October 1, 2014

Suggestions for ADA

I am sure all of us could all come up with favorites for the American Diabetes Association to do, but being a group by and for doctors, I doubt we will see changes that we wish would happen.

I have seen several bloggers use the term “Stage 1” to mean prediabetes and “Stage 2” for type 2 diabetes. Yet none go as far as Brenda Bell did in her Tuesday, April 20, 2010 blog. I have lifted this from her blog and thank her for this, even though I did not appreciate it at the time. While I am at it, I sincerely wish she would do more blogging, as she was often enlightening before other bloggers even thought about it.

Quote: An initial straw man chart can be derived from the American Association of Clinical Endrocrinologists' Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus (2007) examples for initial pharmacotherapy of T2DM:

Classification of Type 2 Diabetes Mellitus (based on initial therapy algorithms)
Progression Level
HbA1c (untreated)
Stage 1 (Prediabetes)
5.7 - 6.4
Stage 2
6.5 - 7.0
Stage 3
7.0 - 8.0
Stage 4
8.0 - 10.0
Stage 5
> 10.0

Other issues that play into determining the progression of T2DM include the deterioration of endogenous insulin production, the development of complications of diabetes, and the degree to which a person's blood glucose levels and HbA1c are responsive to pharmacotherapy. A more complex table of progression might include these in a manner such as this:

Classifications of Type 2 Diabetes Mellitus (proposed)
Effective Therapy
Evidence of
Stage 1 (Pre-Diabetes)2
< 6.03
ILM. Oral medication optional for aggressive treatment.
Stage 2
< 6.5
Oral medication and/or insulin sensitizer required
Stage 3
< 7.0
Combination therapy and/or insulin required
possible comorbid conditions
Stage 4
< 7.0
Insulin therapy required, with or without oral medications and/or pramlintide (Symlin)
possible comorbid conditions
Stage 5
< 8.0
Intensive insulin therapy required, possibly in conjunction with insulin sensitizers
obvious; one or more
comorbid conditions

1 While the HbA1c goals at the more advanced levels of diabetes progression are high enough that complications are likely to develop or intensify, those goals may not be realistically achievable with current medical and pharmaceutical technology.

2 Includes all previous diagnoses of gestational diabetes or Type 2 diabetes in which pharmacotherapy is not currently indicated

3 More aggressive practitioners may argue for an HbA1c goal of under 5.5 for Stage 1, under 6.0 for Stage 2, and under 6.5 for later stages of T2DM. The less-aggressive goals are informed in part by the (ACCORD) study, in which the tested combination therapy suggested a higher mortality risk for intensive control.

A classification scheme of this sort may remove the ambiguity of a diagnosis of "prediabetes" and its associated laissez-faire ("It's not diabetes") attitude, as well as the popular belief that once diagnosed, one can become "undiagnosed" (or perhaps "de-diagnosed"). It can also alert a medical practitioner to the need for ongoing monitoring and assessment of a person's glucose metabolism. On the other hand, classification will add to the pool of people indicated to have diabetes those who do not consider themselves to be currently affected by diabetes -- and in an environment where a positive diagnosis can mean the denial of employment, medical insurance, or healthcare, this can have worse repercussions than living with undiagnosed or untreated Stage 1 (or even Stage 2) T2DM. Unquote

The above quoted information is the most comprehensive that I have seen and I wish the ADA would give this consideration.

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