April 28, 2013

Diabetes Guidelines You Can't Avoid

In diabetes it is not what the patient wants, but what the doctor can command and bully his way into making the patient do. Now the American Association of Clinical Endocrinologists (AACE) has developed another way, an algorithm this time, to force, where possible, patients into submission. Much of what is shown in the layout of the algorithm is aimed at convincing the patient to follow their doctor's wishes and desires. How else will they, the doctors, meet their goals? I wonder how soon this will be put into effect. The algorithm is available herehttps://www.aace.com/publications/algorithm in PDF format.

Following the Table of Contents, the first page is – Complications-Centric Model for Care of the Overweight/Obese Patient. They start the information off with Step 1 - evaluation for complications and staging. This is not a nice way of saying how we are to be treated. Step 2 is treatment options where only three options are allowed – lifestyle modification, medical therapy, and surgical therapy (a must if body mass index is equal to or greater than 35) They will push medication on top of medication in the medical therapy and insulin is one of those mentioned when we exhausted our options with the oral medications. They leave no doubt that surgical procedures will be sought for BMI's over the limit.

Step 3 is where they may actually dismiss us as patients as they state, “If therapeutic targets for improvements in complications not met, intensify lifestyle and/or medical and/or surgical treatment modalities for greater weight loss.” Apparently, diabetes patients will no longer have a choice and must be made compliant.

The next page is the Prediabetes Algorithm. In searching the page, they do not allow patients to stay off of medications or start and then wean themselves off medications. The assumption is that prediabetes will progress to diabetes. There is one improvement and that is the use of metformin for those at low risk. Maybe now we will see some action by Medicare and insurance. The counter to this is multiple medications when fasting plasma glucose is greater than 100 mg/dl with two-hour plasma glucose greater than 140 mg/dl.

The next page covers - Goals for Glycemic Control. They leave no doubt about where they are coming from and what they will be setting for their patients. If you are a compliant healthy patient without concurrent illness and at low hypoglycemic risk, you will be allowed to have an A1c of 6.5% or lower. If on the other side (greater than 6.5%), they will individualize goals for patients with concurrent illness and at risk for hypoglycemia.

On the next page, we come to what should make anyone with diabetes nervous. The page is titled Glycemic Control Algorithm. It is further subtitled Lifestyle Modification (Including Medically Assisted Weight Loss). So not to forget, they are supposedly talking about a couple of the weight loss medications approved by the FDA. Still in my mind, this should be classified as medication weight loss therapy and not medically assisted weight loss. This sounds more like surgery than medication therapy.

There are three entry A1c listings - 1) A1c that is less than 7.5%, 2) A1c that is equal to or greater than 7.5%, and 3) A1c greater than 9.0%. 1) above starts out as Monotherapy. Metformin is listed first, but they also list several others and even some that should be used with caution because of studies lately that show problems affecting the heart and other side effects. The bottom should raise alarm bells as you are only given three (only three) months to show improvement, or you will be moved to Dual therapy. Here basal (long acting insulin) may be part of the therapy, but this is supposed to be done with caution.

If you don't show improvement in dual therapy by the end of three months, you are to be moved to Triple therapy. This means three oral medications and with the order of suggested usage, they are going with oral medications that should be used with caution or basal insulin. If you don't succeed in three months here, you are to be moved to insulin therapy and oral medications.

Now look at 2) above. Here you will start on Dual therapy and if no improvement in three months, you move to Triple therapy. If you don't succeed on triple therapy in three months, insulin therapy is up next. If you started at 3) above, then if you have no symptoms (probably meaning no complications or concurrent illness) you may start at Dual therapy if your A1c is under 8.0%, otherwise you may start at Triple therapy and this is when basal insulin is recommended in Dual or Triple therapy. Now if you have symptoms, then you are to start on basal insulin and other oral medications as necessary.

The page following this is – Algorithm for Adding/Intensifying Insulin. The left side of the page is for basal (long-acting insulin) and not using sulfonylureas but other oral medications. I will not get into the titration part. That is between you and your doctor. On the right side is more intensifying of oral medications and adding prandial (mealtime) insulin (or short- or rapid- acting insulin).

The last three pages discuss cardiovascular disease (CVD) risk factor modifications algorithm, profiles of antidiabetes medications. I was surprised that for the most part, the page is right on. For comparison on most, use the different inserts here for each medication. The cardiovascular page discusses statins and blood pressure lowing medications.

The last page summarizes the guiding principles for the algorithms. I some ways this is difficult to swallow as it explains the importance of a lifestyle modification, the individualization of treatments, and their targets. The minimization of weight gain and hypoglycemia are worthy discussions.

I summary, I am surprised at what is not included. This would be exercise (covered in a blog by Tom Ross) and allowing patients to start without medications or using medications for bringing prediabetes and diabetes under excellent management and then weaning off medications as lifestyle goals are met. No mention is made of working at the prediabetes level of lifestyle changes to prevent the onset of type 2 diabetes.  Also missing is the option for those patients wanting off oral medications and onto the full insulin therapy.  Apparently this is not allowed under the algorithm.   For these reasons, I feel strongly that the algorithm is shortsighted and presents a defeatist attitude.

As a patient, I am very concerned about how they feel that diabetes is progressive and they offer no hope of people preventing this. One article about the algorithm may be read here and another here.

No comments: