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Barriers to Diabetes Control
Mark E. Molitch, MD
NHANES: Achieving ADA
Recommendations, 2003-2006
• Individuals reaching glycemic control targets:
• HbA1c <7%
57.1%
• Individuals achieving other ADA goals of therapy:
• BP <130/80 mm Hg
45.5%
• LDL <100 mg/dL
46.5%
• Only 12.2% of individuals met all 3 goals
Abbreviations: BP, blood pressure; HbA1c, glycosylated hemoglobin; LDL, low-density lipoprotein;
NHANES, National Health and Nutrition Examination Survey
Cheung BM, et al. Am J Med. 2009;122:443-453.
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Treatment Algorithm for Type 2 Diabetes
STEP 1
At diagnosis:
Lifestyle + Metformin
HbA1c >7.0%
STEP 2
Add basal
insulin
STEP 3
Add
sulfonylurea
Add DPP-4
inhibitor
Add GLP-1
agonist
Add
pioglitazone
Intensive insulin
NOT glyburide, chlorpropamide
NOT rosiglitazone
Abbreviations: DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide
Nathan DM, et al. Diabetes Care. 2009;32:193-203.
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Combination Therapy in Type 2 Diabetes:
Decision Considerations
 HbA1c efficacy
 Reductions from baseline
 Reaching target
 Synergy of mechanisms of action
 Side effects and toxicity profile
 Frequency and severity of hypoglycemia
 Effect on weight gain
 Avoiding polypharmacy and complex
regimens
 Compliance and convenience
 Cost
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Barriers to Diabetes Control
•
•
•
•
Clinical inertia
Financial
Adverse effects of oral agents
Insulin
•
•
•
Fear of injections
Fear of hypoglycemia
Complexity of management
• Targets of treatment
•
Need to adjust to individual patient
• Cultural
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Earlier and More Aggressive Intervention May Improve
Treating to Target Compared With Conventional Therapy
 Typical progression is to wait for HbA1c to reach 8–9%
before moving to next step
Monotherapy
Uptitrate dose of
monotherapy
Add 2nd and then
3rd drug
Moving more aggressively
to more potent treatment can
achieve goal of HbA1c
of < 7% more quickly
Add basal insulin
then multiple
insulin injections
per day
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Advantages & Disadvantages of Type 2 Diabetes Medications
Class (examples)
Potency
Risk of hypoglycemia
Weight
Other
(glipizide,
glyburide, glimepiride)
+++
+++
Greatest
increase
Less likely to maintain
control as monotherapy
Meglitinides (nateglinide,
+
++
Increase
Short acting
Metformin
+++
+
Neutral
Thiazolidinediones
++
+
Greatest
increase
Fluid retention, worsen
CHF, fractures. Risk of
cardiac events.
+
+
Decrease
Intestinal gas, poor
tolerance
+
+
Neutral
+
+
Decrease
Injection, GI effects
+++
+++
Greatest
increase
Injection
Sulfonylureas
rapaglinide)
(Rosiglitazone,
Pioglitazone)
α-Glucosidase
inhibitors (acarbose,
GI intolerance, rare
lactic acidosis
miglitol)
DPP-4 inhibitors
(sitagliptin, saxagliptin,
Headache, risk of
infection
linagliptin)
GLP-1 analogs
(exenatide, liraglutide)
Insulin
AACE/ACE Diabetes Algorithm for Glycemic Control. Endrocr Pract. 2009;15:540-559.
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Barriers to Insulin Therapy: Common Concerns
Insulin therapy might cause:
• Worsening insulin resistance
– But reduction of glucose toxicity improves resistance
• More cardiovascular risk
– But reduction in glucose improves cardiovascular risk
• Weight gain
– Yes, it does occur with improved metabolic efficiency
• Hypoglycemia
– Very rare with type 2 diabetes
– Common with type 1 diabetes as approaching optimum
glycemic control
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Challenges and Opportunities in Minority
Populations
•
•
•
•
•
•
Rapidly growing populations
High rates of type 2 diabetes and its complications
Groups with unique culture, health beliefs, myths,
and food preferences
Diverse level of education and socio-economic status
Insufficient culturally oriented diabetes care, education,
and research programs
Health care system and health professional barriers
Cultural competency is key to approaching patients in a
beneficial way
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Why We Cannot Always Extrapolate to
Older Adults with Diabetes
• Heterogeneity
• Comorbid conditions
– Functional limitations
– Cognitive decline
• Polypharmacy
• Life expectancy versus
– Time to incidence or progression of microvascular
or macrovascular complications
– Time to expected benefit of intervention
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