“Tight Glycemic Control More ‘Burden’ Than Benefit for Many,” a Medscape Medical News piece proclaimed. Reading this online article later in JAMA Internal Medicine really got my blood boiling. The proposed “solution,” in the guise of “patient-centered care,” is to “personalize treatment.” Sounds nice, but consider also the potential to blame failure-to-successfully-treat ON THE PATIENT, rather than on the WRONG TREATMENT PLAN, and then to assign the failure to the patient’s “burden” of treatment, thus relieving the patient of the moral burden for failure. Neat, huh?
The primary end-point was “to estimate the treatment burden vs. benefits from intensive vs. moderate glycemic control in patients with Type 2 diabetes.” The outcome: “Using a simulation model, the researchers discovered that for patients with Type 2 diabetes who are on Metformin and have an HbA1c below 9%, adding other antidiabetic therapies to try to lower glucose further may only confer modest benefits 15 to 20 years later.” Even though, the authors acknowledge, “Lowering HbA1c delays the onset and slows the progression of early microvascular disease.”
So, what did we learn here? The new Standard of Care “for many” would be an A1c <9%, equal to an AVERAGE glucose of 212mg/dl? And that for these “many,” the treatment plan, described as having “a low-treatment burden,” is simply to prescribe Metformin and do nothing else. Because the benefit gained is only “modest”? What could lead anyone with a clinical practice to reach this conclusion? Could it be THE FAILURE OF THE TREATMENT PLAN?
This study was carried out by doctors from the University of Michigan and the VA Ann Arbor Healthcare System. Not to slam yet another VA facility, but – I have to wonder – are the vets at this VA facility subjected to this lower Standard of Care? If true, shame on these doctors. But maybe I’m just piling on. Maybe, by JAMA Internal Medicine publishing this piece, they too are advocating a broader application of this lower standard of care. A new paradigm!
Why lower the Standard of Care? Because, “for patients older than 50, especially, any potential benefits are often outweighed by ‘burdens’ of lifelong treatment – such as substantial weight gain from sulfonylureas, the need to frequently inject insulin, or the risk of hypoglycemia.” But, “patients older than 50” includes most people initially diagnosed with Type 2 diabetes, so this new paradigm would then thus apply to almost everyone!
The authors state that the decision to “start new medications” (beyond Metformin, assuming Metformin is tolerated) should be “based on individual circumstances and preferences.” “These are important decisions,” they say, “because Type 2 diabetes is a chronic disease that requires lifelong treatment. [only on the wrong treatment plan]. Thus, shared decision making, in which patient preferences are specifically elicited and considered, appears to be the best approach to making most decisions about glycemic management….” Get patient “buy in” of less “burden.” Sounds appealing!
But the most disingenuous statement in this article was this: “What really surprised us was you end up with a reduction of quality of life for many patients – basically those who are a little bit older when they are diagnosed or those who really don’t like their treatments.” Don’t like their treatments? If the treatment “really bothers you, then you just need to understand that you have a slightly higher risk [according to the ‘simulation model’ they constructed] of these complications, and it may not be worth treating to prevent that,” they concluded. That’s confirmation bias!
It’s true: Some people can’t tolerate Metformin. And some anti-diabetic meds (e.g.SUs) do cause weight gain, and injecting insulin is a “bother” and can cause weight gain and does entail a risk of hypoglycemia. But do these “constant annoyances of having to be on a medication and experience the side effects” constitute a “burden” that exceeds the benefits of having improved glucose control? Or is this construct just rationalization to justify a failed treatment plan?
And if the treatment plan included dietary changes, such as carbohydrate restriction, would not the benefits of losing weight, taking less or no anti-diabetic oral medications, and stopping insulin injections, far exceed the “burden”?I know people who tell me they could “never” give up bread, pasta, rice, corn and potatoes, or beverages sweetened with sugar or HFCS. “I really wouldn’t like that treatment plan,” they say. But…you know what? IT REALLY WORKS.