Researchers are busy trying to find the best new approaches for treating Type 2 diabetes amid concerns that current treatment options are doing more harm than good.
New guidelines strongly encourage doctors, most of whom consider diabetes to be a public health crisis, to vary their treatments depending on age, general health, and personal preferences of the patient.
The updated guidelines, published in June in the journal Diabetes Care, recommend doctors push their patients less to get their blood sugar to a standard level. Aiming for a very low blood sugar level might be a good goal for a younger patient, but older patients may do better with a less aggressive approach.
"We need to be less dogmatic about what matters and be open to different approaches and give patients a voice" in their treatment decisions, said
Victor Montori, a diabetes specialist for the
Mayo Clinic in Rochester, Minnesota, who supports the new guidelines.
Along with the less pushy approach, bariatic surgery has been more and more commonly prescribed for patients with diabetes. The surgery comes with the risk of serious complications, but the operation has been shown in recent studies to lead to a rapid lowering of blood sugar, which sometimes allows patients to go off all or some of their diabetes medications.
Other professionals are questioning the benefits of gradually stepping up the intensity of drug therapy, which is a widely accepted approach, reaffirmed in the new guidelines. The goal is to maintain a patient's blood sugar level while keeping up with the progressive nature of the disease. Researchers at the
UT Southwestern Medical Center in Dallas argue the opposite is true: hit diabetes hard and early.
There have been conflicting findings over the benefit for patients of keeping blood sugar strictly controlled, helping to fuel uncertainty about how to best treat the disease. Many popular drugs come with side effects, including weight gain, bone loss, and even a small risk of certain cancers. And some data shows that aggressive efforts to achieve glucose control can lead to troubling episodes of low blood sugar called hypoglycemia or to increased risk for serious heart related problems. There is a lack of data to show whether available drugs prevent or delay complications of diabetes.
"The goal for treatment and the choice of individual drug must be personalized depending on the patient," said Vivian Fonseca, the ADA's president for science and medicine and chief of endocrinology at Tulane University Health Sciences Center in New Orleans.
The first line of therapy for newly diagnosed Type 2 diabetics is to improve diet and exercise habits to reduce blood sugar levels. Usually metaformin, a basic diabetes medication, is prescribed. Those with mild cases of elevated blood sugar levels should try to reform their diet and exercise on their own for six months to see if they can control the disease before taking medication.
Blood sugar is considered under control when the patient's A1c level is under 7%. Newer, motivated, and younger patients should aim for an A1c closer to 6%, which is expected to keep the disease from progressing. Older patients with severe hypoglycemia or who may already have cardiovascular disease should try to aim for 8%, which should reduce the burden of side effects from medications.
Those who fail to comply with the doctor's first line of defense calls for the doctor to add a second drug. There are few trials comparing drugs against each other on long-term benefits and the new guidelines encourage doctors to discuss with patients the pros and cons of each drug. The Mayo Clinic, for example, has developed an online tool for patients that takes account of such factors as weight change, cost, low blood sugar risk, blood testing requirements and side effects. Patients for whom weight gain is a concern should stay away from drugs where that is a side effect.
Patients typically progress through three or four tiers, adding insulin injections to control their blood sugar. Researchers at UT Southwestern Center argue that such a graduated treatment strategy does little to change the disease process and means that patients' own insulin producing-beta cells remain continuously exposed to high blood sugar.
In the study presented in June, reseacher Ildiko Lingvay said that two types of more aggressive treatments using insulin and drugs started when patients were initially diagnosed, effectively preserved the function of beta cells in a study of 58 patients who were followed for three years. The treatment included three months of insulin injections combined with metaformin for all patients. Patients were then randomly assigned to either the same treatment or a combination of three oral drugs, which continued for more than three years. The limitations of the study included the small number of patients and the lack of control group that was followed with standard therapy to compare benefits and side effects.
"At our institution we treat patients intensively from the time of diagnosis. We have no question this pays off in the long term," said Dr. Lingvay.
Other research efforts to treat patients early with insulin have had mixed results, with patients on both regiments at UT Southwestern gaining weight.
Gordon Weir, researcher at Harvard-affiliated
Joslin Diabetes Center, Boston, believes in a strategy using short-term insulin treatment of a couple of weeks to several months to push blood sugar levels back to safer levels. However, diabetes "is a terribly difficult problem. If we had a great treatment for obesity, that would make a huge impact."
If you are a
diabetic and do not currently see a podiatrist, call our Bristol office to make an
appointment.
Richard E. Ehle, DPM
Connecticut Foot Care Centers
Diabetic Foot Care in CT
Podiatrist in Bristol, CT
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