Physicians have the wrong priorities when treating patients with diabetes, according to a research letter in the Archives of Internal Medicine.
Mann et al looked at data from diabetics participating in the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2006. During the course of the study period the use of medications to treat glucose, cholesterol, and hypertension increased broadly, although the most impressive changes occurred in glucose control. By the end of the study more than half the patients had HbA(1c) levels lower than 7%, compared to only 43% who had controlled cholesterol and 39% who had controlled hypertension.
By the end of the study, nearly all diabetics were receiving glucose control agents, while only 78% were taking antihypertensives and 51% were taking statins. This result, write the authors, “highlights the concerns that a disproportionate emphasis is placed on controlling hyperglycemia at the expense of the more evidence-based CVD risk reduction strategies of controlling hypertension and high cholesterol level.”
The authors conclude:
The data from this study support the perception that control of hyperglycemia frequently takes precedence over control of hypertension and high cholesterol level among adults with diabetes. These observations support the argument for a reprioritization of diabetes treatment goals emphasizing hypertension and cholesterol control before tight glycemic control as part of an evidence-based global CVD risk reduction effort.
Darren McGuire sent the following comment to CardioBrief:
These data are speaking directly to a principal problem in diabetes management, where the clinical culture primarily equates DM treatment with glucose treatment. In fact, paradoxically, the authors themselves reveal this bias, referring throughout the paper to glucose-lowering medications as “antidiabetes medications”. The most potent “antidiabetes medications” are the statins and at least 5 classes of blood pressure lowering medications, followed by aspirin.
No doubt that glucose lowering treatment is an important part of DM management, it simply cannot remain as the cornerstone with an abundance of outcomes data for both macro- and micro-vascular risk reduction with aggressive BP treatment and also with the statins.
In addition, these data likely also reflect the well-intended but off-target consideration of measures of glycemic control as the basis for most quality assessment for DM treatment most often at the exclusion of more evidenced-based measures like prescription of statins, BP meds, and ASA and achievement of BP and lipid therapeutic targets. The sooner we culturally re-define DM quality management in accord with these measures, the sooner we will afford the patient population with DM “quality” care.
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