Kasia Lipska, MD

June 28, 2013

CHICAGO — I have to admit it's a bit ironic that I am worried about overtreatment. In many low-income countries, patients die because they can't access insulin. I spent a year in Southern India where things weren't as grim as that, but I quite routinely saw diabetes patients with HbA1c readings in the 11% – 13% range. Honestly, I can't recall a patient with an HbA1c under 7%. Many simply couldn't afford treatment, even a cheap medication like metformin.

In a strange twist of fate, while I was working at the hospital there, my husband was writing a story for the New Yorker about a treasure worth billions of dollars discovered in the nearby Sri Padmanabhaswamy temple. Unfortunately, the treasure belongs to the temple's deity and is not going to solve the diabetes problem. In fact, it's going to stay right there in the temple and serve no earthly purpose at all, but you'll have to read his story to find out why.

Dr. Kasia Lipska

Meanwhile, many patients around the world will continue to go without treatment for diabetes. Given these realities, is overtreatment really worth stressing about? Perhaps, our energies should be better spent fighting for more insulin, more metformin, more drugs for diabetes?

On the other hand, submitting patients to treatment that is likely to cause more harm than good is unacceptable. Primum non nocere. First, do no harm. I took the pledge 10 years ago, on the steps of the Harvard Medical School building, in my freshly starched white coat. So did most doctors across the globe who are practicing today.

We are all committed to helping our patients do well, but I now wonder whether sometimes we've lost sight of what that means. Overdoing glucose control is one example.

How Low Is Too Low When It Comes to HbA1c?

Right now, no one knows precisely how often overtreatment of glycemia occurs, and it's pretty hard to measure.

But Leonard Pogach, MD, from the New Jersey Veterans Health Administration Healthcare System, East Orange, New Jersey. and colleagues started to look into this problem. and this week they presented their data at the American Diabetes Association (ADA) 2013 Scientific Sessions. They analyzed electronic medical records of diabetes patients treated in the US Veterans Health Administration facilities. Specifically, they focused on patients taking sulfonylureas or insulin with 1 other risk factor for hypoglycemia (such as elevated creatinine, cognitive dysfunction, dementia, or age 70 years or older). Then they examined how many achieved an HbA1c lower than they should have.

It's hard to know how low is too low, but it's fair to say that an HbA1c below 7% is probably risky in these situations. Yet they found that nearly half of patients (48.4%) reached that goal. In case that doesn't raise your eyebrows, 27.1% had an HbA1c below 6.5% and 10.5% had an HbA 1c below 6%.

Who are these patients, and, more important, who are these doctors, I ask?

Pushing glucose levels down into the nearly normal range may minimize microvascular complication rates, but it's not without its consequences. After a particularly scary experience when a patient of mine crashed into a tree, I always ask my patients on insulin about driving. Thankfully, it was only a tree, and my patient survived and recovered. I was terrified, however. I had prescribed him a drug that made him completely lose consciousness and control. He and I needed to be absolutely confident that it was worth the risk.

Consider a 75-year-old woman on insulin injections with an HbA1c of 6.3%. She doesn't report hypoglycemia, and you are hesitant to change course at this point. She is beaming because we've been teaching her for years that she is meeting her goals and doing well. Now, what? Throw in the towel and tell her it's time to loosen up control?

It's possible that she may do just as well staying the course. It's also quite possible that she may experience a serious hypoglycemic event. It's unlikely that an HbA1c level below 6.5% will contribute to palpable benefits for her. At the very least, she should know that.

We've created a healthcare system in which conversations about deescalating glycemic control are not only difficult but also not rewarded or even expected. There is no guideline that tells us when and how to initiate these discussions. The obsession with "know your number" (in this case, HbA1c) has completely overshadowed the need for conversations about real risks and benefits, those with respect to things that patients experience and things that matter to them, like serious hypoglycemia.

Back on those steps, taking my oath, the line between doing good and causing harm was clearly visible and I was not worried about ever crossing it. I was confident I never would. Now, I realize it can be tough to see the line. I say, let's all keep our eyes wide open.

Dr. Kasia Lipska is an endocrinologist at Yale University School of Medicine. Between clinical care, teaching, outcomes research, motherhood, and sports, she does her best to blog for Medscape Medical News about diabetes meetings. Dr. Lipska has reported no relevant financial relationships.

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