COMMENTARY

Congratulations! We're Making Strides in Diabetes Care

Anne L. Peters, MD, CDE

Disclosures

June 17, 2014

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Here's to Fewer Complications of Diabetes

Hi. I'm Dr. Anne Peters from the University of Southern California. Today I am going to congratulate all of us who for the past 20 years have been taking care of patients with diabetes, because the recent news is positive. We are doing a better job. I want to discuss 3 articles that address the care of patients with type 2 diabetes.

The study of which I am most proud was published in the New England Journal of Medicine.[1] It is a report from the Centers for Disease Control and Prevention, and it looked at rates of 5 different complications of diabetes: myocardial infarction, stroke, lower-extremity amputation, end-stage renal disease, and death from a hyperglycemic crisis.

In the past 20 years, rates of all of those complications have significantly declined, with the highest reduction in the rates of myocardial infarction. Those rates fell by almost 68% -- which is a big reduction, much greater than we have seen in the nondiabetic population. Rates of all other complications have also declined, with the least decline seen in the rate of end-stage renal disease -- but even that declined by about 28%. With our focus on treating both micro- and macrovascular risk factors in our patients, we have made a difference in their health, and that makes me incredibly happy.

Prediabetes Numbers Improving

This second study is from the National Health and Nutrition Examination Survey (NHANES) database. NHANES is a big study that has followed patients over a very long period and gives us cross-sectional data about how patients are faring with a variety of health conditions, including type 2 diabetes. This article was published in the Annals of Internal Medicine,[2] and it gives us a lot of data, so I'm not going to go into all the details. I will just mention a few of the most important points.

As we know, the number of people with diabetes is increasing. The good news is that the proportion of people with prediabetes has remained fairly flat, so we are doing a better job of diagnosing patients with diabetes and not missing people who should be diagnosed.

In terms of actual numbers, the NHANES looked at A1c levels in patients with diabetes, and overall, the proportion of patients with an A1c level < 7% who are treated for their type 2 diabetes is approximately 60%. That is very good. We are getting better at reaching and maintaining near-normal blood sugar levels, and the proportion who have an A1c level < 8% is now up to about 80%. This shows that a larger proportion of our patients with diabetes are getting down to lower targets.

Unfortunately, this isn't true for all subsets of patients. Among Mexican Americans and black persons, fewer of those individuals are reaching those targets. Among these subsets, 48% of Mexican Americans and 50% of black persons had A1c levels < 7%, compared with approximately 61% of the white population. There are clear racial/ethnic disparities, and it is important that we are aware of this and continue our efforts to include glycemic control across the entire population, so that all can have similar improvements and outcomes.

Diabetes Drug Trends. The final study that I want to talk about is slightly off-topic. It was published in Diabetes Care.[3] This study was conducted by several epidemiologists who work at the US Food and Drug Administration (FDA). Using a large drug dispensing database, they examined the use of diabetes drugs across the population.

There were several findings. As expected, the use of diabetes drugs increased over time because the number of patients is increasing. The use of such agents as the thiazolidinediones (TZDs) has increased, along with dipeptidyl peptidase (DPP)-4 inhibitors, glucagon-like peptide (GLP)-1 receptor agonists, and others. The most commonly used drug is metformin, and it should be the most commonly used drug. It is most commonly used as monotherapy, but the researchers found that among patients on oral agents, many weren't on metformin; rather, many were on a DPP-4 inhibitor alone instead of a DPP-4 inhibitor plus metformin.

We are doing stepped therapy for many of our patients, starting with metformin and then adding on another treatment. We don't know from the NHANES data whether patients who had been on metformin had stopped taking it because of contraindications or side effects. From the database, approximately one third to one half of the patients who weren't on metformin (who perhaps should have been) were on another drug. It makes us think about how we are stepping patients up in terms of their therapy.

Conversely, about one third of the patients who were on insulin were also on metformin. It's a good idea to use combination therapy (eg, insulin plus metformin or insulin plus a GLP-1 receptor agonist) in appropriate patients to get them to target without as much hypoglycemia or weight gain.

This is great news. We are doing a better job than ever. I am so proud of everyone for reaching these milestones in reducing risk and complications and lowering A1c levels. We clearly have our work cut out for us, but for a moment we need to reflect and enjoy the progress we have made in the past 20 years. This has been Dr. Anne Peters, for Medscape.

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