Changing trends in diabetes treatmentBy Rafael Castillo M.D.
We’ve always said that medicine is a humbling profession. Because it was never and will never be an exact science, one can expect shifting trends in the way we treat most medical problems. Despite all the advances of research, physicians will never know enough of any particular illness. And as we get to know more because of continuing research, the realization is that one’s specialty is simply too wide-ranging, beyond the capability of any human physician to be considered a specialist in; hence, the need to subspecialize further into smaller fields or even specific diseases.
Diabetes is one example. It’s not as simple as having elevated blood sugar. It’s a lot more complicated, and specialists now acknowledge that it’s just part of a complex which consists of a myriad of other serious medical problems like elevated blood pressure, cholesterol problems, obesity, eye problems, blood vessel abnormalities which can lead to leg gangrene and possible leg amputation, and chronic kidney diseases which can lead to an end-stage requiring dialysis or possibly kidney transplantation.
One with uncontrolled diabetes has a shortened lifespan, which ironically can be partly due to overaggressive treatment of blood sugar and blood pressure (BP). That indeed was a humbling learning from recent landmark clinical trials and researches showing increased deaths and rates of complications with overaggressive control of the BP and blood sugar. Now, we have to sing a different tune when we explain to our patients. And not a few patients have politely reminded us that we told them differently up to a year ago.
That’s the challenge of being a physician—how to keep up with a dynamic field as the practice of medicine. It has the twists and turns one can expect to see only in our never-ending telenovela plots.
But the evolving consensus in diabetes treatment only highlights the fact that computers or robots can never replace human physicians in treating patients. Many seem to be entertaining the possibility that because of the advances in technology, there will come a time in the foreseeable future when one just has to key in his or her symptoms, and the computer will generate the prescription and treatment regimen to make that person well. That will never work for most medical problems, and diabetes is a perfect example. It’s not one-size-fits-all, and there’s no ready-to-wear treatment regimen. Hence, the consensus is that a physician should have an individualized treatment plan for each patient, aiming for a reasonable and not necessarily aggressive blood-sugar and BP control.
Late last year, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes came out with a joint position statement taking back their old recommendations and emphasizing that intensive blood-sugar control may not be the best way to go for diabetic patients. They now recommend a patient-centered approach with individualized targets. Those with new-onset diabetes who are more motivated will benefit from a more stringent control but those with long-standing diabetes—who have limited life expectancies because of multiple risk factors, and who have a high risk for hypoglycemia or low blood sugar because of aggressive treatment—would fare better with less-stringent control. These include elderly diabetics.
A physician should therefore exercise flexibility in setting treatment goals for their diabetic patients. Glycosylated hemoglobin (HbA1c) is usually requested every three months to determine control of the blood sugar. Theoretically, the normal value is 6.1 percent. Previously, the goal was set 7 percent as a measure of acceptable diabetes control. But based on the results of recently published landmark trials, strict blood-sugar control had little effect on the risk of deaths and other complications associated with diabetes.
A similar trend is also noted on recommendations on BP control in patients with type 2 diabetes. The ADA guidelines previously recommended that “most patients with diabetes” should receive antihypertensive treatment to reach systolic and diastolic BP levels of less than 130 mm Hg and less than 80 mm Hg, respectively. A recent meta-analysis of five well-designed trials involving thousands of patients with type 2 diabetes showed that although the ADA’s BP targets were associated with a small absolute reduction in risk of stroke, there was no impact on the risk of deaths or heart attacks, compared with less stringent standard targets of just slightly lower or higher than 140/90 mm Hg.
Another observational study that involved 126,000 patients showed similar results, with lower BPs (<110/75 mm Hg) being associated with a higher death risk. This is explained by some experts as the paradox in overaggressive lowering of the BP, which compromises the circulation in the heart more and could lead to heart attacks.
In a nutshell, in the management of type 2 diabetes, clinicians should: 1) aim for reasonable—but individualized, and not necessarily aggressive—blood sugar and BP control; 2) address other cardiovascular risk factors such as cholesterol problems, smoking and obesity; 3) assess patients for existing or developing complications in all organs, specifically in the kidneys, heart, brain, eyes and leg arteries; and, 4) encourage exercise and other beneficial lifestyle changes.
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