12-month post-index date period. ^bA total of 274 (72.9%) patients had HbA1c values recorded in the 12-month post-index date period. ^cA total of 878 (68.8%) patients had HbA1c values recorded in the 12-month post-index date period

Fig. 3

Mean HbA1c by cohort and time period among patients with uncontrolled T2D initiating 2-OAD therapy, GLP-1 RA, or basal insulin. a Longitudinal HbA1c, b change from baseline. ^aLast available follow-up measure defined as the last available HbA1c test value observed during the 15-month post-index period