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In episode 58, the fourth in our installment of podcasts on diabetes, we briefly talk about the evidence surrounding intensive glucose lowering (ACCORD, ADVANCE, VADT and UKPDS trials) – podcasts #9 and #38 did this in more detail. At the end of the podcast, Mike identifies many of James’ flaws, but does it with compassion and kindness; at least he says he does.
Show Notes
1) Does tight glycemic control burden patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return?
2) ACCORD and ADVANCE studies
Click here for a synopsis of the results
N Engl J Med 2008 358:2545-2559
N Engl J Med 2008 358:2560-2572
Also listen to Episode 9: News Flash: Aggressive Blood Sugar Control Not All Sweet
3) VADT trial
Also listen to Episode 38: New trials you need to know about
4) Glucose lowering meta-analysis – do the results support the conclusions?
5) UKPDS data
6)UKPDS – 10 year update (recent results)
{ 6 comments… read them below or add one }
Hi – Long time listener first time commenter
. I’m a pharmacist in Australia (currently attempting the registration process in Canada) and Australians have a couple of new medications for diabetes that I’m not sure we have in Canada yet. Admittedly I haven’t listened fully to this diabetes series but have you guys mentioned or know any of the evidence behind exenatide (incretin mimetics) and sitigliptin (DPP-Inhibitors) for Type-2 Diabetes?
Thanks – great podcast by the way!
Hi David – thanks for the comment about the podcast – as for these newer agents, there still isn’t well designed data on clinical outcomes so all we really know is they lower blood glucose. Personally, until that sort of data comes out – because we have been burned so often in the past (rosiglitazone, atenolol, rofecoxib, torcetrapib, prazosin, ACCORD, ADVANCE, VADT etc) I think one needs to wait and see. But that is just my belief system and isn’t based on “evidence” per se – but I guess it’s based on lack of evidence. Thanks for the comment.
Hi James … its really interesting how real life refuses to behave.
I have a wonderful old patient. She is thin, mildly osteopenic, She has had Type 2 Diabetes for some years. Since leaving home where she struggled for years she is in a rest home where she she is miraculously happy!!! Here terrible arthritis is in abeyance ( is that how it is spelt?).
Since being in less pain she is eating more ( but well.) She has put on a little weight.
She hates needles. She cannot tolerate Metformin even in the tiniest dose. She hates the idea of Insulin and has never felt better in her life.
The only down side is that her Glyc Hb has climbed from around 7.5 to 9.
She is SO well … and for the forsrt time in 20 years is enjoying her life. Now at 88 I am disinclined to start her the new drugs.
So just how dangerous is that Glyc Hb. She does not by the way have significant proeinura, her Cholesterol is 3.5 ( on statins) and her BP is well controlled.
I feel relaxed about her sugar. Feankly my feeling is that if anything we could start a small dose of insulin daily.
With all her other risk factors well controlled ( non smoker and drinker as well ) … I see a lady who has never been better .. the nurses think I am terrible … are they right??
Hi Tom – I have no idea if the nurses are correct about you being terrible – that’s their value judgement
. However, in regard to your patient, there are no data on 88 year olds- the UKPDS risk engine is really only valid for ages up to 65 – nonetheless if I put in the following numbers.
Age 88, duration of diabetes 10 years, A1c 7.5, SBP 130, T chol 3.5, HDL 1.0, non smoker I get a 10 year risk of CHD around 40%. If I change the A1c to 9.0 it goes to 45%.
First off I would make sure she eats healthy, nutritious and delicious food in reasonable quantities. Whatever meds she can tolerate – no side effects, no or little cost and no annoyance – would seem reasonable, however as she can’t tolerate metformin (no hypoglycemia) I would have thought the risk of hypoglycemia with the other agents would be an important issue in her. The bottom-line is, you are working in a completely evidence-free zone – but It is important to remember it is impossible to make an asymptomatic patient feel better. However, if at some time she develops symptoms secondary to her blood glucose it may be worth while starting with a VERY low dose of your favourite glucose-lowering drug du jour. If it was me I’d rather use 1.25 or 2.5 mg of glyburide than insulin but that’s just me. Hope some of this helps.
Just a thanks and a little self-promotion. Your podcasts have totally changed the way I practice and review the literature. What was I thinking all thse years prescribing expensive new me-too drugs with no outcomes data? Your diabetes podcasts from the “early years” inspired me to write a Letter to the Editor that was just published in Archives of Internal Medicine at http://tinyurl.com/l8yunz . Keep up the great work!
Hi Ronald – I had seen your letter and was very much in agreement with your comments – congrats on getting it published – glad you feel our podcasts have changed how you practice – hopefully for the better
. In the response to your letter the author stated “Therefore, it makes no sense for third-party payers to hold practitioners to a non–evidence-based measure of an HbA1c level below 7%” – hopefully someone will follow this advice, however once something becomes “law” it takes a long time to reverse the process.
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