Slowing a diabetic's decline (American College of Physicians annual meeting)

With more diabetes patients living longer, a greater number need more intensive glucose-controlling regimens and help with managing complications.

By Victoria Stagg Elliott — Posted June 4, 2007

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A handful of newly approved therapies for patients with diabetes have very different profiles from those previously available -- complicating questions about what to do as the disease progresses, according to presentations at Internal Medicine 2007, the American College of Physicians' annual meeting, in April in San Diego.

"The choices have exploded," said Irl B. Hirsch, MD, professor of metabolism, endocrinology and nutrition at the University of Washington School of Medicine.

The Food and Drug Administration approved exenatide, the first drug to affect incretin hormones, in April 2005. Sitagliptin, by itself and in a pill combined with metformin, was approved within the past year.

Both of these new treatments have been proven to improve control, but it's not entirely clear how they will work alongside the many other medicines that diabetics frequently take.

"We're going to need more data to know how these drugs fit into our armamentarium," said Janet A. Schlechte, MD, professor of internal medicine at the University of Iowa College of Medicine in Iowa City.

For instance, patient response to exenatide has been mixed. The drug needs to be injected, and many physicians consider the needle to be a barrier to getting patients to accept it. Some are now reporting that patients have been able to get past that issue primarily because exenatide has been shown to cause weight loss. Still, experts caution that insulin is still preferred as early as appropriate.

"Exenatide is not going to take the place of insulin. If someone needs insulin, they have got to be given insulin," said Jason C. Baker, MD, assistant professor of medicine and endocrinology at New York Presbyterian/Weill Cornell Medical Center.

But insulin has also experienced technological improvements, and there are many more versions from which to choose. An inhaled version was FDA-approved in January 2006, although doctors say its use has been limited by the size of the delivery device needed to administer it. The associated need for pulmonary testing is also an impediment.

Nonetheless, many physicians say it could be a viable option for moving patients to mealtime insulin, especially those who are resistant to administering injections. This transition is particularly critical, since experts do not believe that diabetics with very high A1c levels -- despite treatment with several oral agents -- will get their blood glucose under control only with a bedtime basal insulin shot. In addition, evidence suggests that pre-meal insulin by itself may be an effective strategy.

"Some may find the inhaled insulin more acceptable. Three injections of very short-acting insulin works really well, but that's not acceptable to a lot of people," said Dr. David S. H. Bell, an endocrinologist in Birmingham, Ala.

Experts also said that the new delivery means for insulin as well as the drugs affecting incretin were first-generation attempts. Improvements on these as well as more novel ways to treat this disease are to come. With A1c targets expected to be lowered as data is released from large diabetes trials, these options will become even more important. Diabetes experts say, however, the central issue is the need to change regimens in response to these developments and the progress of the patient's disease.

"What the problem is in real life is that we often start these patients on whatever therapy you pick and then they stay on it, and we don't do a very good job as a group, myself included, in pushing the therapy as the guidelines suggest we should," said Dr. Hirsch.

Important interventions

While the overall emphasis of diabetes treatment continues to be the prevention of complications from ever developing, some sessions focused on managing them when they do occur. Diabetes has become a significant cause of heart disease, limb loss, visual impairment and kidney damage, and experts say it is very possible to interfere with their progress after they start appearing.

"These numbers are increasing because our number of people with diabetes is increasing, but we are doing something right," said Mark E. Molitch, MD, professor of endocrinology, metabolism and molecular medicine at Northwestern University's Feinberg School of Medicine in Chicago. "We can make a difference."

Blood glucose control, of course, is the first priority. Other strategies include inspection by physicians of the bottom of diabetic patients' feet -- something many who are obese cannot do themselves. Doctors should also assess any loss of sensation. Patients should be strongly encouraged to receive regular eye exams. And medications can be prescribed to lower cholesterol, control blood pressure and protect the kidneys.

"The diabetic patient is exquisitely sensitive to blood pressure lowering," said Dr. Bell. "We need to be looking at their lipids as much as we can look at the glucose. We need to look at their feet, especially if they have neuropathy, and we need to be looking for albuminuria."

In order to improve outcomes for these patients, the college launched the ACP Diabetes Care Guide, which includes a printed manual and a CD-ROM, and the Web-based Diabetes Portal The guide is intended to be used by multidisciplinary teams to improve collaboration, and the portal provides the latest evidence-based guidance for patients and physicians.

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The toll of diabetes

  • Heart problems and stroke cause 65% of deaths among patients with diabetes; 5.2 million diabetics older than 35 have some form of cardiovascular disease.
  • Diabetes accounts for 44% of new cases of kidney failure; more than 43,600 diabetics began treatment for end-stage renal disease in 2002.
  • More than 60% of lower-limb amputations occur in people with diabetes; about 75,000 lost a limb in 2003.
  • Diabetes is the leading cause of blindness among adults; about 3 million diabetics have some form of vision impairment.

Source: Centers for Disease Control and Prevention's National Diabetes Surveillance System

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ACP works to improve patient understanding of doctor instructions

The American College of Physicians wants to make it more likely that what a doctor says is understood by his or her patient -- no matter what the patient's first language.

ACP is calling for interpreter services to be available and reimbursed. It also urges the establishment of a national clearinghouse for patient education materials in languages other than English, according to a white paper released at Internal Medicine 2007, held in San Diego in April.

"If we are unable to communicate with our patients, it doesn't matter how brilliant the physician is," said Lynne Kirk, MD, ACP's immediate past president.

The American Medical Association has policy calling for interpreters to be paid directly by patients or third-party payers as well as with federal funding.

The ACP's action was taken in response to data from a member survey released at the meeting, in which 65% of the 2,022 respondents had at least a few patients with limited English proficiency. Few practices had mechanisms for documenting the patient's main means of communication, but these patients did take extra time. Reimbursement for translation services was rare, though many physicians provided them.

Experts argue that better funding may save money over the long run by improving compliance, which in turn could reduce complications, emergency department visits and hospitalizations. "The amount of money saved could be enormous," said William E. Golden, MD, immediate past chair of ACP's Board of Regents.

The college also released "Living with Diabetes: An Everyday Guide for You and Your Family," in both English and Spanish. The guide is meant to be used in conjunction with a health care professional to help patients with diabetes make lifestyle changes as well as take oral agents and insulin correctly.

The tool was developed in both languages in order to ensure cultural relevance.

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Debate over stent vs. drug therapy in cardiovascular treatment

Recent studies have complicated decision-making regarding whether to use a stent and what kind it should be, according to a debate at the American College of Physicians' Internal Medicine 2007 meeting in San Diego.

Data presented at medical conferences and Food and Drug Administration advisory committee meetings suggest that drug-eluting stents, in comparison with bare metal ones, may increase the risk of late-stent thrombosis.

In March, results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation -- COURAGE -- trial, which were presented at the American College of Cardiology meeting in New Orleans in March and published simultaneously in the New England Journal of Medicine, questioned whether a stent should be used at all in patients with stable coronary artery disease. This study compared intensive pharmacologic therapy either by itself or in addition to percutaneous coronary intervention. This procedure, which frequently includes stenting, did not provide any additional benefit. Those who received only the intensive drug regimen also had slightly lower rates of death, hospitalization and heart attack.

Armed with this information, physicians said medical therapy was preferable for this population. Although a stent will treat a particular lesion, medical therapy improves overall cardiovascular health.

"Delayed risk of death or MI is really dependent on the behavior of the entire vasculature," said George Vetrovec, MD, chair of cardiology at the Virginia Commonwealth University Medical Center.

Other experts, though, said revascularization should continue to be favored for stable patients because they are more likely to return to normal activity quickly after this procedure and need fewer drugs. This circumstance, in turn, can lead to a reduction in drug-related side effects.

"This is really not a contest between stents and statins. It's more a contest between having your artery opened up and going back to full activity, versus loading up on a bunch of beta-blockers," said Spencer King, MD, director of interventional cardiology at the Fuqua Heart Center in Atlanta and a COURAGE investigator.

Specialists caution, however, that the findings do not say anything about how sicker patients should be treated, although they will most likely end the practice of angioplasty in patients with very mild disease.

"Every patient with a little bump in a coronary artery found on a screening CT scan without evidence of ischemia does not need a stent," said Dr. Vetrovec.

Another session highlighted the impact of data released over the past few years on the care of women with heart disease. Secondary prevention appears to be the same between men and women, but primary prevention seems to be distinct. Aspirin can reduce cardiovascular disease risk, but does not appear to benefit women as much as it does men. And high triglycerides as well as blood glucose and insulin issues appear to have a greater impact on women's hearts.

The question of hormone therapy also has become more complicated with further crunching of data from the Women's Health Initiative. Although it appears that this regimen does not have any cardiovascular benefits and may cause harm for most women, those close to menopause may benefit. Experts caution that this may have more to do with atherosclerotic burden than age. Hormone therapy may still be hazardous for young women with heart disease.

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External links

Lectures, presentations and other developments at Internal Medicine 2007, the American College of Physicians' annual meeting (link) .

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