Taking Your Type 2 Diabetes Diagnosis Seriously


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Diabetes Management: A Work in Progress


 snow footprint

 

 

There’s a blizzard outside and today we’re snowed in. In Rochester, NY where I grew up, we rarely had snow days. Being close to Canada and having snow for almost 8 months of the year meant the city was well equipped to meet extreme weather.

But here in New York state, it’s been snowing in snowballs. It’s been too cold to go outside, too cold to go anywhere and did I mention… it’s frigging cold out there! I am not sure what I was thinking leaving behind endless summers ,but it’s been quite a shock to my blood sugar levels. I really thought I had things down but I’ve realized that my diabetes management is still a work in progress.

In spite of the cold, I went into the city this week to meet with Craig Kasper the creator of the Bravest Podcast. Craig also lives with type 1 and created the podcast so he could learn and explore what it is that enables people to live extraordinary lives in spite of their diabetes.

In the interview, we talked about levels of bravery. As our discussion progressed I shared that acceptance continues to be a process. There was that moment of diagnosis, where I felt like I had to swallow a bitter pill, the long years of denial where I kept thinking that controlling my diet and walking up hills would cure me, the moment where I gave myself my first injection through a rain of tears, the day where I knew I needed to change my management strategy by splitting my basal dose and finally yesterday pulling up a ½ unit of bolus insulin into a syringe and taking the plunge.

insulin pen

Living with Latent Autoimmune Diabetes in Adults (LADA) is no picnic. A friend recently commented that it’s easier to calculate your insulin to carb ratio when your beta cells don’t produce any insulin. Living with LADA is like playing roulette. Some days the ball lands on the money and other days I leave the table in despair.

The only way I get through each and every wonky moment is with the varied practices of yoga. I love working with the medium of sound in my practice because sound is so direct and immediately calms and centers me.

Working with sound in yoga is called mantra. The word mantra comes from two words, manas, meaning mind and trayati meaning freedom. A mantra is a sound, which frees the mind by giving the mind a focus so it’s naturally drawn out of its preoccupation with thoughts, ideas, and beliefs.

I know it’s natural to be obsessed with thoughts about the ins and outs of daily management. In working up to that first bolus injection I would sit down to meditate and replay worst case scenarios over and over.

That thought loop went on for days until I caught myself. It’s up to me to stop my need to identify with the thought by asking myself; what kind of investment do I have in that thought? Can a thought make me happy? How can a thought, which has no substance or dimension get the better of me?

It’s like trying to catch a snowflake. Impossible!

And it’s not about stopping the thought either. Try and banish any thought, another impossible task.

Mantra is such a profound way to bring the mind into a one-pointed focus, it can be chanted out loud or internally. Each nuance has a different effect on the mind and body. Chanting audibly affects the pituitary gland, the master gland in the body. It vibrates during chanting which tones and tunes all the other glands in the body. It also affects the vagus nerve which is responsible for increasing immunity

Chanting out loud increases the length of exhalation too. The longer the exhale the calmer the nervous system. Finally, mantra increases our ability to recognize that moment of getting lost in a thought. Thoughts come and go. It’s the thinker of the thoughts that matters.

For today’s practice join me in a simple chanting practice with the sound, om.

URL: https://soundcloud.com/the-flying-yogini/om-chanting-for-health-and-wellbeing

The Relentlessness of Diabetes Management


relentness of diabetes management

There are days where I find myself exhaling loudly out of exhaustion. My alarm wakes me for work at 6:30 a.m., while I want nothing more than to close my eyes and go back to sleep. I find myself unable to muster any enthusiasm for the new day ahead of me, nor for the people around me. I find myself walking around with a long face and an expression that will put a damper on everything and everyone around me. There are days where I feel like coffee, toast, and swear words are the bane of my existence. Then, there’s the inevitable feeling of limping toward the finish line on a Friday afternoon.

Over the years, I’ve told myself that I was burned out. Or that I wasn’t eating the right kinds of foods. That I was overworked and trying to juggle too many different things. I wondered if it was the exhausting nature of roller coaster blood glucose levels. Or the mixed bag of emotions that came from dealing with an unpredictable condition that was downright isolating.

Time has gone by, however, and I think it’s safe to say that I’ve addressed each of these issues to the best of my ability. The variability in my glucose levels is far less significant than they once were. I am more connected, supported, and engaged in my management. I have a far better understanding of a condition that even at the best of times makes no sense. I am far more conscious of taking time out for myself and not burning out.

time for oneself

But I’d be lying if I said that those feelings don’t linger, like flames from a fire that simply will not go out. There’s only one rational explanation that I keep coming back to.

Diabetes.

Diabetes is relentless. The physical and mental effort required to keep those flames at bay is huge. Throw in a full-time job, freelance writing, friends, family, and time out for myself, all while working towards financial independence, a career, and other life goals, and it’s no surprise that at times I feel like I’m only further fanning those flames.

Diabetes is no easy feat.

When I look on in envy at the person with a spring in their step while I’m limping it toward the finish line of a Friday afternoon after a challenging week, I remind myself that most people around me don’t have to deal with the relentless diabetes demands that I do.

ADA’s 2018 Standards of Medical Care Released


Standards of Medical Care in Diabetes 2018

Every year the American Diabetes Association (ADA) puts out an updated Standards of Medical Care approved by their board of directors which is their official position and provides all of their current clinical practice recommendations.

In this year’s Standards they state that “To update the Standards of Care, the ADA’s Professional Practice Committee (PPC) performs an extensive clinical diabetes literature search, supplemented with input from ADA staff and the medical community at large.” they update it each year or as needed online based on incoming evidence or regulatory changes.

It should be noted that most current Standards supersedes all previous ADA position statements.

Citing the way the field of diabetes moves quickly, the 2018 Standards of Care reveals the following major revisions:

Limits of A1c and Diagnostic Recommendations

Since recent evidence shows limits to A1c measurements because of hemoglobin variants among individuals, conditions that affect red blood cell turnover, and assay interference, recommendations have been “added to clarify the appropriate use of the A1C test generally and in the diagnosis of diabetes in these special cases,” states the ADA.

The ADA now recommends pre-diabetes and type 2 diabetes screening in children and teens who are overweight or obese and have one or more additional risk factors.

Comprehensive Medical Evaluation and Comorbidities

Components of a comprehensive medical evaluation now includes “information about the recommended frequency of the components of care at both initial and follow-up visits.”

The ADA added information about “the importance of language choice in patient-centered communication.”

They also now recommend healthcare providers consider checking serum testosterone levels in men with diabetes who have signs/symptoms of hypogonadism.

Dietary Clarification

The ADA stresses a clarification regarding nutrition: the ADA states that “there is no universal ideal macronutrient distribution and that eating plans should be individualized.” They have also included text to “address the role of low-carbohydrate diets in people with diabetes.”

low-carb diet for people with diabetes

On this point the Standards state, “The role of low-carbohydrate diets in patients with diabetes remains unclear,” They write that some of this confusion is due to different definitions of low-carb diets. “While benefits to low-carbohydrate diets have been described, improvements tend to be in the short term and, over time, these effects are not maintained,”

They concede that some studies show “modest benefits of low-carbohydrate or ketogenic diets” which entail under 50 grams of carbohydrate per day and say that ” this approach may only be appropriate for short-term implementation (up to 3–4 months) if desired by the patient, as there is little long-term research citing benefits or harm.”

The ADA does recommend children and adults with diabetes to reduce their intake of refined carbohydrates and added sugars and to get carbohydrates from vegetables, legumes, fruits, dairy, and whole gains. They write that the “consumption of sugar-sweetened beverages and processed “low-fat” or “nonfat” food products with high amounts of refined grains and added sugars is strongly discouraged,”

CGM Recommendation

Considering the latest data, the ADA now recommends the use of CGM (continuous glucose monitoring) in adults with type 1 diabetes to all adults ages 18 and up who are not meeting their glycemic targets (recommendation was previously for age 25 and up).

Drug Recommendations for Blood Sugar Treatment

Recommendations have been added due to data from the recent cardiovascular outcomes trial (CVOT) which shows that people with atherosclerotic cardiovascular disease should start with lifestyle management treatments plus metformin and “subsequently incorporate an agent proven to reduce major adverse cardiovascular events and/or cardiovascular mortality after considering drug-specific and patient factors.”

Managing Blood Pressure from Home

All patients with high blood pressure are now recommended to monitor their blood pressure at home to find out if they have “masked or white coat hypertension” and to help motivate patients to take their hypertension medication via awareness of elevated blood pressure.

Caution in Older Adults

New recommendations have been added to indicate how important individualized drug therapy is in older adults in order to lower the risk of low blood sugar episodes and to avoid over-treatment, as well as simplifying complicated regimens if at all possible while keeping the A1c target.

Pregnancy and Diabetes

A new recommendation emphasizes that insulin is “the preferred agent for the management of type 1 and type 2 diabetes in pregnancy.”

Citing new evidence, the ADA now recommends that pregnant women with type 1 and type 2 diabetes take a low-dose aspirin beginning at the end of the first trimester for the purpose of lowering the risk of developing preeclampsia.

Diabetes Care in Hospital

Insulin degludec (Tresiba) has been added to the insulin dosing for enteral/parenteral feedings.

For all the revisions visit the Summary of Revisions. For the pdf of the 2018 Standards of Care go here.

Preparation key to diabetes management during air travel


The mismanagement of diabetes during air travel can lead to adverse consequences, including hypoglycemia during eastward travel and hyperglycemia or diabetic ketoacidosis during westward travel, according to a speaker here.

“Travel disrupts people’s normal routines, whether that’s their diet or their [insulin] dosing times,” Rahul Suresh, MD, MS, a second-year resident at the University of Texas Medical Branch in Galveston, said during a press conference at the AACE Annual Scientific & Clinical Congress. “In order to avoid complications with medication dosing, insulin and other diabetes medicines have to be taken at certain times, with respect to carbohydrate intake and overall calorie intake.”

Rahul Suresh

Rahul Suresh

Research on diabetes and air travel is limited, Suresh said, but anecdotal evidence suggests that up to 10% of travelers with diabetes encounter complications in flight, often related to hypoglycemia. Additional studies have noted that, of all severe complications that occur causing the diversion of aircraft, almost 2%, or one in 50, are due to diabetes, Suresh said. Currently, Suresh said, there is a lack of available data detailing why people with diabetes encounter these complications in flight.

“This is not something that airlines like to divulge,” Suresh said. “But what we do know is that when people travel, especially those who are on insulin, if they are not attentive to their insulin regimen, [they] can over- or under-dose their insulin.”

Insulin dosing errors can occur if a traveler is not eating enough or taking insulin too early, which can happen most often when a person is traveling east across time zones, Suresh said.

“When you travel east, you shorten the length of your day, and if you aren’t attentive to your watch and change your destination time zone, now you’re next dosing time is early,” Suresh said. “Similarly, when you go west, your day lengthens, and as a result, people may have gaps in their insulin coverage, causing hyperglycemia. In type 1 diabetics, you can develop [diabetic ketoacidosis]”

In an analysis of nine peer-reviewed articles and two diabetic nursing guidelines, Suresh and colleagues identified six recommendations based on a combination of expert opinion and one prospective cohort study. Recommendations were updated to address general preparation advice, cabin environment and equipment, medication adjustments and insulin pump use.

Suresh and colleagues recommended no dose adjustment for short- or rapid-acting insulin; however, during eastward travel, intermediate- and long-acting insulins should be reduced in a dose proportional to hours lost. During westward travel, correction scale insulin with rapid-acting insulin can be used, or the dose to be administered during travel can be given as divided doses to span the longer travel day. Pre-mixed insulins are discouraged, Suresh said, due to difficulty in titrating effects. Sulfonylureas and glinides should be held during eastward travel.

For travelers on insulin pump therapy, caution needs to be exercised, Suresh said. Cabin depressurization may lead to up to 1 unit of unintended bolus dosing, increasing the risk for hypoglycemia.

“Insulin pumps, theoretically, have the risk for bubbles and extra bolusing when they are used during ascent or descent,” Suresh said. “The recommendations are to disconnect the pump on ascent, remove any air bubbles once you arrive at altitude, and then reconnect the pump so that it can continue to function.”

Bringing backup medication is advised, the researchers wrote, and traveling patients should be informed of the differences in concentration and varying availability of international insulin products. – by Regina Schaffer

Bariatric Surgery for Weight Loss and Glycemic Control in Nonmorbidly Obese Adults With DiabetesA Systematic Review


 

Importance  Bariatric surgery is beneficial in persons with a body mass index (BMI) of 35 or greater with obesity-related comorbidities. There is interest in using these procedures in persons with lower BMI and diabetes.

Objective  To assess the association between bariatric surgery vs nonsurgical treatments and weight loss and glycemic control among patients with diabetes or impaired glucose tolerance and BMI of 30 to 35.

Evidence Review  PubMed, EMBASE, and Cochrane Library databases were searched from January 1985 through September 2012. Of 1291 screened articles, we included 32 surgical studies, 11 systematic reviews on nonsurgical treatments, and 11 large nonsurgical studies published after those reviews. Weight loss, metabolic outcomes, and adverse events were abstracted by 2 independent reviewers.

Findings  Three randomized clinical trials (RCTs) (N = 290; including 1 trial of 150 patients with type 2 diabetes and mean BMI of 37, 1 trial of 80 patients without diabetes [38% with metabolic syndrome] and BMI of 30 to 35, and 1 trial of 60 patients with diabetes and BMI of 30 to 40 [13 patients with BMI <35]) found that surgery was associated with greater weight loss (range, 14.4-24 kg) and glycemic control (range, 0.9-1.43 point improvements in hemoglobin A1c levels) during 1 to 2 years of follow-up than nonsurgical treatment. Indirect comparisons of evidence from observational studies of bariatric procedures (n ≈ 600 patients) and meta-analyses of nonsurgical therapies (containing more than 300 RCTs) support this finding at 1 or 2 years of follow-up. However, there are no robust surgical data beyond 5 years of follow-up on outcomes of diabetes, glucose control, or macrovascular and microvascular outcomes. In contrast, some RCT data of nonsurgical therapies show benefits at 10 years of follow-up or more. Surgeon-reported adverse events were low (eg, hospital deaths of 0.3%-1.0%), but data were from select centers and surgeons. Long-term adverse events are unknown.

Conclusions and Relevance  Current evidence suggests that, when compared with nonsurgical treatments, bariatric surgical procedures in patients with a BMI of 30 to 35 and diabetes are associated with greater short-term weight loss and better intermediate glucose outcomes. Evidence is insufficient to reach conclusions about the appropriate use of bariatric surgery in this population until more data are available about long-term outcomes and complications of surgery.

Source: JAMA

 

Empagliflozin provided sustained glycemic control, weight loss in type 2 diabetes.


  • The novel investigational sodium-glucose cotransporter 2 inhibitor empagliflozin demonstrated 90 weeks of sustained glycemic control and weight loss in patients with type 2 diabetes. Study researcher Thomas Hach, MD, a senior medical director at Boehringer Ingelheim, spoke withEndocrine Today about the data presented during a late-breaking session here.

“We feel there is an important obligation for us to understand patient benefits: to look at benefit-risks and to really understand which patients will benefit most or where there could possibly be limitations,” Hach said.

In active-control studies, Hach told Endocrine Today that he and colleagues saw comparable efficacy. They conducted a randomized, open-label, 78-week extension study on empagliflozin (Boehringer Ingelheim/Eli Lilly and Company).

They investigated empagliflozin 10 mg (n=81), 25 mg (n=82) or metformin (n=80) as monotherapy, or empagliflozin 10 mg (n=71), 25 mg (n=70) or sitagliptin (n=71; Januvia, Merck) as add-on to metformin in patients with type 2 diabetes who also completed one of two 12-week randomized control trials.

According to 90-week data, adjusted mean changes in HbA1c from baseline were: –0.51% (empagliflozin 10 mg), –0.60% (empagliflozin 25 mg) and –0.64% (metformin); and –0.61% (empagliflozin 10 mg), –0.74% (empagliflozin 25 mg) and –0.45% (sitagliptin).

Further data indicate adjusted mean changes in fasting plasma glucose were: –32.4 mg/dL (empagliflozin 10 mg), –28.1 mg/dL (empagliflozin 25 mg), and –25.9 mg/dL (metformin); –23.3 mg/dL (empagliflozin 10 mg), –31.8 mg/dL (empagliflozin 25 mg), and –11.7 mg/dL (sitagliptin).

Moreover, changes in weight were reported as: –2.1 kg (empagliflozin 10 mg), –1.9 kg (empagliflozin 25 mg), and –0.9 kg (metformin); –2.9 kg (empagliflozin 10 mg), –3.8 k (empagliflozin 25 mg), and –0.6 kg (sitagliptin).

“If I was still in clinical practice, I would look forward to having something new in my armamentarium. Unfortunately, there’s still a huge unmet need in diabetes,” Hach said.

The medication was well tolerated, and the most common adverse events associated with empagliflozin include urinary tract and genital infections. Hach said clinicians should use caution with elderly patients or those with renal impairment because those patients are more susceptible to adverse events.

In March, a new drug application for empagliflozin was submitted to the FDA. Further data will be presented at the American Diabetes Association Scientific Sessions in Chicago next month, Hach said. – by Samantha Costa

For more information:

Ferrannini E. Abstract #1102. Presented at: the AACE Annual Scientific and Clinical Congress; May 1-5, 2013; Phoenix.

Source: Endocrine today

 

Intensive Glycemic Control and End-Stage Renal Disease in Type 2 Diabetes.


One case of ESRD was prevented for every 430 intensively treated patients.

In recent randomized trials, intensive glycemic control did not prevent macrovascular events in patients with longstanding type 2 diabetes. In one of those trials (ADVANCE, with 11,000 patients overall; JW Gen Med Jun 6 2008), intensive control prevented macroalbuminuria, a surrogate endpoint for microvascular disease, from developing in some patients. Now, the researchers present information on the most important renal endpoint — progression to end-stage renal disease (ESRD).

After 5 years, mean glycosylated hemoglobin (HbA1c) levels were 7.3% and 6.5% in the standard- and intensive-treatment groups, respectively. ESRD occurred in 20 standard-treatment patients and in 7 intensive-treatment patients. The difference is statistically significant, but about 430 patients underwent intensive glycemic control to prevent 1 case of ESRD. Researchers found no significant differences between groups in incidences of “renal death” or doubling of serum creatinine level.

Comment: The authors believe that their results show “intensive glucose lowering using ADVANCE-like regimens may be beneficial for many people with diabetes.” However, the word “many” here is in the eye of the beholder: Editorialists express concern about the large number needed to treat and note that intensive control can confer both benefits and harms. They conclude that “an A1c target <6.5% for type 2 diabetes should be used cautiously, if at all — perhaps only in well-informed patients who are younger, at lower risk for hypoglycemia, and free of symptomatic cardiovascular disease.”

Source: Journal Watch General Medicine

Sulfonylurea Drugs Associated with Increased Cardiovascular Risk vs. Metformin .


An observational study of patients beginning diabetes treatment finds that sulfonylureas carry a roughly 20% greater risk for major cardiovascular events than metformin. The work appears in the Annals of Internal Medicine.

Researchers used federal data from the Veterans Health Administration to ascertain outcomes in 250,000 veterans (almost all of whom were men) starting monotherapy for diabetes with a sulfonylurea (either glyburide or glipizide) or metformin. The primary outcome — a composite of hospitalization for acute MI or for stroke, or death — was more common among sulfonylurea users by 2.2 events per 1000 person-years of observation after adjustment for multiple factors, such as blood pressure and BMI.

An editorialist considers the findings “credible and important,” but ultimately “hypothesis-generating” in the absence of a randomized trial.

Source: Annals of Internal Medicine

New EASD/ADA Position Paper Shifts Diabetes Treatment Goals?


A new position statement for the treatment of type 2 diabetes takes an approach much more focused on the individual patient compared with the “one number fits all” target of glycated hemoglobin (HbA1c) used up to now.

These new recommendations from the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA), announced here today in a news conference at the European Association for the Study of Diabetes (EASD) 48th Annual Meeting, put the patient’s condition, desires, abilities, and tolerances at the center of the decision-making process about the goals and methods of treatment. “Our recommendations are less prescriptive than and not as algorithmic as prior guidelines,” the authors write.

In light of the increasing complexity of glycemic management in type 2 diabetes and the wide array of antidiabetic agents now available, as well as uncertainties about the benefits of intensive glycemic control on macrovascular complications, a joint task force of the EASD and the ADA sought to develop recommendations for the treatment of nonpregnant patients with type 2 diabetes to help clinicians determine optimal therapies. Their aim was to take into account the benefits and risks of glycemic control, the efficacy and safety of the drugs used to achieve it, and each patient’s situation. The resulting guidelines are published simultaneously in Diabetes Care (2012;35:1364-1379) and Diabetologia (2012;55:1577-1596) by the EASD and the ADA and are available on the EASD Web site.

“What we’re trying to do is encourage people to really engage in a complex world with the patient, given the variety of choices,” said David Matthews, MD, DPhil, from the Oxford Centre for Diabetes, Endocrinology and Metabolism at Churchill Hospital and the National Institute for Health Research, Oxford Biomedical Research Centre, United Kingdom, and cochair of the Position Statement Writing Group of the EASD and ADA. “And the algorithmic approach, in our view, has finally had its day. We can’t do that anymore.”

Dr. Matthews said the EASD and ADA writing group decided not to issue guidelines but rather to take positions and issue recommendations. “Published guidelines tend to be algorithmic, yet few clinicians prescribe by algorithms…and so there’s a lot of lip service to explicit guidelines,” he said.

Furthermore, there’s a danger in guidelines in that some payers and regulatory bodies focus on them as an absolute measure of success or failure and pay accordingly, or not. So for this reason, the authors did not put a specific HbA1c number in their position statement, and in addition, they did not want to give the impression that it is all right for the number to drift upward if it is below a certain level.

On the other hand, a lower HbA1c value may not be best for some patients. “We’ve got trial data challenging the simplistic view of the lower-the-better approach to glycemic control…. That tells us we need to be careful about just using numbers, however important they may be, to treat patients,” Dr. Matthews said.

So the plan is to have the physician and patient combine the best available evidence with clinical expertise and patient preferences to determine the course of treatment, which may include lifestyle interventions such as physical activity, dietary advice, and oral or injectable antidiabetic drugs, including insulin.

Main Points to New Approach

The position statement lays out 7 key points:

  • Individualized glycemic targets and glucose-lowering therapies
  • Diet, exercise, and education as the foundation of the treatment program
  • Use of metformin as the optimal first-line drug unless contraindicated
  • After metformin, the use of 1 or 2 additional oral or injectable agents, with a goal of minimizing adverse effects if possible (despite limited data to guide specific therapy)
  • Ultimately, insulin therapy alone or with other agents if needed to maintain blood glucose control
  • Where possible, all treatment decisions should involve the patient, with a focus on “patient preferences, needs and values”
  • A major focus on “comprehensive cardiovascular risk reduction”

The authors highlight several elements that need to be gauged for making decisions about the appropriate levels of effort to reach glycemic targets. Patient attitudes and expected efforts may range from highly motivated with good adherence and self-care abilities to poor motivation, nonadherence, and poor self-care abilities. The potential risks for hypoglycemia and other adverse effects are another element in decision-making.

The recommendations also focus on duration of disease, life expectancy, significant comorbidities, established vascular complications, and the patient’s resources and support system.

The authors make the point that although the recommendations focus on glycemic control, clinicians and patients should also pay attention to other risk factors, and specifically, “aggressive management of cardiovascular risk factors” in light of the increased risk for cardiovascular morbidity and mortality among patients with type 2 diabetes. Physicians should encourage as much physical activity as possible, aiming for a minimum of 150 min/week, consisting of aerobic, resistance, and flexibility training if possible.

If newly diagnosed patients are at or near the HbA1c target of less than 7.5% and they are highly motivated, they should be given a trial of lifestyle changes for 3 to 6 months with a goal of avoiding pharmacotherapy. But for patients with moderate hyperglycemia or for whom lifestyle changes are expected to be unsuccessful, antidiabetic drug therapy, usually with metformin, should be initiated. If lifestyle efforts are eventually successful, drug therapy may be modified or discontinued.

Information to Guide Pharmacotherapy

Many of the drugs to control blood glucose have similar efficacy, said Writing Group cochair Silvio Inzucchi, MD, professor of medicine, clinical director of the Section of Endocrinology, and director of the Yale Diabetes Center at the Yale School of Medicine in New Haven, Connecticut.

Based on an extensive review of more than 500 articles, “all of these drugs work more or less to the same extent,” he said. “In the grand scheme of things, when you’re talking about a patient taking a medication for years, perhaps decades, and being faced with side effects of medications, the differences in hemoglobin A1c may actually pale in comparison to how they experience that medication.”

To guide choices of glucose-lowering agents, the authors provide in tabular form summaries of the cellular mechanisms, physiological actions, advantages, disadvantages, and costs of classes of agents and drugs within the classes. They also show an algorithm for escalating treatment, starting with lifestyle changes and progressing to initial drug monotherapy, 2- and then 3-drug therapy, and finally to basal and then more complex insulin strategies.

The recommendations end with considerations of the effects of age, weight, sex/racial/ethnic/genetic differences, the comorbidities of coronary artery disease, heart failure, chronic kidney disease, liver dysfunction, and concerns about hypoglycemia. The authors also point out several areas where data are insufficient and therefore where research efforts should be aimed.

When asked if the new recommendations are feasible given the time allotted to seeing a patient, Andreas Pfeiffer, MD, DrMed, chief of the Department of Clinical Nutrition at the German Institute of Human Nutrition Potsdam-Rehbruecke in Nuthetal, Germany, and professor of internal medicine and director of the Department of Endocrinology, Diabetes and Nutrition at Charité Universitaetsmedizin Berlin, Germany, was cautious in his answer.

“If you calculate the time a doctor has per patient, it’s something like 7 minutes or so, and most patients are used to the physician telling him what he’s supposed to do,” Dr. Pfeiffer said. “In some ways it’s unrealistic” for a physician to explore a patient’s desires, capabilities, tolerances, and social support systems in that amount of time. On the other hand, patients return to the doctor several times over the course of a year, so there are more chances to expand the discussion.

But Dr. Pfeiffer worries whether diabetes specialists may become lax if they are not trying to treat to a specific goal. “Diabetologists have average HbA1c’s in Germany of around 7%, which is pretty good, actually…. And now if you relax the guidelines and say, ‘You don’t really have to care so much about it,’ so where do they go?” he wondered.

Source: Mescape.com