title: Slow response to loss of glycemic control in type 2 diabetes mellitus.
abstract: BACKGROUND
  To achieve glycemic control in type 2 diabetes mellitus, the American Diabetes Association (ADA) recommends intensification of glucose-lowering therapy when the glycosylated hemoglobin (HbA1c) level exceeds 8.0%.
  
  
  OBJECTIVE
  To study glycemic control before and after initiation of secondary antihyperglycemic therapy to better understand the pace and patterns of therapeutic failure and clinical responses to failure.
  
  
  METHODS
  A retrospective, population-based observational study.
  
  
  METHODS
  From a 12-year-old diabetes registry of members of Kaiser Permanente Northwest, a large group-model HMO, we tracked the glycemic control histories of all 570 registrants who, in 1998, added metformin therapy to sulphonylurea monotherapy.
  
  
  RESULTS
  The last HbA1c level before metformin use averaged 9.4%. Metabolic decompensation accelerated over time. Patients typically spent numerous months at and had several measurements of HbA1c >8.0% before a final glycemic spike to >9.0%. Persons experiencing more gradual failure accumulated greater glycemic burdens before changing therapy.
  
  
  CONCLUSIONS
  The level of HbA1c that seemed to trigger glucose-lowering action was 9.0% or higher, not 8.0% as recommended by the ADA. A substantial hyperglycemic peak preceded change in therapy even in this relatively tightly controlled population with type 2 diabetes mellitus. Earlier therapeutic changes, but not more frequent testing, would prevent the glycemic excursions we observed. Low mean HbA1c levels in populations do not necessarily indicate that loss of glycemic control is being rapidly addressed for most patients. More research is needed to estimate the impact of these peaks on current well-being and future complications.
authors.affiliation: Kaiser Permanente Center for Health Research, Portland, Ore 97227-1110, USA. jonathan.brown@kpchr.org
authors.forename: Jonathan B
authors.initials: JB
authors.lastname: Brown
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Nichols
mesh_terms: D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000032:analysis*; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000188:drug therapy*; D019468:Disease Management; D004359:Drug Therapy, Combination; D005260:Female; D005905:Glyburide / Q000627:therapeutic use*; D006442:Glycated Hemoglobin / Q000032:analysis*; D006279:Health Maintenance Organizations; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D008297:Male; D008687:Metformin / Q000627:therapeutic use*; D008875:Middle Aged; D015205:Northwestern United States; D012042:Registries; D012189:Retrospective Studies; D014481:United States
chemical_list: D001786:Blood Glucose; D005905:Glyburide; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D008687:Metformin; C417231:Glucovance