Clinical inertia in the management of type 2 diabetes mellitus: a focused literature review

Sachin Khunti, Melanie J Davies, Kamlesh Khunti


Achieving tight glycaemic control early on in the disease trajectory has been shown to have beneficial effects on macrovascular and microvascular complications and mortality in people with type 2 diabetes. International guidelines recommend individualised targets for glycaemic control, but many people with type 2 diabetes are not adequately reaching these targets. One major reason for not achieving these targets is ‘clinical inertia’, defined as ‘failure of healthcare providers to initiate or intensify therapy when indicated’. This article gives an overview of clinical inertia in the management of type 2 diabetes, relating to the initiation of oral antidiabetic and insulin therapies, reasons for clinical inertia and strategies for overcoming clinical inertia.

Full Text:



International Diabetes Federation. International Diabetes Federation Diabetes Atlas Update 2012. IDF, Brussels, Belgium. Available from: (accessed April 2015)

Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-89.

Stone MA, Charpentier G, Doggen K, et al. Quality of care of people with type 2 diabetes in eight European countries: findings from the Guideline Adherence to Enhance Care (GUIDANCE) study. Diabetes Care 2013;36(9):2628-38.

Inzucchi SE, Berganstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: A patient-centered approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015;38:140-9.

Chatterton H, Younger T, Fischer A, Khunti K. Risk identification and interventions to prevent type 2 diabetes in adults at high risk: Summary of NICE guidance. BMJ 2012 (Online),345(7867).

Phillips LS, Branch Jr WT, Cook CB, et al. Clinical Inertia. Ann Intern Med 2001;135(9):825-34.

Guisasola FA, Mavros P, Nocea G, Alemao E, Alexander CM, Yin D. Glycaemic control among patients with type 2 diabetes mellitus in seven European countries: findings from the Real-Life Effectiveness and Care Patterns of Diabetes Management (RECAP-DM) study. Diabetes Obes Metab 2008;10(s1):8-15.

Fu AZ, Qiu Y, Davies MJ, Radican L, Engel SS. Treatment intensification in patients with type 2 diabetes who failed metformin monothereapy. Diabetes Obes Metab 2011;13(8):765-9.

Khunti K, Wolden ML, Thorsted BL, Andersen M, Davies MJ. Clinical inertia in people with type 2 diabetes: A retrospective cohort study of more than 80,000 people. Diabetes Care 2013;36(11):3411-17.

Shah BR, Hux JE, Laupacis A, Zinman B, Walraven CV. Clinical inertia in response to inadequate glycemic control: do specialists differ from primary care physicians? Diabetes Care 2005;28(3):600-06.

Evans ML, Sharplin P, Owens DR, Chamberlain GH, Longman AJ, McEwan P. Insulin usage in type 2 diabetes mellitus patients in UK clinical practice: a retrospective cohort-based analysis using the THIN database. Br J Diabetes Vasc Dis 2012;12:146-51.

Calvert MJ, McManus RJ, Freemantle N. Management of type 2 diabetes with multiple oral hypoglycaemic agents or insulin in primary care: retrospective cohort study. Br J Gen Pract 2007;57(539):455-60.

Khunti K, Damci T, Meneghini L, Pan CY, Yale JF. Study of once daily Levemir (SOLVE™): insights into the timing of insulin initiation in people with poorly controlled type 2 diabetes in routine clinical practice. Diabetes Obes Metab 2012;14(7):654-61.

Zafar A, Stone MA, Davies MJ, Khunti K. Acknowledging and allocating responsibility for clinical inertia in the management of Type 2 diabetes in primary care: a qualitative study. Diabet Med 2015;32:407-13.

Grant R, Adams AS, Trinacty CM, et al. Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management. Diabetes Care 2007;30(4):807-12.

Marrett E, Zhang Q, Kanitscheider C, et al. Physician reasons for nonpharmacologic treatment of hyperglycemia in older patients newly diagnosed with type 2 diabetes mellitus. Diabetes Ther 2012;3:5.

Hayes RP, Fitzgerald JT, Jacober SJ. Primary care physician beliefs about insulin initiation in patients with type 2 diabetes. Int J Clin Pract 2008; 62(6):860-8.

Zafar A, Davies M, Azhar A, Khunti K. Clinical inertia in management of T2DM. Primary Care Diabetes 2010;4(4):203-07.

Parchman ML, Pugh JA, Romero RL, Bowers KW. Competing demands or clinical inertia: The case of elevated glycosylated hemoglobin. Ann Fam Med 2007;5(3):196-201.

Bruggen RV, Gorter K, Stolk R, Klungel O, Rutten G. Clinical inertia in general practice: widespread and related to the outcome of diabetes care. Fam Pract 2009;26(6):428-36.

Ziemer DC, Doyle J, Barnes CS, et al. An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting. Arch Intern Med 2006;166(5):507-13.

Del prato S. Megatrials in type 2 diabetes. From excitement to frustration. Diabetologia 2009;52:1219-26.

Rodbard D, Vigersky RA. Design of a decision support system to help clinicians manage glycemia in patients with type 2 diabetes mellitus. J Diabetes Sci Technol 2011;5:402-11.



  • There are currently no refbacks.

The Journal of the Association of British Clinical Diabetologists