Effective diabetes care: a need for realistic targets

Winocour, Peter

doi:10.1136/bmj.324.7353.1577

Cited by 88 publications

(73 citation statements)

References 22 publications

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“…However, a recent study in primary care revealed a 17% reduction in HbA 1c in 288 poorly controlled patients, after supporting GPs with flow-charts, treatment schemes for OHA and visits from facilitators, suggesting a certain degree of under-performance [18]. No matter how, these findings force us to be realistic regarding the control of hyperglycaemia that can be achieved with current treatment regimens, in particular insulin therapy [19]. Other treatment factors as involvement in shared care, and more visits for diabetes, were not associated with better glycaemic control.…”

Section: Discussionmentioning

confidence: 99%

Patient Characteristics do not Predict Poor Glycaemic Control in type 2 Diabetes Patients Treated in Primary Care

et al. 2003

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Abstract. Many diabetic patients in general practice do not achieve good glycaemic control. The aim of this study was to assess which characteristics of type 2 diabetes patients treated in primary care predict poor glycaemic control (HbA 1c P 7%). Data were collected from the medical records. 1641 patients were included who had mean HbA 1c 7.1(SD 1.7)% , and 42% had HbA 1c P 7%. On univariate analysis younger age; longer duration of diabetes; higher levels of blood glucose at diagnosis; most recent fasting blood glucose (FBG), total cholesterol, and triglyceride; higher body mass index (BMI); treatment with oral hypoglycaemic agents (OHA); treatment with insulin; more GP-visits for diabetes in the last year; and lower educational level were associated with poor control. Both in multiple linear regression and in multiple logistic regression higher levels of FBG (odds ratio (OR): = 1.6, 95% confidence interval (CI): 1.49, 1.70), treatment with OHA (OR: 2.1, 95% CI: 1.41, 3.04), treatment with insulin (OR: 7.2, 95% CI: 4.18, 12.52), lower educational level (OR: 1.26, 95% CI: 1.01, 1.56) were independently associated with poor levels of HbA 1c . When FBG levels were excluded from the model, higher blood glucose at diagnosis, higher values for triglyceride and total cholesterol, and younger age predicted poor glycaemic control, but these variables explained only 15% of the variation in HbA 1c . In conclusion prediction of poor glycaemic control from patient characteristics in diabetic patients in general practice is hardly possible. FBG appeared to be a strong predictor of HbA 1c , which underlines the usefulness of this simple test in daily diabetes care. The worse metabolic control in those treated with either OHA or insulin suggests that current treatment regimes might be not sufficiently applied to reach the targets of care. Providers of diabetes care should be attentive to patients with lower educational level.

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Section: Discussionmentioning

confidence: 99%

Patient Characteristics do not Predict Poor Glycaemic Control in type 2 Diabetes Patients Treated in Primary Care

et al. 2003

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“…The Health of England Survey (12) suggests that Ͻ30% of affected patients receiving treatment have attained target BP. Furthermore, it has been suggested that with current models of care, the attainment of these stringent BP targets for patients with diabetes may not be attainable in the majority of cases (13). These observations imply that alternatives to conventional care for patients with hypertension and diabetes are required.…”

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confidence: 97%

Management of Uncontrolled Hypertension in a Nurse-Led Clinic Compared With Conventional Care for Patients with Type 2 Diabetes

et al. 2003

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OBJECTIVE -To compare the effectiveness of a nurse-led hypertension clinic with conventional community care in general practice in the management of uncontrolled hypertension in patients with type 2 diabetes.RESEARCH DESIGN AND METHODS -We studied 120 men and women outpatient attendees (61% non-Caucasian) with type 2 diabetes and a seated blood pressure (BP) Ն140/80 mmHg. All patients were being treated for hypertension, and 71% had increased urinary albumin excretion (UAE). Patients were allocated to either a nurse-led hypertension clinic or conventional primary care. The primary outcome measure was a change in systolic BP. Secondary outcome measures were total cholesterol, HDL cholesterol, total triglycerides, HbA 1c , UAE, serum creatinine, and changes in absolute stroke and coronary heart disease (CHD) risk scores.RESULTS -The mean (95% CI) difference in the decrement of systolic BP was 12.6 mmHg (5.9 -19.3) (P ϭ 0.000) in favor of the nurse-led group, whose patients were three times more likely to a reach target systolic BP Ͻ140 mmHg compared with conventional care (P ϭ 0.003). A significant fall in 10-year CHD (P ϭ 0.004) and stroke risk (P ϭ 0.000) scores occurred only in the nurse-led group. There were no significant differences in the reduction of diastolic BP or any of the other secondary outcome measures at 6 months.CONCLUSIONS -Compared with conventional care, a nurse-led hypertension clinic is a more effective intervention for patients with type 2 diabetes and uncontrolled hypertension. A target systolic BP Ͻ140 mmHg is more readily achieved and may be associated with significant reductions in 10-year cardiovascular disease risk scores. Diabetes Care 26:2256 -2260, 2003H ypertension is a major and modifiable risk factor for cardiovascular disease that frequently coexists with diabetes (1). A progressive rise in blood pressure (BP) is also a promoter of renal dysfunction and the development of end-stage renal failure (2). The presence of proteinuria and hypertension also increases the risk of premature death from cardiovascular disease eightfold compared with unaffected patients (3,4). A large evidence base of randomized controlled trials have demonstrated that treating hypertension reduces morbidity and mortality from hypertension-related diseases (5,6). More recently, the use of antihypertensive agents that interrupt the renin-angiotensin system has been shown to be an effective strategy to retard the progression of nephropathy and reduce cardiovascular events in people with diabetes (7-9). Throughout the western world, expert committees on hypertension recommend that treatment to lower BP is warranted in patients with diabetes who have a systolic BP Ն140 mmHg (10,11). Currently, hypertension is poorly managed. The Health of England Survey (12) suggests that Ͻ30% of affected patients receiving treatment have attained target BP. Furthermore, it has been suggested that with current models of care, the attainment of these stringent BP targets for patients with diabetes may not be attainable in the maj...

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“…Limitations to achieving normal A1C may be the severity of diabetes or physiology such that certain classes of oral hypoglycemic agents are less effective, fear of hypoglycemia by either subject or physician limiting further aggressive control, and noncompliance with recommended regimens. Winocour (12) has raised concerns about the feasibility of the A1C targets of Ͻ7% being applied to all subjects. Treatment compliance may suffer if polypharmacy is involved in glycemic control and is then combined with medications for comorbid conditions of type 2 diabetes (hypertension and dyslipidemia).…”

Section: Treatment Switchersmentioning

confidence: 99%

Insulin 70/30 Mix Plus Metformin Versus Triple Oral Therapy in the Treatment of Type 2 Diabetes After Failure of Two Oral Drugs

Schwartz

Sievers²,

Strange³

et al. 2003

Diabetes Care

103

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OBJECTIVE -Subjects (n ϭ 188) with type 2 diabetes and inadequate response to two oral medications (A1C Ͼ8.0%) were randomly assigned to treatment with either a third oral medication or an insulin 70/30 mix b.i.d. plus metformin for a comparison of efficacy, safety, and cost.RESEARCH DESIGN AND METHODS -The protocol called for aggressive dose titration to achieve target values of fasting blood glucose (80 -120 mg/dl), postprandial glucose (Ͻ160 mg/dl), and A1C (Ͻ7%). These efficacy parameters were evaluated at weeks 2, 6, 12, and 24 of therapy. If dose adjustments failed to achieve targeted glycemic control, subjects were switched to an alternate therapy.RESULTS -At the end of study (week 24 of therapy), A1C and fasting plasma glucose (FPG) values showed comparable decreases in the two treatment groups. Only 31% (oral therapy) and 32% (insulin plus metformin) of subjects achieved target values of A1C (Ͻ7%). A total of 10 of the 98 subjects randomized to triple oral therapy (10.2%) who failed to improve sufficiently were switched to insulin therapy. An additional four subjects dropped out of the oral treatment group due to adverse events felt to be potentially drug related. Only two of the subjects randomized to insulin plus metformin had to be switched to basal-bolus regimens (regular insulin and NPH insulin). Cost analysis determined that insulin plus metformin (mean cost $3.20/day) provided efficacy equal to that of a triple oral drug regimen ($10.40/day).CONCLUSIONS -Insulin 70/30 mix plus metformin was as effective as triple oral therapy in lowering A1C and FPG values. The triple oral regimen was not as cost effective, and a high percentage of subjects (total of 16.3%) did not complete this regimen due to lack of efficacy or side effects.

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Effective diabetes care: a need for realistic targets

Cited by 88 publications

References 22 publications

Patient Characteristics do not Predict Poor Glycaemic Control in type 2 Diabetes Patients Treated in Primary Care

Patient Characteristics do not Predict Poor Glycaemic Control in type 2 Diabetes Patients Treated in Primary Care

Management of Uncontrolled Hypertension in a Nurse-Led Clinic Compared With Conventional Care for Patients with Type 2 Diabetes

Insulin 70/30 Mix Plus Metformin Versus Triple Oral Therapy in the Treatment of Type 2 Diabetes After Failure of Two Oral Drugs

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