medwireNews: Doctors are faster to initiate pharmacologic type 2 diabetes treatment in people from ethnic minorities than in White people but are then slower to intensify their treatment when needed, show data from the UK.
Rohini Mathur (London School of Hygiene & Tropical Medicine) and study co-authors note that delayed intensification may sometimes be appropriate, when factors such as frailty and treatment burden come into play.
“However, even after accounting for burden of comorbidities, age, HbA1c [glycated hemoglobin], BMI, and medications, we found compelling evidence that ethnic minority groups nevertheless experience treatment inertia to a far greater degree than the white population,” the researchers write in PLOS Medicine.
These differences “likely contribute, at least in part, to the worse outcomes seen in ethnic minority populations in the UK,” they add.
The team studied 162,238 people with type 2 diabetes identified in the UK’s Clinical Practice Research Datalink, of whom 92.9% self-reported their ethnicity as White, 5.0% as South Asian, and 2.1% as Black.
The median time between diagnosis and noninsulin monotherapy initiation was 3.2 months, and the time to initiation was a significant 21% faster for South Asians and 29% faster for Black people, compared with the majority White population. This was independent of variables including age, sex, comorbidities, HbA1c, and number of consultations and medications.
Mathur et al say that this faster initiation may reflect more advanced diabetes in the ethnic minority groups at diagnosis; average HbA1c was 65.8 and 69.3 mmol/mol (8.2 and 8.5%) in the South Asian and Black groups, respectively, compared with 63.6 mmol/mol (8.0%) in the White patients. And this was despite the ethnic minority groups being “markedly younger,” at a corresponding 53 and 56 years of age, compared with 63 years.
The more rapid initiation “may also reflect a preference for initial pharmacological (as opposed to lifestyle) interventions in ethnic minority groups, possibly indicating greater awareness of the disproportionate risk of major vascular outcomes in South Asian and black populations,” the team suggests.
During the 1990–2017 study period, the median time to adding additional noninsulin medications was 2.4 years and that to starting insulin was 3.8 years. But this was significantly longer for ethnic minority groups than for the White population, by around 20% for noninsulin medications and 31–51% for insulin.
Further analysis allowed the researchers to “propose a mechanism via which these inequalities might occur—namely, via delayed intensification of treatment and therapeutic inertia following the identification of uncontrolled risk.”
They defined therapeutic inertia as a failure to intensify treatment within 12 months of the individual recording an HbA1c level above 7.5% (58 mmol/mol). This was very common overall, affecting 68% of patients for moving from noninsulin monotherapy to combination therapy and 93% for adding insulin to combination therapy.
But again, therapeutic inertia disproportionately affected ethnic minorities versus White people, being 1.45- and 1.43-fold more likely for South Asian and Black people, respectively, when starting combination therapy and 2.68- and 1.82-fold more likely when starting insulin.
“Our data suggest that excessive delays in treatment intensification in ethnic minority populations may result from poorer monitoring of risk factors in these populations,” say Mathur and team.
“[I]n our study, both South Asian and black groups received fewer HbA1c measurements than white groups prior to intensification with both noninsulin combination therapy and insulin.”
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