"More Aggressive Diabetes Treatment Needed: Presented at AAFP"
By Crystal Phend
SAN FRANCISCO, CA -- October 11, 2005 -- Physicians need to treat diabetes more aggressively and use all available tools to prevent cardiovascular disease, according to a diabetes management presentation at the annual meeting of the American Academy of Family Physicians (AAFP).
"Treat to target, not to failure," was the theme of the presentation here on September 28[th.
Primary care physicians treat about 90% of all patients with diabetes in the United States, but receive relatively little training in medical school on the subject, said Jeff Unger, MD, Director, Chino Medical Group Diabetes and Headache Intervention Center, Chino, California, United States.
Guidelines from the American Diabetes Association and other organizations suggest that the target hemoglobin (Hb) A1c level, which reflects blood sugar control, should be 7%. The average in the United States is 9% and about 20% of individuals with diabetes have HbA1c levels above 11%, according unpublished data he presented from the Texas Department of Health.
The best prevention is to manage diet and lifestyle aggressively, but physicians should be wary of trying to manage the disease that way, he said. "Patients will come in and say, 'Don't worry doc', I'll control it with diet and exercise,'" Dr. Unger said. "That does not work."
Both type 1 and 2 diabetes are progressive diseases, so most patients over time will need insulin therapy, Dr. Unger said.
He recommended that patients be started on insulin therapy when they are symptomatic, unable to achieve acceptable HbA1c levels within 2 to 4 months of starting triple combination oral therapy, under special conditions like infections, hospitalization, or pregnancy, or if they have triglyceride levels above 700 mg/dL, especially if patients have coronary artery disease.
"Early intervention with insulin can reduce long-term complications," he said.
To rapidly get HbA1c levels down to target levels, he recommends a forced titration of split dose insulin, with patients taking injections at breakfast that are adjusted by the previous pre-dinner blood glucose level and vice versa.
The patient should call their physician's office to report their blood glucose level so the nurse can instruct them on how to adjust the insulin dose. Target fasting blood glucose levels should be 80 to 100 mg/dL and dinner glucose levels should be <140 mg/dL.
This regimen typically gets levels under control within 12 weeks, Dr. Unger said. "It's easy, it's safe, it's effective," he said, adding that "82% of your patients will go down to AIc 7%."
Inhaled insulin, which is expected to be available in the next 3 to 4 months in the United States, may be a good idea as a bridge therapy to injections, Dr. Unger said. Also, he suggested that statins should be used to control cardiovascular risk for diabetics over age 30.
"Aggressive control of hyperglycemia and diabetes risk factors reduce micro- and macrovascular complications and decrease endothelial inflammation, Dr. Unger said. "Your patient will live longer with less morbidity!"
[Presentation title: Intensive Diabetes Management: A Physiologic Approach. Session 536]
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