What to do with diabetes therapies when HbA1c lowering is inadequate: add, switch, or continue? A MASTERMIND study

McGovern, A. P., Dennis, J. M., Shields, B. M., Hattersley, A. T., Pearson, E. R., Jones, A. G. and , (2019) What to do with diabetes therapies when HbA1c lowering is inadequate: add, switch, or continue? A MASTERMIND study. BMC Medicine, 17, 79. (doi: 10.1186/s12916-019-1307-8) (PMID:30979373) (PMCID:PMC6460517)

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Abstract

Background: It is unclear what to do when people with type 2 diabetes have had no or a limited glycemic response to a recently introduced medication. Intra-individual HbA1c variability can obscure true response. Some guidelines suggest stopping apparently ineffective therapy, but no studies have addressed this issue. Methods: In a retrospective cohort analysis using the UK Clinical Practice Research Datalink (CPRD), we assessed the outcome of 55,530 patients with type 2 diabetes starting their second or third non-insulin glucose-lowering medication, with a baseline HbA1c > 58 mmol/mol (7.5%). For those with no HbA1c improvement or a limited response at 6 months (HbA1c fall < 5.5 mmol/mol [0.5%]), we compared HbA1c 12 months later in those who continued their treatment unchanged, switched to new treatment, or added new treatment. Results: An increase or a limited reduction in HbA1c was common, occurring in 21.9% (12,168/55,230), who had a mean HbA1c increase of 2.5 mmol/mol (0.2%). After this limited response, continuing therapy was more frequent (n = 9308; 74%) than switching (n = 1177; 9%) or adding (n = 2163; 17%). Twelve months later, in those who switched medication, HbA1c fell (− 6.8 mmol/mol [− 0.6%], 95%CI − 7.7, − 6.0) only slightly more than those who continued unchanged (− 5.1 mmol/mol [− 0.5%], 95%CI − 5.5, − 4.8). Adding another new therapy was associated with a substantially better reduction (− 12.4 mmol/mol [− 1.1%], 95%CI − 13.1, − 11.7). Propensity score-matched subgroups demonstrated similar results. Conclusions: Where glucose-lowering therapy does not appear effective on initial HbA1c testing, changing agents does not improve glycemic control. The initial agent should be continued with another therapy added.

Item Type:Articles
Additional Information:On behalf of the MASTERMIND Consortium: William E Henley, Mike Lonergan, Lauren R Rodgers, Willie T Hamilton, Naveed A Sattar, Rury R Holman, Catherine Angwin, Kennedy J Cruickshank, Andrew J Farmer, Stephen CL Gough, Alastair M Gray, Christopher Hyde, Christopher Jennison & Mark Walker
Status:Published
Refereed:Yes
Glasgow Author(s) Enlighten ID:Sattar, Professor Naveed
Authors: McGovern, A. P., Dennis, J. M., Shields, B. M., Hattersley, A. T., Pearson, E. R., Jones, A. G., and ,
College/School:College of Medical Veterinary and Life Sciences > Institute of Cardiovascular and Medical Sciences
Journal Name:BMC Medicine
Publisher:BMC
ISSN:1741-7015
ISSN (Online):1741-7015
Copyright Holders:Copyright © 2019 The Authors
First Published:First published in BMC Medicine 17:79
Publisher Policy:Reproduced under a Creative Commons License

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