December 2016
On Diabetes Management

In the September issue of Family Practice News the headline reads "Can It Be True: New scientific evidence doesn't support tight glycemic control." Actually the evidence is not new, but studies show that it can take up to 17 years for an obvious truth to be finally adopted into medical practice. The strength of consensus determines the level of resistance. For decades there has been an overwhelming consensus that tight control (HgA1c below 7.0 - BS <154) in diabetes mellitus type 2 is needed to prevent long-term complications; but extensive research done over the past ten years shows otherwise. Finally, the NIH asked two Endocrinologists from the Knowledge and Evaluation Research Unit of the Mayo Clinic to review all of the evidence and render a report Their evaluation was published in August of 2016 in Circulation: Cardiovascular Quality and Outcomes. They concluded that tight control does not reduce stroke, heart attack, mortality, renal failure, neuropathy, amputation or any outcome significant to patients. It only helps decrease retinopathy, but does not decrease blindness.

It is important to understand that Diabetes Mellitus Type 1 and Diabetes Mellitus Type 2 are two completely different diseases. They share the symptom of having elevated blood sugar but otherwise have little in common. Type 1 is associated with a lack of production of insulin from the pancreas; we think this is an autoimmune process whereby antibodies attack the insulin producing cells and shut them down; but even that is not certain. and we do not know what triggers the process. Type 2, on the other hand, is associated with glucose resistance whereby the cells cannot take up the glucose/insulin complex to use the sugar as fuel, so the complex remains in the bloodstream. Some theorize that it is the sugar in the blood that does the damage to end organs whereas others believe it is the insulin or the complex itself; we simply do not know. But what we know is that both diseases progress despite treatment. Tight control helps delay progression ofthe disease in Type 1, but not in Type 2 because they are very different entities. Fever is a symptom of strep throat, but controlling it does not prevent progression to rheumatic fever and heart damage; this is why we treat strep with antibiotics. Yet we treat the symptom of elevated sugar without addressing the underlying disease because we do not yet understand the real cause.

So what does all this mean in practice. My approach is to treat with diet/exercise and Metformin only - if at all possible. Metformin is the only sugar medication that reduces risk of stroke and heart attack. (The manufacturer of the new drug Jardience also makes this claim, but as yet there is no independent verification.) The sulfonylureas (which produce more insulin) and insulin may actually increase risk of stroke and heart attack. But elevated sugar can cause distress to a patient even without long-term consequence, manifesting as fatigue with urinary frequency and thirst; so I will try to keep the HgA1c below 9.0 (BS <214) by adding other oral medications or Byetta shots to Metformin. I will use insulin only if all else fails.