Forums » Open clinical » Diabetes » Should we be relaxed about glucose control in diabetes?
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Should we be relaxed about glucose control in diabetes?
posted at 4/7/2011 12:57 PM BST
on bmj.com
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*Moderator*
Posts: 681
First: 17/11/2008 Last: 16/5/2013 |
The website Trusttheevdience.com has great evidence based (of course) blogs. Of which this one I thought might be of interest to the Diabetes forum. Its by Ami Banerjee. The UK Prospective Diabetes Study (UKPDS) found that intensive blood-glucose control by either oral agents or insulin reduced the risk of the so-called “microvascular” complications (i.e. kidney disease, retinal disease and neuropathy), but not macrovascular disease (heart attacks and stroke) in patients with type 2 diabetes. The study led to a focus on the microvascular complications of diabetes. The DIGAMI (Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction) study suggested that after heart attacks, all diabetic patients should receive intensive glucose control with an insulin/dextrose infusion, even if they were not usually on insulin. This study meant that all diabetic patients with MI were put on insulin infusions for 48 hours after their MI. The DIGAMI-2 trial and other later studies have not been so clear- cut in their results and so this practice has largely stopped. Although a recent meta-analysis has shown that diabetes leads to a doubling in the risk of vascular disease (including MI), independently from other conventional risk factors, fasting blood glucose levels are, AT BEST, modestly associated with this risk. The authors of that meta-analysis concluded that “In people without a history of diabetes, information about fasting blood glucose concentration or impaired fasting glucose status did not significantly improve metrics of vascular disease prediction when added to information about several conventional risk factors”. Another meta-analysis of 5 trials of intensive versus standard glucose-lowering therapies found no difference in effect on stroke or death, but a 17% reduction in non-fatal heart attacks. In diabetic patients, the benefits of intensive glucose control do not seem to be as great as initially thought, whether in primary (before a heart attack) or secondary (after a heart attack) prevention. If you had to treat anything intensively, I would go for Intensive blood pressure control which is a more effective treatment in reducing vascular disease in these patients. http://blogs.trusttheevidence.net/ami-banerjee/should-we-be-relaxed-about-glucose-control-in-diabetes/110621154 |
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Re: Should we be relaxed about glucose control in diabetes?
posted at 4/7/2011 5:01 PM BST
on bmj.com
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Posts: 873
First: 17/6/2011 Last: 17/5/2013 |
I think this is very interesting because from my perspective in cardiology I worry much more abut the blood pressure and the lipids than I ever do about the absolute glucose or HbA1C value. I for one changed my practice after DIGAMI 2 was published. I do worry however that sometimes I'm ignoring the microvascular complications - retinopathy and neuropathy and from what I remember of UKPDS there was about a 25% reduction in the microvascular complications. Perhaps to the patients preservation of vision etc is more important? |
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Re: Should we be relaxed about glucose control in diabetes?
posted at 6/7/2011 5:05 AM BST
on bmj.com
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Posts: 624
First: 13/4/2011 Last: 15/5/2013 |
Hello Luisad: I agree with this simple but wise statement: We should be more relaxed about glucose control in diabetes. Of course that mostly aplies to our overweight or obese type 2 diabetics. Fasting hyperglycemia, elevated HBA1C, post-prandial hyperglycemia, seem to impact much less in the global absolute risk for diabetic macro and microvascular complications than insulin levels, endothelial dysfunction, atherogenic dyslipidemia, hypertension, and genes. Type 2 diabetes is a much chronic, serious, maladaptative, and progressive disease that demands a comprehensive aproach, that is not based on soft, cheap, easy to achieve, intermediate, good for the pharmaceutical industry not for the patient, clinical outcomes. A treatment just trying or putting too much emphazis to normalize glycemic levels is like over prescribing diuretics in heart failure, over prescribing ACE-Inhibitors in hypertension, over prescribing Beta-blockers in chronic atrial fibrillation, or over prescribing norepinephrine for the patient in septic shock. There are a number of clinical studies showing that. All best, Joey
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Re: Should we be relaxed about glucose control in diabetes?
posted at 6/7/2011 9:13 AM BST
on bmj.com
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Posts: 220
First: 10/12/2010 Last: 1/6/2012 |
Hi cardiologists!! You are talking of indoor treatment of AMI. Intensive treatment is possible only under these settings. Glucose infusion is probably there to avoid hypoglycemia. Even in indoors, I have seen many many cases of hypoglycemia. Few patietns went into even in irreversible coma and remained comatose for months. What about we the poor GPs in developing counteries. Here stable patietns of AMI simple refuse to go to hospitals (may be rightly so, if we know what kind of hospitals we have). A popular slogan is " Doctor! please let this patient die in your clinic, rather than in hospital where no body will even bother that some body is near to death." Under these conditions, the advice by lucaid agreed upon by Sadian and Joey is really realistic. On outdoor basis you never push to intensive control in AMI. Even with blood pressure we should be very careful. If patient is new to antihypertensive treatment and you are starting ani-hypertensive therapy for the first time, please go slow. Prefer 140-150/80-90, for initial few days rather than 120-130/80-85. Although I advise my old patients who are on antihypertensives for years to have 110-120/75-80 as an ideal target. |
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Re: Should we be relaxed about glucose control in diabetes?
posted at 21/4/2012 9:30 PM BST
on bmj.com
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Posts: 3031
First: 27/3/2012 Last: 11/5/2013 |
Hello Dr. Luisad! I have been very impressed by your intelligent perception, going through all of your posts. I think highly obliged to share my clinical opinions with you. We should never be relaxed about good glucose control in a diabetic patient! The syndrome of diabetes is very complicated in many aspects. Especially even if we are able to control the blood glucose levels easily, the unseen complications of diabetes, like retinopathy, nephropathy, autonomous/peripheral neuropathy, & cardiovascular complications go on progressively with little or no effect of the modern preventive measures. |
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Re: Should we be relaxed about glucose control in diabetes?
posted at 21/4/2012 10:07 PM BST
on bmj.com
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Posts: 453
First: 29/4/2011 Last: 14/5/2013 |
I urge our readers to read my blog on the new Joint EASD/Ada type 2 diabetes treatment statement at http://doc2doc.bmj.com/blogs/diabetes/_new-bible-diabetes-care Basically the statement states that we physicians need to involve our patients more in their care and setting therapeutic goals and that individualization of treatment goals is essential given the results from recent large trials that demonstrate intensive management becomes problematic as the duration of diabetes and the presence of cardiovascular disease increases. The statement itself can be found online at: http://www.easd.org/easdwebfiles/statements/EASD_ADA%20position%20s
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Forums » Open clinical » Diabetes » Should we be relaxed about glucose control in diabetes?
