Posted On: April 30, 2012 by Patrick A. Malone

Re-Thinking Diabetes Care

People diagnosed with diabetes quickly learn to test their own blood sugar levels several times a day using a home glucose kit. They also know that their periodic visits to a laboratory for tests measuring their A1C level should show a value no higher than 7, which is a widely accepted benchmark that the disorder is being well managed.

At least it used to.

These days, diabetes is among the disorders many enlightened practitioners are including in “patient-centered” care. That trendy term signifies the evolution of the practice of medicine that, along with a clinical diagnosis, embraces the individual’s circumstances and values to treat a disorder, and puts a priority on the sharing of medical decisions. That’s opposed to the traditional default of treatment based on technology, doctor preference/convenience, hospital equipment/protocol/location and the pure science of eradicating or ameliorating disease.

As explained in a story on NPR.org, “new diabetes management guidelines .. will cut many people with diabetes some slack.” The American Diabetes Association (ADA) officially now encourages diabetics and their doctors to determine an A1C level appropriate for each patient.

People who are diagnosed with Type 2 diabetes at a younger age reasonably might aim for a level of 7 or 6; older folks with accompanying heart disease might manage the disorder sufficiently if their level is 8, according to a study published in Diabetes Care.

"It it unrealistic to expect that everybody with diabetes should have the same goals and use the same medication," Vivian Fonseca, president of the ADA, told NPR.

As the director of one hospital diabetes center said, "It was a misguided public health concept that one number would make it easy for patients and doctors to remove the ambiguity and prevent diabetes complications. The problem is getting to goal safety and with patients' buy-in."

We’ve discussed the need for patients and doctors to craft a diabetes management program that acknowledges individual situations. But the new guidelines and the focus on customized care also shines a clarifying light on the knee-jerk use of diabetes drugs.

In a companion story on NPR.org, the American College of Physicians (ACP) encourages newly diagnosed diabetics and their doctors not to fall for the “newest is best” approach toward pharmaceuticals. This reflects the groundswell of support for rejecting unnecessary and expensive tests and treatments that often worsen a patient’s condition.

The ACP, NPR reports, advises some patients against taking certain drugs, and even directing them toward treatment from nonphysician competitors. There are lots of ways to manage diabetes, and taking drugs is only one. The patient-centered approach is part of what the organization calls “high value care.” Instead of taking vigorously marketed diabetes drugs such as Actos, Januvia and Avandia, Type 2 diabetics should opt first for an older generic drug.

We’ve covered the adverse events associated with these brand-name drugs here, here and here.

The ACP recommends that the first choice for newly diagnosed diabetics should be metformin, a generic drug nearly 20 years old. A month’s supply of metformin costs about $14; a month’s supply of Actos runs $230-$370, and the cost for Januvia is about $265. According to ACP guidelines, metformin "lowers blood sugar levels more than newer drugs do.” It also reduces bad cholesterol; the newer drugs don’t, and sometimes they raise it.

Steve Weinberger, CEO of the ACP, told NPR that, "In these days of crisis in health care costs, the medical profession should take its ethical and professional responsibility to do what we can to reduce costs while not compromising care." He realizes that doing so requires fortitude, thanks to the financial incentives physicians often have to prescribe more expensive treatments. Hospitals also tend to supplant the simpler and less expensive with the newer and more remunerative care option.

If your doctor isn’t heading up a patient-centered diabetes team, maybe it’s time to find a new coach.

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