[acb-diabetics] tight control

Mon Jun 21 15:41:29 GMT 2010

http://notes.kateva.org/2008/02/strict-control-of-type-ii-diabetes.html

Wednesday, February 06, 2008

Strict control of type II diabetes increased mortality in one (big) study

I left longitudinal primary care practice before metformin. Back then tight
control of Type II diabetes was just about impossible. If we pushed insulin

patients just got heavier. In the rare event that we got reasonable control
we feared the that occasional hyopglycemia could be deadly.

Times changed. Metformin and subsequent medications transformed Type II DM
care. Now it's possible, with a dedicated and disciplined patient, to
achieve

tight control. Studies of intermediate measures (heart disease, renal
failure, eye disease) in patients with both Type I and Type II diabetes
showed the

value of tight control. Physicians were financially penalized for patients
who didn't get good control, and roundly chastised for a lack of energy in
pursuing

this goal.

There was only one problem. We didn't really know that reducing the rates of
nerve, kidney, heart, vessel and eye disease would actually reduce
mortality.

It certainly seemed that it should...

Diabetes Study Partially Halted After Deaths - New York Times

For decades, researchers believed that if people with diabetes lowered their
blood sugar to normal levels, they would no longer be at high risk of dying

from heart disease. But a major federal study of more than 10,000
middle-aged and older people with Type 2 diabetes has found that lowering
blood sugar

actually increased their risk of death, researchers reported Wednesday...

Even the control group, who weren't under "tight" control, had very low
glucose levels by the standards of the bad old days. So we're not talking
about

a return to the dark ages. The question instead is how hard to push, I think
this study alone will cause payors to back off on financial penalties for

"good" rather than "great" glucose levels.

Incidentally, a similar finding has come up many times over the past 20
years in studies of cholesterol reduction and all cause mortality. We know
that

reducing cholesterol lowers the risk of heart disease, but it doesn't reduce
the risk of death in patients who do not have known heart disease or
diabetes

(1990:

... Mortality from coronary heart disease tended to be lower in men
receiving interventions to reduce cholesterol concentrations compared with
mortality

in control subjects (p = 0.06), although total mortality was not affected by
treatment. No consistent relation was found between reduction of cholesterol

concentrations and mortality from cancer, but there was a significant
increase in deaths not related to illness (deaths from accidents, suicide,
or violence)

in groups receiving treatment to lower cholesterol concentrations relative
to controls (p = 0.004).

Later studies suggest that, on balance, persons with diabetes or known
vascular disease benefit from simvastatin. Maybe a lot. There's still the
suspicion

that the harm may outweigh the benefit for non-diabetic patients with no
known vascular disease (primary prevention) though.

These are tough questions, and in this domain my much loved animal model
studies aren't that helpful. All cause mortality can only be studied in
humans.

2/15/2008: It occurred to me that results like these could suggest the
possibility of unsuspected quality issues with the medications we consume.

John S Wilkinson

Rome, NY

Martin Buxbaum - A dog wags its tail with its heart.

-----Original Message-----

From: 

diabetesworld at yahoogroups.com

[mailto:

diabetesworld at yahoogroups.com

]On Behalf Of John S Wilkinson

Sent: Sunday, June 20, 2010 10:09 AM

To: 

diabetesworld at yahoogroups.com

Subject: RE: [diabetesworld] VA Diabetes "Education"

There is also a report that tight control in Type 2 Diabetics causes more
deaths than 

regular control. I can't find the reference right now.

John S Wilkinson

Rome, NY

Martin Buxbaum - A dog wags its tail with its heart.

-----Original Message-----

From: 

diabetesworld at yahoogroups.com

[mailto:

diabetesworld at yahoogroups.com

]On Behalf Of whimsy2

Sent: Sunday, June 20, 2010 10:04 AM

To: 

diabetesworld at yahoogroups.com

Subject: Re: [diabetesworld] VA Diabetes "Education"

I think doctors need to tell newby diabetics that if they can keep their 

A1Cs under 6 they'll be a LOT more likely to avoid diabetic related 

complications. And then they should list all the complications 

thoroughly. Maybe even connect them with another patient who ignored 

that advice and is poorly controlled so they can learn the painful 

consequences of poor control.

Then tell newbies that by avoiding high GI carb foods they can probably 

keep their A1Cs near or at this number. And do some education about 

what exactly high GI foods are. Connect the patient with someone who's 

been able to keep their numbers under 6. (If they can find one).

And refer them to diabetes lists such as this one for support.

So if they're "not comfortable" with this, at least they'll know the 

consequences.

Then it becomes an educated choice.

I'm not real optimistic that this will ever happen in my lifetime, 

though.

Vicki

----- Original Message ----- 

From: "John S Wilkinson" <

jwilkins at twcny.rr.com>

To: <

diabetesworld at yahoogroups.com>

Sent: Sunday, June 20, 2010 5:02 AM

Subject: RE: [diabetesworld] VA Diabetes "Education"

These type reports are responsib le for the change in mind of tight 

control for type 2 diabetics.

http://www.annals.org/content/150/11/803.full

Glycemic Control in Type 2 Diabetes: Time for an Evidence-Based 

About-Face?

1. Victor M. Montori, MD, MSc; and

2. Mercè Fernández-Balsells, MD

+ Author Affiliations

1.

>From the Mayo Clinic, Rochester, Minnesota, and Hospital 

Universitari de Girona Doctor J. Trueta, Girona, Spain.

Abstract

Some diabetes guidelines set low glycemic control goals for patients 

with type 2 diabetes mellitus (such as a hemoglobin A1c level as low as 

6.5% to 7.0%) to avoid or delay complications. Our review and critique 

of recent large randomized trials in patients with type 2 diabetes 

suggest that tight glycemic control burdens patients with complex 

treatment programs, hypoglycemia, weight gain, and costs and offers 

uncertain benefits in return. We believe clinicians should prioritize 

supporting well-being and healthy lifestyles, preventive care, and 

cardiovascular risk reduction in these patients. Glycemic control 

efforts should individualize hemoglobin A1c targets so that those 

targets and the actions necessary to achieve them reflect patients' 

personal and clinical context and their informed values and preferences.

============================CUT=============================================
======

-----Original Message-----

From: 

diabetesworld at yahoogroups.com

[mailto:

diabetesworld at yahoogroups.com

]On Behalf Of Composed

Sent: Saturday, June 19, 2010 5:56 PM

To: 

diabetesworld at yahoogroups.com

Subject: Re: [diabetesworld] VA Diabetes "Education"

That sounds like a HORRIBLE class, Rochelle.

I had an educator recently who told me that my A1C that was in the lower 

5's was good, but I shouldn't be working so hard to get there, etc.

My reply was that I feel much better at that level than the 6+ she was 

suggesting. How can we get past this ignorance?

Glenn

Sent from my iPhone.

On Jun 19, 2010, at 2:39 PM, "Rochelle Weber" <

riweber at mchsi.com

> wrote:

Thursday, I attended a diabetes education class at the VA. I was 

appalled

at what the nurse told the class in terms of numbers he expects from his

patients. His numbers for "tight control" were fairly reasonable, and I

quoted the newbie letter about testing new foods before eating as well 

as

one and two hours later to see what kind of post-parandial spikes and 

drops

you're getting. He agreed that was a good idea, then said that anyone 

who

is elderly or has other medical problems should NOT strive for tight 

control

and that a "good" A1C is between 6 and 7 percent. I argued that if 

you're

keeping tight control, your A1C should be within normal range and he 

said

no, because that indicates to him that you're having huge spikes and

dangerous lows. He actually DISCOURAGES his patients from letting their 

A1C

fall below 6%! I, of course, argued with him and he and the whole class

shot me down. And, of course, by policy, the VA will not issue testing

strips for more than one test three days a week for anyone on oral meds

alone. GRRRRRR!

Then I tried to get more test strips for myself. I am on insulin and

therefore qualify for more strips. However, the VA can't get my records

from Danville and the baseline A1C I had drawn when I got here was 5.9%, 

so

they show me as not having diabetes. They have no record of my insulin

prescription, diabetic supply prescriptions, etc. And my primary care

physician is out of town until after the Mensa AG (where I'm rooming 

with

Peg). I will definitely run out of strips while I'm there and since her

pump constantly monitors her BG, Peg no longer uses strips. I've ordered

some from Danville, but they may not get here in time. I might have to 

make

a trip down there before I leave for Michigan, which would kind of suck 

in

terms of gas used, etc. But with my Prius, that might actually be less

expensive than buying strips. Besides, maybe I could also stop by 

Medical

Records and get a hard-copy to bring back with me since they seem to 

have so

much difficulty accessing my records through the computer network.

Either that or fast for a day, then shoot double insulin in the waiting 

room

at the VA and let them scrape me off the floor when I go into insulin 

shock.

I was admitted last month and they gave me insulin while I was an

in-patient. Why can't they go by that? More GRRRRRR.

Hugs,

Rochelle

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