How to Avoid Excessive Treatment in Diabetes

Evidence-based medicine should guide type 2 diabetes medication to prevent overtreatment, according to new recommendations.

Researchers from the UT Southwestern Medical Center outlined their suggestions that evidence based medicine — the approach that embraces individualized care – in a review published in the journal Circulation. The study authors called over treatment “pervasive” and said it “leads to potential patient harms and excessive costs in health care.” Overuse, they added, can account for as much as a fifth of the estimated $750 billion of wasted spending in the health care industry in the United States.

By applying evidence based medicine approaches to individualized treatments, physicians can prevent over treatment and promote patient centered care, the researchers explained. They applied their reasoning to a discussion about the treatment of type 2 diabetes.

The investigators first examined the use of absolute rather than relative estimates of benefits to inform treatment decisions. They said that in diabetes cases, published studies indicate that after 10 years of intensive glycemic control, a patient may only experience mild positive effects. Additionally, risk for cardiovascular disease typically drops. To estimate the absolute benefit, the researchers were forced to rely on simulations rather than clinical outcomes. In these scenarios, it became clear that the potential benefit of intensive glycemic control declined significantly with the age at which the patient was diagnosed.

“Relying on relative risks can vastly over estimate the benefits from treatment, which is why absolute risks are the preferred method to inform therapeutic decisions,” the study authors wrote.

The next part of the study discussed the time horizon to benefit of treatments, where the researchers determined that the patient’s life expectancy is a significant factor. For example, as recently reported in MD Magazine, a diabetes patient’s life may be shortened by up to nine years because of their diagnosis. Additionally, the researchers reported, the first time a patient is hospitalized for heart failure, their five-year mortality rate reaches 70 percent. The researchers said that because of these such mortality rates, intense glycemic control for diabetes may not have any benefit beyond a conventional glycemic control strategy.

The study authors also considered the evidence based medicine principle of balancing potential harms and benefits. Risks, which can also be individualized, usually include weight gain, severe hypoglycemia and a decrease in quality of life on an intensive glycemic control regimen. The researchers conceded that while patients may experience net benefits from intensive glycemic control, those with greater risk for microvascular and cardiovascular disease compared to those of average risk, may find additional benefit in a more intense regimen. But, they said, individuals with lower than average risks have even less potential to see benefits from an intensive glycemic control program.

Shared decision-making, the fourth and final pillar of evidence based medicine, revealed to the researchers the importance of the patients’ values and preferences that go into treatment decisions. Physicians should follow these four steps, they said: 1) explain to the patients that there exists an understood method on how best to treat the disease; 2) present alternative choices on the basis of the best available medicine; 3) support conversation between the therapeutic choices and best methods of implementation based on values and lifestyle, including social support, financial means, and workload factors; and, 4) come to a joint decision.

“Evidence based medicine is often misunderstood as a call for universal, cookie-cutter medicine, which has led to an epidemic of overtreatment in type 2 diabetes,” senior author Dr. Oanh Nguyen, explained in a press release. “Instead, evidence based medicine is a critical tool in the physician’s arsenal to provide individualized and person centered care.”

Currently, the study authors added in the statement, the standard of care for type 2 diabetes includes strict blood sugar control. But because that may only provide a modest benefit, they said, it can decrease quality of life in patients and even lead to possible harm stemming from the therapy.

The Circulation paper was titled “An Evidence-Based Medicine Approach to Antihyperglycemic Therapy in Diabetes Mellitus to Overcome Overtreatment.”

The study authors were quoted in a UT Southwestern news release entitled “Researchers urge use of evidence-based medicine to avoid overtreatment of type 2 diabetes.”

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