Meeting the demands of diabetes (American Diabetes Assn. Scientific Sessions)

What's the story on clinical inertia and diabetes? Are physicians really turning a blind eye when it comes to stepping up therapies for patients whose blood glucose levels and blood pressures are climbing into the stratosphere?

Some studies presented at the June 9-13 American Diabetes Assn. scientific sessions in Washington, D.C., suggested just that. But hold on, cautioned others.

Diabetes is a tough disease to manage. Given the explosion of new cases, perhaps physicians should be applauded for trying to hold the line.

That the diabetes rate is expected to rise with the nation's collective weight gain is no surprise. "The majority of American adults are overweight or obese throughout most of their lives," said K.M. Venkat Narayan, MD, chief of epidemiology and statistics in the Centers for Disease Control and Prevention's Diabetes Center. And the foreboding path from obesity to insulin resistance and then to type 2 diabetes or cardiovascular disease is well-worn.

Nearly 21 million Americans have diabetes, and the fear is that poor control of it will lead to greater numbers of severe or fatal complications such as heart disease, blindness, kidney disease and amputations.

While it's clear that physicians will need help from across the health care community and from patients themselves to achieve better management, several studies presented at the ADA meeting showed an opposite scenario in which physicians are not reaching the patients whose blood glucose levels or blood pressures are well above established goals.

Treatment complexities

"Our study showed that failure to appropriately intensify antihypertensive treatment is a very common problem in diabetes care. ... Physicians intensified antihypertensive treatment in only 12% of visits in which we found sub-optimally controlled blood pressure," said Shari Bolen, MD, senior clinical fellow in internal medicine at the Johns Hopkins University School of Medicine in Baltimore.

A retrospective analysis of the pharmacy and lab claims of more than 9,000 patients revealed that by the time they were started on an oral anti-diabetic drug -- either metformin, a sulfonylurea or a thiazolidinedione -- hemoglobin A1c levels averaged 8.4%, which is significantly higher than the ADA-recommended 7%, reported Craig A. Plauschinat, PharmD, MPH. He is an outcomes research manager at Novartis Pharmaceuticals Corp and senior author of the study. Plus, more than two-thirds had levels of 9.5% or higher, he noted.

Still, there has been progress, noted James Gavin III, MD, PhD, immediate past president of the National Diabetes Education Program. While only 39% of patients were at appropriate A1c levels in 1997, that number had increased to 55% by 2002.

Plus, there might be some good reasons for what appears to be clinical inertia, said Eve Kerr, MD, MPH, associate professor of internal medicine at the University of Michigan Medical Center in Ann Arbor. One study of 23,000 patients found that physicians had refrained from bumping up medications because patients were moving toward goal, though not there yet, she said. Such an approach actually could constitute good clinical care.

And because as many as 40% of adults with diabetes have three or more comorbid conditions, treatment decisions could be complicated. Physicians contend with multiple guidelines plus patients' priorities, she said. In a 10-minute office visit, physicians can't do it all. An approach must involve physicians, pharmacists and nurses working together.

Physicians also overestimate the extent to which patients comply with treatment, said Betsy Sleath, PhD, associate professor of pharmacy at the University of North Carolina, Chapel Hill. "Patients want the doctor to think they are doing a good job. They want us to like them."

A checklist of treatment goals

ADA President Robert A. Rizza, MD, challenged doctors to do a better job monitoring diabetic patients. "We have the means at hand to reduce the risk of serious diabetes complications by over 60% ... [and] medical costs by $150 billion over the next 30 years."

The ideal would be for each patient to get optimal diabetes care, he said. In addition to an A1c level of less than 7%, patients' blood pressure should not exceed 130/80 mmHg. All should be prescribed a statin drug to normalize cholesterol levels to an LDL of less than 100 mg/dL, HDL equal to or greater than 40 mg/dL for men and 50mg/dL for women, and triglycerides less than 150 mg/dL. Patients should take a baby aspirin daily, not smoke and have a body mass index less than 25.

By achieving these goals in 100% of people with diabetes, 8 million fewer heart attacks, 1.6 million fewer strokes, 2.2 million fewer episodes of kidney failure and 100,000 fewer amputations would occur, Dr. Rizza said.

He recommended the formulation of a "polypill" to be taken once a day by people with diabetes. The pill, which does not yet exist, would contain 1000 mg of metformin, 75 mg of aspirin, 50 mg of a generic statin and 10 mg of a generic ACE inhibitor. Such a pill could cost about $100 per year and would target most of the ills that accompany the disease. But because such a magic bullet isn't even in the pharmaceutical pipeline, physicians will still have to roll up their sleeves.

"We've got work to do," Dr. Gavin said. There are many Web-based tools available that can help, he said. Some are available on the NDEP site and others at the site maintained by the National Institutes of Health, online (link).