Objective: This study investigated clinical inertia in the management of type 2 diabetes mellitus (T2DM), a major challenge in clinical practice. The primary aim was to assess the delay in therapeutic intensification among patients with persistently elevated hemoglobin A1c (HbA1c) levels (>8.0%) who were already receiving two oral antidiabetic drugs, considering the availability of newer effective therapies.

Research design and methods: We conducted a retrospective cohort study using data from the Clalit Health Service database in Israel. The initial cohort comprised 554 patients with T2DM and HbA1c >8.0%, of whom 518 managed by general practitioners were included in the primary analysis. Patients were stratified into two subgroups: HbA1c >8% to ≤9% and HbA1c >9%. Data were analyzed to determine the timing, type, and effectiveness of treatment intensification decisions over up to 18-month follow-up period.

Results: Therapeutic intensification with a third medication occurred in 58.4% of patients with HbA1c >9% compared to 47.4% of those with HbA1c >8% to ≤9% (p = 0.012), with shorter median time to intensification in the less controlled group (6.4 vs 10.3 months respectively, p = 0.034). The most common form of intensification was the addition of a third oral agent (79.2% vs. 53.4%, p <0.001). Injectable therapies were used less frequently, and insulin was preferred over glucagon-like peptide-1 receptor agonists (GLP-1Rs) (32.9% vs. 11.8% for insulin, p <0.001; 16.4% vs. 10.2% for GLP-1RAs, p = 0.137). Despite intensification, many patients did not achieve their glycemic targets.

Conclusions: Clinical inertia represents a significant barrier to effective T2DM management. Targeted educational interventions are urgently needed to improve adherence to current clinical guidelines among primary care physicians.

Hyperglycemia, Diabetes care, Clinical inertia, General practitioner, Oral antidiabetic drugs (OADs), Glucagon-like peptide 1 receptor agonist (GLP1-RA)