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Obstacles to Changing Type 2 Diabetes Care

Published: 12/19/22 12:10 pm
By Andrew Briskin

Early and aggressive interventions can often lessen the risk of diabetes complications, but after diagnosis, many people’s treatment regimen doesn’t change for years, even when a person isn’t meeting treatment goals. Knowing about options to improve your health can be the first step toward breaking this cycle of “clinical inertia.”

When treating chronic diseases like cancer or HIV, doctors usually take an aggressive approach soon after diagnosis, trying to limit the health effects as quickly as possible. But with type 2 diabetes, it often seems that the most effective drugs and technology are considered as options only after the condition has progressed past a certain point. 

Why is that? Research has demonstrated that keeping glucose levels down early and immediately after a diabetes diagnosis leads to better long-term health. However, there is a perception that needing to add another oral medication or insulin means “failure” of diabetes treatment. 

This resistance has greatly impacted the health of people with diabetes. Intensifying diabetes treatment earlier has been shown to reduce the risk for complications, heart attack, or death from any diabetes-related cause. However, more than 1 in 4 people with type 2 diabetes and an A1C above 7% have not changed their treatment in over four years. This is an example of something called “clinical inertia.”

What is clinical inertia?

Clinical inertia, also called therapeutic inertia, is a situation when treatment is not adjusted despite an individual’s glucose levels being too high.

Dr. William Polonsky, president and co-founder of the Behavioral Diabetes Institute in San Diego, California, said, “Someone might have an A1C of 9%, and it would take years before a second medication was introduced. If insulin was needed, it was many years before that was prescribed.”

He added that common terminology about diabetes medications may contribute to people and their healthcare providers not wanting to advance care. 

“We see ‘treating to failure’ all the time in diabetes,” Polonsky said. “A lot of it also has to do with the terminology. Even the most well-meaning physicians will sometimes say, ‘the patient failed on metformin.’”

This can affect people’s views about adding or changing medications. Statements like this suggest that changes are only made due to “failure”, when, in reality, medication changes should happen periodically to improve care. 

Also, people do not always like to add medications to their routine, especially if it’s to prevent a condition that doesn’t affect how they feel yet. “People sometimes don’t think it’s a good thing that they have to take a medication forever,” Polonsky said. “The benefits to many drugs are long term, so there is no immediate evidence that the medications are doing something.” 

New oral medications like GLP-1 receptor agonists, SLGT-2 inhibitors, and Mounjaro, which can help people with type 2 diabetes lower glucose, lose weight, and protect against complications, have the potential to provide long-term benefits if started early. However, there is a clear obstacle when someone needs them, and their healthcare provider doesn’t know about the available options.

While it can be challenging to understand the different treatment options available, especially when managing diabetes complications, knowing enough to discuss them with your healthcare team can have a big impact. 

What can be done about clinical inertia?

Improving communication between people with diabetes and healthcare providers is key to overcoming clinical inertia. For healthcare providers, knowing about available medications and discussing  that information with patients to ensure they understand, makes a big difference in preventing long-term complications.

Additionally, it’s important that all members of a person’s health care team (dieticians, pharmacists, and nurses) are all in agreement about treatment goals. People with diabetes may interact more often with their pharmacist or other members of their care team than with their doctors, and these care providers can help educate and inform them about new treatments. 

Polonsky suggested bringing a list of questions to your appointment and making sure you get answers.

A study on clinical inertia also suggested that using a device that assists with insulin dosing, or using a diabetes self-management app, could help with learning about medications and advancing therapy if needed. 

Clinical inertia remains a significant obstacle preventing people with diabetes from getting the care they deserve. Initiating the conversation with your healthcare provider and being your own best advocate may help you improve your health.

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About the authors

Andrew Briskin joined the diaTribe Foundation in 2021 after graduating from the University of Pennsylvania with a degree in Health and Societies . Briskin is an Editor for diaTribe Learn.... Read the full bio »