Focus Shifts for Long-Term Diabetes
For Advanced Diabetes, Intense Blood Sugar Control May Be Wrong Goal
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How Low Should Blood Sugar Go? continued...
"We are going to leave the A1c target at 7% for these people. But we give their doctors the opportunity to make adjustments either up or down depending on the circumstances," Skyler tells WebMD. "We want better glucose control in those younger patients with earlier diabetes ... and we relax the standard if the risk of hypoglycemia becomes such that to reach 7% you have to do it with some struggle."
Skyler says that most diabetes experts can get most patients -- even those with longstanding diabetes -- pretty close to an A1c of 7%.
"If they are under 9% but not close to 8%, I would like them to work harder," he says. "You can get people under 8% without working too hard."
Duckworth, who has treated diabetes patients for 40 years, says that's an unrealistic goal for many patients.
"To my older patients with longstanding diabetes, I say, "We will get your glucose down to reasonable levels, to an A1c of 9%, and try to get it lower if we can do it without risking severe hypoglycemia, and without decreasing your quality of life, and without causing financial or other burdens," Duckworth says. "We simply don't have evidence that a lower A1c is worth it for these people with advanced diabetes who are in their 60s and older."
Skyler says much of the problem with glucose control is the reluctance of patients -- and doctors -- to take or to offer insulin. And this reluctance, he's found, is largely based on two misconceptions about insulin.
The first misconception is that it's painful to take insulin injections. Diabetes patients must frequently test their blood sugar, and that means pricking their finger to get a drop of blood. Many patients (and, Skyler says, many doctors) think that an insulin injection will be even more painful -- but it's actually far less of a bother.
And because many patients put off taking insulin until late in the disease, people have come to associate insulin with the bad outcomes seen in very advanced diabetes. Taken earlier in the course of disease, insulin actually prevents these bad outcomes.
The Duckworth study appears in the Jan. 8 issue of the New England Journal of Medicine. The Skyler article appears in the January issue of Diabetes Care.
Duckworth reports receiving consulting fees from Novo Nordisk, GlaxoSmithKline, and Caremark and lecture fees from Sanofi-Aventis. Skyler receives support from, holds stock in, and serves as a board member and/or advisor to a number of pharmaceutical and medical device companies.