Give Us a Hand! Focus First on CVD Risk in Diabetes

Marlene Busko

March 18, 2014

In the brief time a general practitioner (GP) has with a type 2 diabetes patient, he or she should emphasize 5 key interventions to reduce cardiovascular disease (CVD), whereby glycemic control is the least important, according to a recent editorial in the February 15 issue of American Family Physician.

The authors propose communicating this 5-step plan to patients using an open hand as a memory aid, where "from thumb to little finger, each digit portrays one intervention in decreasing order of benefit: smoking cessation (thumb), blood-pressure control (index finger), metformin therapy (middle finger), lipid reduction (ring finger), and glycemic control (little finger)."

They note that recent evidence has confirmed that tight glucose control can be harmful.

But "I'm not sure if that idea has fully taken fast yet, particularly because the quality measure from insurance companies and other payers tend to overly focus on HbA1c" as an indicator of quality of care, lead author Deborah R. Erlich, MD, from Tufts University School of Medicine, in Boston, Massachusetts, told Medscape Medical News.

"It's not to say that blood sugar is not important at all, but…there are other much more important interventions," she stressed. "So as we said in the editorial, worrying about the minutia of blood-sugar control when a patient has uncontrolled high blood pressure and high cholesterol and is still smoking is like rearranging the deck chairs on the Titanic. It's really a complete distraction from what we should be doing to save patients' lives."

The Hand is a Useful Symbol

Research has shown that patients with type 2 diabetes have an increased risk for mortality if their HbA1c is consistently lowered below 7.5%, whereas smoking cessation, blood-pressure control, metformin therapy, and lipid reduction can extend lives in diabetes, the editorialists write.

Metformin therapy delays premature mortality independent of its effect on glucose levels "and should be prescribed for overweight patients with type 2 diabetes unless contraindicated," they say. And lowering cholesterol levels, preferably with statin therapy and lifestyle changes, extends life by up to 3.4 years in men and by up to 2.4 years in women, they add.

And a fasting blood glucose level of less than 200 mg/dL (11.1 mmol/L) is reasonable in these patients. A management plan should center on controlling hyperglycemic symptoms in concert with individual patient preferences.

This is reflected in new guidelines from the American Diabetes Association and the European Association for the Study of Diabetes, which also propose a less stringent HbA1c goal of less than 8% for patients with type 2 diabetes who have comorbidities, they note.

"When you only have 15 minutes with a patient, it's much more beneficial for the patient to spend that time talking about [quitting] smoking, for example — the thing that is most likely to kill the patient with diabetes — and then we move down the hand either in that visit or subsequent visits, showing each finger as a way to remember the interventions that are the most important," Dr. Ehrlich explained.

"The hand is a very useful symbol…to focus on the things that are really going to prevent heart attack and strokes," she noted.

Physicians should not let "well-intentioned but misguided concerns for glucose levels distract them from attending to other interventions that more profoundly affect mortality," she and her colleagues conclude.

"This approach requires a shift in the thinking of patients and physicians. Patients with type 2 diabetes who currently focus first on glycemic control will need to 'reverse the hand' to improve the duration and quality of life."

The editorialists have reported no relevant financial relationships.

Am Fam Physician. 2014;89:257-258.


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