Major Medical Associations Feud Over Diabetes Guidelines

A major medical association today suggested that doctors who treat people with Type 2 diabetes can set less aggressive blood sugar targets. But medical groups that specialize in diabetes sharply disagree.

Half a dozen medical groups have looked carefully at the best treatment guidelines for the 29 million Americans who have Type 2 diabetes and have come up with somewhat differing guidelines.

Read more: https://www.npr.org/sections/health-shots/2018/03/05/590922698/major-medical-associations-feud-over-diabetes-guideline

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I heard this on NPR yesterday and also read about it online. One of the things that was so outlandish to me in the controversial recommendations was that they were based on the fear of hypoglycemia. In commentary, someone from the ADA rightly pointed out that the authors of the recommendations had ignored decades of advances in medication and technology that makes hypoglycemia much less an issue (from an epidemiological perspective) now that it used to be.

The idea of recommending that Type 2s aim for an A1c of 7.0% is retrogressive in the extreme, and also suggests strongly that doctors just write off the health and long-term wellbeing of Type 2 patients. Horrible stuff.

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This type of article showing up in the press with a credible medical group behind it really bothers me. Cynically I expect this approach to start showing up in our insurance coverage determinations for both type 1’s and 2’s. Getting a letter in the mail someday saying “Your A1C is too low, insulin is no longer covered” would not surprise me.

The other thing that bothers me about this is how bad I feel when my BG is too high. Closest way to describe it is a hangover without the nausea, ability to function like a nominally fit and awake (and employable) person is zilch. Why would the medical profession wish that high BG on anybody when there are so many good modern treatment tools out there?

I suppose if I was laying flat on my back in a nursing home at age 90 and unable to self-treat lows I would expect my doctor to recommend a higher A1c but not when it is still feasible to keep it lower.

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I think doctors don’t trust us to manage our blood sugars well enough. They’re worried that if we drop low, we won’t treat it properly, and we’ll die.

It’s true that diabetes is not an easy disease to manage. I feel like the response to that SHOULD be better education and demanding access to cgms rather than reducing our quality of life by setting lower (or rather higher) goals.

Perpetually high blood sugars will not only result in long term complications, but would also result in people not functioning at their optimal levels TODAY. I do not think as clearly when my blood sugar levels are high so there would be an immediate impact on my quality of life if my A1c went up to 7.5%.

This is outrageous:

“For people who have already achieved a lower level, ‘consider de-intensifying treatment,’ Ende says. ‘That is, reducing one of the medications, stopping a medication, just allow the A1C to be between 7 and 8.’”

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Sigh. This garbage is old and still seriously stupid. Let the damn docs proceed on those foolish guidelines and watch their patients develop complications-amputations-etc…

Always: “It’s the Carbs, stupid!” Moderate and track your carbs. Live longer with fewer complications—including being able to moderate your need for insulin if you are T1…

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Here’s the full report:

http://annals.org/aim/fullarticle/2674121/hemoglobin-1c-targets-glycemic-control-pharmacologic-therapy-nonpregnant-adults-type4

I found the following disturbing:

Lowering blood glucose may decrease risk for complications, but lowering strategies come with harms, patient burden, and costs.

How do they access potential harms, patient burden and costs on an individual basis?. Would they ask the patient which path to take, or does cost trump it for everyone.

They do talk about “personalizing” the treatment plan with the patient’s involvement – but it isn’t the main point of their report.

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For people with advanced cardiovascular disease, hypoglycemia can be a major risk. I have a friend with Type 2 that must avoid low blood sugars religiously because she has trouble with her heart when her blood sugar drops low. She’s had multiple heart attacks. Her current A1c is 6.7%, and her medical team is mostly comfortable with that level. I can see why higher limits might be appropriate for her circumstance. However, I think setting high limits should only be done for individual cases, not as a general guideline.

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Have to take into account the age of the patient and expected life span. Tight control targets are not appropriate for an 85 year old with cognitive decline… they are appropriate for a 30 year old with no impairments

Pretty much what they say “Guidance Statement 1:
Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care”

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“If you want to treat diabetes ‘by the book’, then you need to write a new book for every diabetic.”

But setting less aggressive blood sugar targets is, in my opinion, idiotic and self-defeating----Especially for T2s. It just underlines something I have long believed: Really smart people can be awfully Dumb sometimes.

And then they treat us T2s as if we are too stupid or careless to take on aggressive care for ourselves. Many of us are not even offered the option of lowering our carb intake as a way of gaining some control. We are just handed a med and sent on our way…Sigh…but Onward! as best we can…Judith in Portland

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Yes, I am cynical.

So, what would this change accomplish?

Gee, less initial money spent by government and insurance, since fewer people would be considered diabetic. More money made by physicians and hospitals and clinics and pharmaceutical companies who treat diabetic complications.

Better health? …Nope!

The real question is who is funding this proposed change.

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Yes, but consider that we are a very small proportion of people with type 2 diabetes. Most folk don’t want to bother (or can’t afford to) change their diets (I’m currently in the position of “if it ain’t supercheap and quick, I can’t afford it, and my family members won’t eat it”) and can’t get the time to check their bgs regularly. I have to presume that this is the reason that most of us get a script and a diet sheet and are sent on our merry way without access to CDEs, support groups, or anything else.__