How Treatment Intensification Affects Veterans’ HbA1c

by U.S. Medicine

August 5, 2016

NASHVILLE—How do common type 2 diabetes treatment intensification regimens  at the VA affect glycated hemoglobin (HbA1c) and body mass index (BMI)?

A study published recently in the journal BMC Endocrine Disorders sought to answer that question.1

A study team led by researchers from the VA Tennessee Valley Healthcare System constructed a national retrospective cohort of veterans initially treated for diabetes with either metformin or sulfonylurea from 2001 through 2008, using both VHA and Medicare data. Patients were followed through September 2011 to identify common diabetes treatment intensification regimens.

Of 323,857 veterans who initiated diabetes treatment, 55 % initiated metformin, 43 % sulfonylurea and 2 % other regimens. Half of the metformin initiators remained on that monotherapy over a median follow-up of 58 months.

Among 80,725 patients who intensified metformin monotherapy, the four most common regimens were addition of sulfonylurea (79%), thiazolidinedione [TZD] (6%), or insulin (8%), and switch to insulin monotherapy (2%).

Across those regimens, median HbA1c values declined from a range of 7.0–7.8% (53–62mmol/mol) at intensification to 6.6-7.0% (49-53mmol/mol) at one year and remained stable up to three years afterwards.

Median BMI ranged between 30.5 and 32kg/m2 at intensification and increased very modestly in those who intensified with oral regimens, but 1–2kg/m2 over three years among those who intensified with insulin-based regimens.

“In this study, we report two main findings,” study authors explained. “First, among a national cohort of veterans with diabetes, 50% of metformin initiators intensified therapy by four years of follow-up and while sulfonylurea was the most common addition, there was an increase in the proportion adding insulin over time. Second, among those who intensified to the four most common regimens, the median HbA1c was between 7 and 7.8% (53-62mmol/mol) at intensification and 6.6 to 7% (49-53mmol/mol) one year later and remained about 7% for the next 3 years. Those on insulin based regimens had a 1–2kg/m2 weight gain over 3 years.”

1 Roumie CL, Greevy RA, Grijalva CG, Hung AM, Liu X, Griffin MR. Diabetes treatment intensification and associated changes in HbA1c and body mass index: a cohort study. BMC Endocr Disord. 2016 Jun 2;16(1):32. doi: 10.1186/s12902-016-0101-2. PubMed PMID: 27255309; PubMed Central PMCID:PMC4890276.

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