Physicians urge aggressive pursuit, treatment of diabetes

Washington -- Early screening for type 2 diabetes -- beginning at age 30 for those at risk -- was among recommendations offered by endocrinologist groups to encourage quick action by physicians and patients to help prevent the disease's serious complications.

Too little is being done to make sure patients are taking the proper steps to control their diabetes, the American College of Endocrinology and the American Assn. of Clinical Endocrinologists announced at a Feb. 2 briefing.

The groups had just concluded a two-day conference to review current research and address questions about the treatment of diabetes.

More than 20 million Americans have diabetes, and another 41 million have pre-diabetes, a condition that can lead to diabetes if untreated, according to the two organizations. The numbers of people with type 2 diabetes have been steadily increasing in recent years, fueled, many believe, by increasing levels of obesity.

"Patients with diabetes are often in denial," said Jaime A. Davidson, MD, chair of the conference. "The problem only mushrooms when physicians miss the window of early detection and treatment."

ACE and AACE recommend early screening for younger patients who have a family history of diabetes, are overweight or are African-American or Hispanic.

Controlling agents

Recent advances now enable physicians to step in to slow the progress of the disease, said conference co-chair Paul Jellinger, MD. Those advances include the understanding that diet and physical activity can play a major role and that oral agents and the proper insulin are very effective.

"Four or five intervention studies show that if we use the proper diet and exercise, we can reduce the new onset of diabetes among people [who are pre-diabetic] from 10% a year to 4% or 5% a year," said Dr. Jellinger, who is president of the ACE and past president of the AACE.

Studies also show that pharmacologic agents have the potential to delay or prevent diabetes, he added.

The need for early control is vital, according to the two groups, because the longer people live with uncontrolled diabetes, the more likely it is that they will develop such serious complications as retinopathy, end-stage renal disease, neuropathy and coronary heart disease.

"Our advice is to treat with everything," said Dr. Davidson, a professor of internal medicine at the University of Texas, Southwestern Medical School in Dallas. If diet and exercise don't work, then oral medications and insulin should be added without lengthy delay, he said.

"If you treat aggressively early, the blood vessels respond well," Dr. Jellinger said.

He compared treating diabetes to treating hypertension. "Twenty or 30 years ago we treated high blood pressure with a single drug and we didn't do very well. Now, if you have high blood pressure, you're likely to be on three different drugs with different mechanisms of action. We now know that that same approach is very valuable in glucose control for diabetes."

Maintaining tight control of patients' A1c levels remains the gold standard of care, noted the groups. They advocate aiming for A1c, levels of less than 6.5% -- slightly below the American Diabetes Assn.'s target of less than 7%.

While the ADA and the endocrinologist specialty groups agree on the big picture -- prevention of diabetes is possible and should be undertaken, especially for those at the highest risk -- some of the details of their respective recommendations do differ, said Nathaniel Clark, MD, ADA national vice president for clinical affairs.

For example, in addition to a difference in target A1c levels, the ADA advises waiting until patients are 45 before screening them. But "in terms of the big messages, we agree," Dr. Clark said.

The ADA and the AMA also participated in the conference.