Identifying Predictors of Diabetes Progression

Pani LN, Nathan DM, Grant RW. Clinical predictors of disease progression and medication initiation in untreated patients with type 2 diabetes and A1C less than 7%. Diabetes Care. 2008;31(3):386-390.

How can clinicians identify which untreated patients with type 2 diabetes mellitus will experience disease progression--and which factors seem to influence treatment initiation? Based on the results of a prospective cohort study, Pani and colleagues conclude, "younger patients with diabetes should be managed more aggressively with earlier initiation of medications."

The study population was selected from a 12-practice network in Massachusetts that represents "a wide range of ages, race/ethnicities, and socio-economic status," as well as outpatient settings (ie, hospital-affiliated academic practices, community health centers, and private offices). Subjects (n = 705) were diabetic adults who had a glycated hemoglobin (A1C) level of less than 7% and who were not receiving glucose-lowering medications at baseline.

During one year of follow-up, 28% of patients experienced disease progression (ie, either had a follow-up A1C level of 7% or higher or started medication for glycemic control). Younger age and baseline A1C level were independent predictors of disease progression. Each 10-year increase in age was associated with a 15% decline in risk of progression. When changes from baseline were examined, a 2% increase in the risk of progression was noted for each 1-lb increase in weight.

Of the 200 patients whose disease progressed, 123 subsequently received medication (metformin being more commonly prescribed than sulfonylureas or insulin). Patients were less likely to start medication if they were older or had lower baseline LDL cholesterol levels: The likelihood of being treated declined by 40% with each 10-year increase in age and by 2.3% with each 1-mg/dL decrease in baseline LDL cholesterol. "[Cardiovascular disease] risk did not predict more aggressive glycemic management," the researchers note.

Factors that may influence treatment decisions--such as medication adherence and lifestyle modification--could not be assessed in this study. But Pani and colleagues say their results "underscore the ongoing need to improve diabetes management and can be used to encourage changes."