The Best Treatment Strategies for Diabetic Patients

“I recommend pumping iron to my diabetic patients. It gets glucose to the muscles.” — Shahady.

We were told that every session where Edward Shahady, MD, was the discussion leader featured standing room only, in addition to an overflow room. This morning’s session, “Diabetes Mellitus Treatment — Advanced Case Studies: Achieving Diabetes Standards of Care,” was no exception. With diabetes being such a hot topic, it wasn’t shocking to see such a packed session.

The main focus was on the best treatment strategies for diabetes patients, with two case studies to illustrate the points Shahady addressed. There was tremendous audience participation as discussions on counseling patients on making healthy behavior changes to reduce the risk of diabetes and cardiovascular disease; blood glucose goals; patient education on how heshe can self manage their diabetes; pharmacologic interventions; and common co-morbidities were addressed.

Case Study #1

A 52-year-old man comes in for a routine physical and has a family history of diabetes and his father died of myocardial infarction at 54 years. He has a BMI score of 28, a 42 inch waist, and FBS is 132. After performing an A1C screening, his level is 6.2.

Shahady asked the audience to consider the following questions:

• What is your diagnosis? Diabetes? Pre-diabetes? Or metabolic syndrome?
• What % of ß cell function has this patient lost?
• What do you think his blood pressure, LDL, HDL, and triglycerides measurements will be?
• How would you treat him?

Physicians, how would you answer the above questions?

To lower triglycerides it is recommended that patients exercise and take metformin. There was a doctor who said, “I’d rather have my patients exercise than take medicine.” Another said that he believes patients should be involved in treatment decisions. Immediately Shahdy asked, “Is there a risk to having patients become involved in treatment decisions? If so, how much is the risk?”

ADA vs AACE

Diagnosing diabetes

In the 2010 ADA position statement on the diagnosis and classification of diabetes mellitus, it stated the following:

• A1C should be greater than or equal to 6.5% based on retinopathy
• Fasting plasma glucose is greater than or equal to 125 mg/dl
• Two hour post-glucose load plasma glucose is greater than or equal to 200 mg/dl
• Random plasma glucose is greater than or equal to 200 with symptoms of hyperglycemia

In the 2010 AACE statement on the use of hemoglobin A1C for diagnosing diabetes stated the following:

• A1C is an optional criteria; not the primary criteria
• To use traditional glucose criteria for diagnosing diabetes when possible
• Not recommended to diagnose type 1 or gestational diabetes
• To only use standardized, validated assays for A1C testing
• A1C may be misleading in any conditions associated with hemolysis, anemia, and severe hepatic or renal disease

Physicians, which set of guidelines do you follow when diagnosing diabetes?

Pre-diabetes

The ADA position statement states the following when diagnosing pre-diabetes:

• Recognizes that intermediate levels of glucose elevation leads to an increased risk of diabetes
• Recognizes that this group of patients is at risk for CVD and some may have signs of retinopathy, nephropathy, and neuropathy. Additionally, an increase in blood pressure and triglycerides and a decrease in HDL are often present
• New guidelines recommend A1C levels of 5.7-6.4% for diagnosing pre-diabetes

The AACE position states the following:

• Do not support using A1C alone to identify patients with pre-diabetes or who are at risk for diabetes
• They agree that A1C levels of 5.7-6.4% can be used as a screening test
• A1C screening test should be followed by a fasting glucose or post-glucose load to confirm the diagnosis

Case Study #2

A 62-year-old woman was diagnosed with diabetes three years ago and was treated with lifestyle changes and metformin. Her A1C was 7.3 at diagnosis and decreased to 6.2. She recently noticed that her blood sugars are higher and her A1C is now 8.3.

Shahady asked the audience to consider the following questions:

• Would you add another oral medication? If so, which one?
• Would you consider adding insulin?
• What about GLP-1 agonist (eg, Byetta, Victoza)?

Physicians, how would you answer the above questions?

In conclusion, there is no doubt that a change in lifestyle has an impact on effective diabetes management. The controversy lies in whether a physician will also prescribe patients metformin.