July 18, 2013

Joslin SEEMS a Fan of AACE Algorithm

It seems that we are going to be continually bombarded with the American Association of Clinical Endocrinologists (AACE) Diabetes Algorithms. This time it is the Joslin Diabetes Center trumpeting the algorithms. The author of the Joslin blog tells us what we know and that is that the algorithms are for practitioners, both the endocrinologists and primary care physicians (PCPs). And yes, most people with diabetes are cared for by a primary care physicians, but that means they will have one diabetes medication stacked on another.

If things hold true, many of the diabetes patients will be kept on oral medications for too long a time as A1c's rise. The algorithms recommend moving to insulin, but many PCPs are very hesitant to move diabetes patients to insulin because they are also afraid of hypoglycemia.

I admit that the following statement by the Joslin blog author has me concerned and wondering why they are agreeing that diabetes is progressive. “They also place greater emphasis on the use of medication early in the pre-diabetes stage of the disease. Including medications as a concomitant part of treatment from the beginning, acknowledges both the difficulty of lifestyle therapy and the progressive nature of the disease.” This disagrees with the statement of Dr. Anne Peters from the University of Southern California, “The authors have eliminated hemoglobin A1c as part of the diagnostic criteria for prediabetes and don't describe in much detail how to decide when to treat somebody with prediabetes. There is no current US Food and Drug Administration-approved medication for the treatment of prediabetes.”

This tells me that Joslin is not afraid to use diabetes medications “off label” and with metformin being economical, this may be acceptable, as most insurance companies will not reimburse for pre-diabetes medications. The fact that Joslin considers diabetes progressive should concern every patient at Joslin, and especially if you are working to prevent progression to complications.

Joslin also apparently follows the American Diabetes Association guideline of 7% as the ideal A1c level and this also indicates that they consider diabetes progressive and that there is no means to prevent this – how very depressing. I can agree with the statement that A1c needs to be individualized for the elderly that are having other disease or comorbid problems, but they don't say this. They only say the target A1c needs modification based on individual risk factors and circumstances. Then the blog concludes with the statement, “Prevention of hypoglycemia is paramount when developing a treatment strategy for patients.”

There are so many issues left unsaid and others that are hinted at, that one needs to wonder who sets policies at Joslin and then if anyone follows these policies, if any exist. In the last few months, more conflicting comments have appeared in Joslin's blogs and in other sources. Then they refuse to identify the person writing the blog by saying the blog is by Joslin Communications.

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