Diabetes, especially type 2 diabetes mellitus affects a large population across the globe. Treatment usually comprises of the use of oral drugs that could reduce the blood sugar and keep the glycosylated hemoglobin levels or HbA1c less than 7 percent.
A new study from the researchers at the Mayo Clinic shows that such tight glucose control may not be the best idea for patients. Their study titled, "Paradox of glycemic management: multimorbidity, glycemic control, and high-risk medication use among adults with diabetes," was published in the latest issue of BMJ Open Diabetes Research & Care.
Treatment of diabetes leads to strict maintenance of blood sugar levels, and HbA1c levels within limits explained the researchers. This could be causing dangerous episodes of hypoglycemia or low blood sugar, which could be harmful to the patients, wrote the researchers.
Rozalina McCoy, lead author of the study and a primary care physician and endocrinologist at Mayo Clinic, explained, "Patients who are older or who have serious health conditions are at high risk for experiencing hypoglycemia, which, for them, is likely to be much more dangerous than a slightly elevated blood sugar level. At the same time, the benefits of intensive treatment usually take many years, even decades, to realize. So many patients may be treated intensively and risk hypoglycemia for no real benefit to them." She added that for younger and healthier individuals the theory is just the opposite. These younger ones are less likely to experience hypoglycemic episodes and thus may benefit from intensive and tight blood sugar control. She said, "These patients should be treated more aggressively, meaning that we should not shy away from using insulin or multiple medications to lower the A1C. We need to ensure that all our patients with diabetes receive high-quality care and are able to manage their disease to prevent complications both now and in the future."
This study revealed that persons who do not require tight glucose control, i.e., the elderly, are usually receiving such therapy. McCoy said, "What makes it even worse is that patients who are treated intensively are those who are most likely to be harmed by it. But at the same time, patients who would benefit from more intensive treatment are not receiving the basic care that they need. The paradox and misalignment of treatment intensity with patients' needs is really striking."
For this study, the team looked at data and records of 194,157 patients with Type 2 diabetes from the OptumLabs Data Warehouse. This extensive database contains electronic health data from large populations of patients. For each of the patients, the team looked at the use of different medications to lower the blood sugar as well as use of insulin. They also looked at the serial blood sugar readings and HbA1c levels of the patients. The data was gathered for patients enrolled between 1 January 2014 and 31 December 2016.
American Diabetes Association and Department of Veterans Affairs guidelines provide certain relaxations as to the target blood sugar and HbA1c levels. To this end, the team of researchers took into account 16 comorbidities that could affect the blood sugar control targets. The authors found, "Multimorbidity is common among adults with type 2 diabetes: 45.2% had only diabetes-concordant comorbidities, 30.6% had both concordant and discordant, 2.7% had only discordant, and 13.0% had advanced comorbidities."
Results showed that those who achieved HbA1c levels of an average of 7.7 percent were persons aged between 18 and 44 years. Persons who achieved an average HbA1c of 6.9 percent – signifying a higher blood sugar control, were an average age of 75 years or older. Average HbA1c of patients with little or no other coexisting illnesses was 7.4 percent compared to 7 percent seen in those with other ailments such as dementia, kidney disease, cancers, etc.
The authors wrote, "Patients least likely to benefit from intensive glycemic control and most likely to experience hypoglycemia with insulin therapy were most likely to achieve low HbA1c levels and to be treated with insulin to achieve them." The team added, "These HbA1c levels reflect HbA1c levels achieved by the patient, not necessarily HbA1c levels pursued by the clinician."
Dr. McCoy said that the exact explanation of this paradoxical management scenario is still not understood, and it needs further exploration.
The authors of the paper conclude, "...clinicians should continue to engage their patients in shared and informed decision-making, weighing the risks and benefits of glucose-lowering treatment regimens in the specific context of each patient, carefully considering the patient's comorbidity burden, age, and goals and preferences for care."
Dr. McCoy also said in conclusion, "We have a great opportunity to simplify and de-intensify the treatment regimens of our more elderly patients, which would reduce their risk of hypoglycemia and treatment burden without spilling over into hyperglycemia. At the same time, we need to better engage younger, healthier patients, work with them to identify barriers to diabetes management, and support them to improve their glycemic control." She added, "As clinicians, we need to be current on the guidelines and the evidence, know our patients and work closely with them to do what is right for them."
The study was supported in part by the National Institute of Health National Institute of Diabetes and Digestive and Kidney Diseases, the Agency for Healthcare Research and Quality, among others.
McCoy RG, Lipska KJ, Van Houten HK, et alParadox of glycemic management: multimorbidity, glycemic control, and high-risk medication use among adults with diabetesBMJ Open Diabetes Research and Care 2020;8:e001007. doi: 10.1136/bmjdrc-2019-001007