June 19, 2014

Type 2 Diabetes Turmoil in Treatments

Yes, there is a lot of turmoil in the type 2 medications treatment arena because of poor science like this article. The headline of the article in Medscape is Deaths Higher When Insulin Is Second-Line Treatment for Type 2 Diabetes.” The title for the WebMD article is “Insulin-Metformin Combo Tied to Poorer Survival” and subtitled, “Other experts dispute the study's conclusions.” This blogger, Jenny Ruhl has a better title - “Why Insulin Plus Metformin May be Associated with Higher Mortality.”

I find it very hard to believe that Medscape and WebMD are related companies because of the two varied titles. I can believe the Medscape article headline is true because too often insulin in the second or even up to the fourth line of treatment. In reality, insulin should be the first line of treatment. David Mendosa writes an excellent blog here about the benefits of insulin being a short first-line of treatment.

I am in disagreement with the lead author of the research, Christianne L. Roumie, MD, associate professor of internal medicine and pediatrics at Vanderbilt University, Nashville, Tennessee. She states it is better to use two oral medications before progressing to insulin use for people with type 2 diabetes. The preferred second drug is a sulfonylurea and her study claims that this combination causes less death than metformin and insulin combination.

What she seems to forget is that the sulfonylureas have come under investigation as causing cardiovascular deaths as well. Read my blog about this here.

Most family doctors or primary care doctors know so little about dosing insulin that they stack oral medication on top of oral medication until insulin is required. They also attempt to keep type 2 patients on oral medications until it is too late for insulin to really help the way it should have if used earlier. In addition, general practitioners are afraid of hypoglycemia and this also drives them to want to keep type 2 patients on oral medications.

Then the author all but negates the study by making the following statement. “She also cautioned that findings from work such as this can create uncertainty. The complex statistical methods needed to overcome the various sources of bias and confounding that are inherent in observational research and the fact that this is a comparative-effectiveness study make it difficult for clinicians to interpret the data, she noted. "Given these caveats, many clinicians will probably refrain from making practice changes based on this study."”

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