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Intensive treatment to lower Blood Sugars.

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catherinecherub

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This report from the B.M.J. is to try and determine all cause mortality and deaths from cardiovascular events related to intensive glucose lowering treatments for Type2 diabetics.

http://www.bmj.com/content/343/bmj.d416 ... 29&q=w_bmj

"The harm associated with severe hypoglycaemia might counterbalance the potential benefit of intense glucose lowering treatments........"

The cynic in me wonders if this will be another weapon used to deny Type2's any test strips.
 
Could be. Just as likely another way to justify their stance of encouraging diabetics to follow a carb-rich diet regardless of weather they're on meds or not. Still don't get it!
Malc
T2, diet controlled, REDUCED carb (not low) and low GI diet, HbA1c 5.5
 
Interesting that one of the responses points out that the analysis focusses on heart problems but states that hyperglycemia is not directly implicated in these.

Even in pure observational studies there is no direct relationship between glycemic levels and cardiovascular mortality, contrary to what happens with blood pressure levels, and also LDL-Cholesterol levels.
Click to expand...

Cheers

LGC
 
For anyone interested in this subject here is one of the responses to the study, taken from the BMJ today.

It is High Time for the Right Therapeutic Targets in Type 2 Diabetes

Jose Mario Franco de Oliveira, Associate Professor of Medicine

Universidade Federal Fluminense

Dear Fellows:

Type 2 diabetes is much more than just a disease of carbohydrates. Actually, hyperglycemia is only a secondary by-product of much deeper metabolic derangements.

If hyperglycemia was that important as a therapeutic target in type 2 diabetes we would not be seeing all these failures and increased death rates(!!!) in clinical trials trying to achieve a normal Glycated Hemoglobin.

Even in pure observational studies there is no direct relationship between glycemic levels and cardiovascular mortality, contrary to what happens with blood pressure levels, and also LDL-Cholesterol levels.
 
The Above mentioned Letter seems very logical to me, because I think of type 2 DM primarily as a high cardiovascular risk disease condition and NOT a primarily sugar disease

"The Higher the Ignorance the Higher the Dogmatism"
Sir William Osler
 
Surely the key point is INTENSIVE.

This reply to the paper is relevant:
John A Lee said:
Unless the harmful effects of increased catecholamines can be reduced by lifestyle changes such as regular exercise, smoking cessation and weight reduction, all of which will decrease catecholamine levels (3), intensive lowering of blood glucose will not result in an improvement in cardiovascular events and deaths.

I believe this shows the need to understand fully the pathophysiology of diabetes and the drugs used to reduce its vascular complications. Last year intensive glucose-lowering by rosiglitazone was found to have increased cardiovascular events in the treatment of diabetes (8). This also emphasises the need for a translational or inter-disciplinary approach to research and practice as set out by Geoff Watts (9) a year ago.
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One intensive agent is discredited. What others may be implicated?

This paper does NOT justify maintaining an HbA1c of 7.5% as was indicated by the earlier paper. It only warns against INTENSIVE drug therapy.
 
Catherinecherub wrote:

The cynic in me wonders if this will be another weapon used to deny Type2's any test strips.
Click to expand...

I may have misunderstood the article completely (which wouldn't surprise me, particularly the use of statistics!), but I would have thought it was another bit of evidence for the correct use of test strips. If hypoglycaemia is so dangerous, all the more reason to test and treat.

Viv 8)
 
Not sure I understand exactly what any of these articles are saying! I must admit it's not 'cardiovascular' events that worry me but all of the other DB probelms related to Hyperglycemia e.g. kidney disease, neuropathy, loss of body extremities etc. What was the point of this bit of research? The NHS still seems over-concerned with fat consumption, blood pressure and so on for those with DB rather than the effects of excess BS on the body overall. As most of us are prescribed statins anyway (that 'wonder' drug!) surely cardiovascular events will be reduced?
 
There is a reply to the study that points out that there have been several meta-analyses sharing much of the same data in other words it's not new information.
Neverthless it's still true that the people with diabetes (T1 or T2) seem to be at a higher risk of CVD than people without it. Whether this is all people with diabetes irrespective of glucose control/lifestyle is hotly debated.
There were several sessions at the recent European diabetes conference that discussed CVD and diabetes.
http://www.medscape.com/viewcollection/32137
 
The real treatment of type 2 diabetes is preventing its complications. And this has not been proven (Very much the contrary) that is achieved with normal glucose or HBA1C levels.

For sure these (glucose and HBA1c) are just loosen numbers, and definetely one size does not fit all.

John Barnes
 
They assume that to acheive hbaic at 5-6 ish we must be having lots of hypos but I have not had a hypo in years and by careful carb and diet management am at hbaic6 so once again the experts are wrong same as saying all type 2,s were fat and lazy 8)
 
Hi all:

Do you know how to interpret another number (just as as Blood Glucose and HBA1C) known as NNT (Number Needed to Treat)?

Do you know how to interpret another number known as NNH (Number Needed to Harm)?


They are the best scientific ways to describe a treatment effect on a particular disease state.

Regards,

John
 
The Cochrane Review.
http://www.npc.nhs.uk/rapidreview/?p=4416

"There is no argument in favour of poor blood glucose control. However, the balance of risks and benefits of intensive blood glucose control needs to be carefully considered on an individual patient basis".

The Results Table is worth looking at in the article.
 
I can't help feeling that they are going nowhere with these studies until they face the fact that T2 is probably more than one disease o disorder.
That is a very good reason for treating them all as individuals and holistically. Such a shame that this part of the NICE advice rarely seems to get through to the "sharp end".

I suppose the real value of diagnosing large numbers of people whom they don't really know how to treat ,is that new treatments wil be developed and stereotypes will slowly be recognised as such.


The other day when I was admited to the Day Ward with for a steroid injection in my eye, my blood sugar was 5.1 one hour after I had eaten. 3 hours later ,afteer the procedure I felt my BS was getting low so I ate the piece of toasted white bread offered to me on my return from the operaing theatre.

During my discharge procedure the nurse said she would check my BS. This particular nurse had worked in the diabetic dept and was well aware that that all T2s are not the same. I told her my BS would be high because I had just eaten he bread. She made a joke about "couldn't have been the chocolate bar it was he bread". She knew very well I had not eaten anything other than the bread. but was amazed when i said the chocolate bar would not have made as much difference as the bread.. So still some work to do there.
 
Unbeliever said:
I can't help feeling that they are going nowhere with these studies until they face the fact that T2 is probably more than one disease o disorder.
Click to expand...

I think that's the fundamental problem too. T2 diagnosis is based on a common symtom (poor glucose tolerance) rather than a common cause. The mantra of this forum is "we are all different" exactly because of this. Most of us are never even told whether we are insulin deficient or insulin resistant.

The Cochrane review stuff is, as ever, very sensible, apart from the fact that a significant subgroup of T2s are at very low risk of hypos, no matter how intensive their BG control.

Maybe I'm being naive, but I always assumed that hypos were undesired side effects of medication (either insulin or insulin production enhancing drugs). Is there any significant risk of hypos for bog-standard insulin resistant T2 diabetics on diet and/or metformin?
 
borofergie said:
Is there any significant risk of hypos for bog-standard insulin resistant T2 diabetics on diet and/or metformin?
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I'm told no. On diet only we're no more likely to go hypo than anyone (non-diabetic) else. If we go a little too low, the liver just compensates. My daughter is non-diabetic and very active. She used to get hypos, but not dangerously. Just went weepy and wanted food!
Metformin, similarly, doesn't lower BG enough to induce hypos.
That's my belief anyway.
 
Malc (Grazer),

That's my impression too.

The next obvious question is, what portion of the T2 community is on diet and metformin (and therefore not likely to get hypos)? My guess would be the vast majority of us. (We could probably get a good estimate from of the poster profiles here, if someone with mod access could dump out a list).
 
Borofergie wrote:

Most of us are never even told whether we are insulin deficient or insulin resistant.
Click to expand...

This is my biggest bugbear. When having my diagnosis interview with our diabetic specialist GP, I asked for a test to show whether or not I was producing sufficient insulin. I was told "Why bother? the sympoms are just the same" :shock: .

Which of course is perfectly true. Nevertheless it would have been helpful to know if my pancreas is functioning okay,and I was suffering from high insulin resistance (which is what I think), or whether my pancreas is damaged. In my (poorly-informed) opinion, there is a big difference between the two, particularly in the point of outcomes.

If my pancreas is still okay, I can treat it right, get the weight off, eat properly so as not to overload it, and it should still function for the rest of my life. If it is already damaged, it may well continue to deteriorate and I may end up needing more medication, however careful I am of my lifestyle.

The difference between these two, to me, means a different approach to the rest of my life.

And I do like to know. Knowledge is power.

As for hypos - it took reading round about diabetes to show me that I had been suffering occasional alcohol-induced nocturnal hypos for years (waking up sweating, heart pounding). Realising that, I changed my lifestyle. I haven't had a single hypo of any sort since. I still drink - but not so often or so much! :oops:

Viv 8)
 
borofergie said:
Malc (Grazer),

That's my impression too.

The next obvious question is, what portion of the T2 community is on diet and metformin (and therefore not likely to get hypos)? My guess would be the vast majority of us. (We could probably get a good estimate from of the poster profiles here, if someone with mod access could dump out a list).
Click to expand...

I'd be happy with that. I guess everyone would have to agree to their info being released, so a general circular from a mod. would be needed. On a similar vein, the article seemed to suggest that all T2's should be on Metformin. Is their an advantage to Metformin other than the obvious for people on Diet only currently? My BG seems O.k, (last A1c 5.9), and I cetainly don't want to lose weight (6ft 1in and 12.5 stone) so are their reasons why I'd benefit from Metformin? That's a real question, not a rhetorical one!
 
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