April 20, 2018
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Debate persists in treating older patients with diabetes

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Rita Kalyani
Rita Kalyani
Tom Finucane
Thomas Finucane

 

NEW ORLEANS — A one-size-fits-all approach on reaching glycemic targets will not work in older patients with type 2 diabetes, according to members of a panel discussion held at the American College of Physicians annual meeting.

About 75% of the older population has diabetes or prediabetes, Rita Rastogi Kalyani, MD, MHS, FACP, associate professor of medicine, division of endocrinology and metabolism at Johns Hopkins University School of Medicine, a member of the scientific program committee as well as the panel's moderator, told Healio Family Medicine in an interview.

“This is an area in clinical medicine where there aren’t as many evidence-based studies done on this population and where there is some debate in terms of the appropriate targets for clinical care,” she said.

Thomas E. Finucane, MD, FACP , professor, division of geriatric medicine and gerontology, Johns Hopkins Medicine, and one of the panel participants, said the debate entered the public domain more than 15 years when Aventis Pharmaceuticals funded the “Aim. Believe. Achieve. Diabetes A1c Initiative,” which involved more than 2 dozen medical organizations.

According to Finucane, this was a 2002 promotional campaign that spurred a mindset that patients with diabetes need to have their HbA1c levels regularly tested and maintained under 7%, despite significant disagreement in the scientific community. He said the mindset must change, but that many in the medical community are reluctant to do so.

“Medical history shows us that changes to deeply established dogma occur slowly and are particularly difficult for people who have invested their careers in an idea that is being bypassed and for people whose income depends on adherence to the dogma,” Finucane said.

The controversy surrounding treatment of patients with diabetes took another turn recently, when the American College of Physicians (ACP) issued a recommendation in March that most patients with type 2 diabetes should be treated to achieve a less intensive HbA1c goal between 7% and 8% and that treatment for older, frailer, more vulnerable patients should focus on symptoms and “avoid targeting an HbA1C level.”

Finucane said regardless of target, pills and insulin are not the way to achieve glycemic control for most people with type 2 diabetes and he emphasized that there is no debate that treatment is necessary for patients who are symptomatic from high glucose levels, with excessive thirst and urination

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“Taking diabetes drugs is of little help if you are obese and sedentary,” he said in the interview. “If you put a desert cactus in a rainforest it will die; it’s evolved to survive with little water and lots of light; it cannot survive lots of water and little light. If you take overweight people who do no physical activity, many of them too will sicken and die. We’re evolved to be slender and active, not for this. As with the waterlogged cactus, the harms from the new environment will be complex. But for now people want to take pills to be healthy, rather than change lifestyle, and an industry suggests this is good enough.”

He also cited statements from the American Diabetes Association and American Cancer Society that indicate some evidence suggests that metformin is associated with a lower risk for cancer.

When it comes to insulin, Finucane said it “is extremely dangerous and very expensive,” noting that a recent meta-analysis showed insulin was no better than dietary management when controlling glycemic levels and did not protect people from diabetic complications.

He said other evidence summaries indicated that aggressive glucose-lowering targets “produce little or no benefit” in reducing sequelae associated with diabetes, such as amputation, blindness, death from myocardial infarction, nerve damage and renal failure.

“If you spend your life taking shots and pills to reach an aggressive glycemic target, it is not going to prolong your life. For most patients with type 2 diabetes, the best advice is simply to eat less and walk more,” Finucane said.

Richard Pratley
Richard Pratley

The other panel participant — Richard E. Pratley, MD, the medical director at the Florida Hospital Diabetes Institute — disagreed with some of Finucane’s statements.

“To not consider insulin at all is an extreme position. Most practicing physicians would be somewhere more toward the middle,” he told Healio Family Medicine, noting that with proper management, medications can play an important role in patients with diabetes.

“We have 12 classes of medications, so we don’t have to rely exclusively on medications that promote hypoglycemia,” Pratley said. “Within the different classes of medications there are GLP-1 receptor antagonists and the SGLT2 inhibitors that are associated with improved patient important outcomes such as reducing myocardial infarction, stroke and heart failure. Where appropriate, in people who have these risk factors and comorbidities, then we should consider using these medications specifically.

“There is good evidence for decreased complications with diabetes in people with type 1 and type 2 diabetes who have good glycemic control over the long term,” Pratley said.

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“However, we also have very good evidence that when we push glycemic targets with medications that are associated with a high risk of hypoglycemia, then we can worsen these outcomes. So, it’s a balance,” he said.

Other evidence, Pratley said, is not so clear.

“There’s a lot of confusion about ... what the appropriate targets are for older patients. And this is promulgated by differing recommendations from differing professional associations,” he said.

Further compounding the lack of a universal glycemic control approach is a very diverse older population, many of whom have diabetes, Pratley said.

“There’s a great deal of heterogeneity among older individuals, and in diabetes in older individuals, so that we really have to tailor our targets and treatments to the patient. And I think if we do that, then we can be safe and have better outcomes than trying a one-size-fits-all approach,” he said.

Kalyani said older patients with type 2 diabetes have “unique considerations” that must be considered when deciding what treatment is best, such as the presence of coexisting chronic illnesses, functional status, risk for hypoglycemia, and life expectancy.

“Geriatric syndromes also occur more commonly in people with diabetes and include polypharmacy, urinary incontinence, falls, chronic pain, cognitive impairment and depression. These can further affect a patient’s ability to self-manage the disease,” she said.

Pratley added that patients, also regardless of treatment approach, need frequent monitoring to ensure its effectiveness.

“You cannot set treatments and forget about them,” Pratley said. “You need to ask yourself: Is the patient achieving their goals? And if not, is it appropriate to intensify therapy? Has their clinical situation changed that warrants changing the glycemic target? If we keep those sorts of things in mind, and do that on a regular basis, then it’s possible to treat patients with diabetes and improve their outcomes.” – by Janel Miller

References:

ACPonline.org. ACP recommends moderate blood sugar control targets for most patients with type 2 diabetes. March 6, 2018. Available at: https://www.acponline.org/acp-newsroom/acp-recommends-moderate-blood-sugar-control-targets-for-most-patients-with-type-2-diabetes. Accessed April 7, 2018.

Boussageon R, et al. Br J Gen Pract. 2017;doi:10.3399/bjgp17X689317.

Finucane TE, et al. Diabetes management in older adults: the debate continues. Presented at: American College of Physicians annual meeting; April 17-21, 2018; New Orleans.

Disclosures: Finucane reports he serves as a consultant for Anthem Insurance and has an official role with Anthem Insurance’s Pharmacy and Therapeutics Committee. Kalyani reports no relevant financial disclosures. Pratley reports he receives research grants and contracts from Lexicon Pharmaceuticals, Ligand Pharmaceuticals, Lilly, Merck, Novo Nordisk, Sanofi-Aventis and Takeda; serves as a consultant for AstraZeneca, Boehringer Ingelheim, Eisai, GlaxoSmithKline, Janssen Pharmaceuticals, Lilly, Merck, Novo Nordisk, Pfizer and Takeda; and serves on the speakers’ bureau for Novo Nordisk and Takeda.