COMMENTARY

Managing Diabetes 'As Complex as Bringing Up Children'

New ADA/EASD Guidance Challenges Clinicians to Be Informed

David R. Matthews, DPhil, BM, BCh

Disclosures

October 23, 2012

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Hello. I am David Matthews, Professor of Diabetes Medicine at the University of Oxford in the United Kingdom, and Co-chair of the Position Statement that the European Association for the Study of Diabetes has produced jointly with the American Diabetes Association.

A group of us, 5 from the United States and 5 from Europe, have come together over the past couple of years to write this position statement, which was published earlier this year both in the European journals and in the American journal, Diabetes Care.[1] This position statement differs from previous guidelines in that it is not a strict guideline. Guidelines have tended to be rather like railway lines, where you go down a certain set of points and you make a decision on the basis of one thing or another. The problem with the guidelines up to now has been that these nodal decision points at which people have decided to give additional therapy are taken from trials, but they are the midpoints of what people have achieved in trials, and we know that in reality, these points of decision are different in different populations. They should be different in older people and probably also should be different in very young people, but we do not have a lot of trial data about that. The one-size-fits-all approach does a disservice to patients. We know that from the ACCORD study, which surprised a lot of people by demonstrating that if you take the one-size-fits-all approach, that if you decide that you are just going to lower the blood sugar, come what may, then you run into problems.

We have developed a position statement that takes the whole of this problem much more liberally, in a sense. We say that it is a complex problem, as complex as bringing up children. You could say, "Okay, you are 6 years old and so bedtime will be 7:30 in the evening, and we are going to stick to that." That might work for some children and it might work on some occasions, but for sure if you say [to a child], "You are 18 years old and bedtime is 9:30 in the evening," you and I know that that is not going to work [for most 18-year-olds]. It does not work with bringing up children and it will not work with a complex disease like diabetes either.

What does it mean when we say that we need a patient-centered approach? It is not the same as an individual approach. An individual approach could mean that I decide what your blood glucose or your hemoglobin A1c should be and I tell you what it should be [and you aim for that]. A personalized, [patient-centered] treatment is when the patient and the doctor sit down together and say, "We have a problem here and it is type 2 diabetes. What are we going to do about glucose control? What can we reasonably do?" What you can reasonably do differs depending on how old the patient is, how enthusiastic the patient is about treating this, what the patient thinks about weight gain, what you and the patient think about hypoglycemia, and what resources are available. It is no good for me to decide that a very expensive treatment will do you a brilliant amount of good if you have low resources. This is a new [idea in our position statement], and it gives us the opportunity to take a very clear, rational view with our patients.

Some people out there will say, "That's a recipe for just sitting back and saying that it doesn't matter what we do; anything will work -- the position statement says that either A or B or C and any combination will be okay." But we do not say that. All of the trial data suggest that within the bounds of what you want to achieve, you try and get to a lower hemoglobin A1c. We know that prevents complications of cardiovascular disease. We know it prevents complications of microvascular disease, problems with the eyes, problems with the nerves, and problems with the kidneys. What we are saying [in this statement] is, you have to make a joint decision with your patient about what you think is achievable, within the bounds of not allowing the patient to have hypoglycemia or even within the bounds that it may not matter if the patient occasionally feels slightly funny from hypoglycemia. If you have very old patients, it looks to be a very bad idea to have hypoglycemia. Your patients may have their own view. They may decide that actually they do not like the nausea associated with some of the oral or injectable agents. They may think this is ruining their quality of life.

I have treated some patients who said, "My life is all about eating, so I cannot tolerate any of those agents." In that case, I need to do something else. On the other hand, some people will say that weight is the biggest problem they have and agents are available now that will help us to reduce weight. There are a variety of things we can do.

I commend the statement to you. It allows you the liberal view of saying that there are many choices that you can make. But it also says that you need to be reasonably well informed to make those choices, and if you are not reasonably well informed, this is the opportunity to become educated about the way some of these agents work, the differences in terms of their effects on hypoglycemia, and so on.

This is a challenge to physicians. It is not a carte blanche to allow you to sit back and do nothing. The challenge is to foster collaboration with a patient that says that you and I between us can manage this diabetes in the best possible way, with the overall challenge of reducing cardiovascular disease, giving you a longer life than you otherwise would have, and resulting in less complications of diabetes. That is what this is about and that is why we produced this position statement.

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