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New joint US-European Guidelines for T2.

phoenix

phoenix

Expert
Messages
5,671
Type of diabetes
Type 1
Treatment type
Pump
Individual targets, medication protocols dependent on the age and motivation of the person
http://www.medpagetoday.com/PrimaryCare/Diabetes/32251
bit more detail here
http://www.medpagetoday.com/PrimaryCare/Diabetes/32251

and if you want to read the actual guidelines:
http://www.diabetologia-journal.org/fil ... _et_al.pdf

edit: I don't really know much about the older guidelines for medication but there is a box that suggests the route through the various options. Quite fast if targets aren't reached or someone is diagnosed with a high HbA1c.
 
Had a quick look Phoenix and the guidelines look interesting. They mostly concentrate of how to set an HBA1c target for an individual patient and from what I can see it looks pretty good. Targeting seems to take into account a wide range of things which is good.

Haven't read the stuff about meds much yet.

They seem to studiously avoid the possibility of arguments over diet and avoid anything remotely contentious by omitting to say anything about starchy carbs at all except for implying each country to their own. So bit of a cop out whatever side of the debate you sit on especially as diet can be the most important factor towards getting control imo.

Dietary advice must be personalised [49]. Patients should
be encouraged to eat healthy foods that are consistent with
the prevailing population-wide dietary recommendations
and with an individual’s preferences and culture. Foods high
in f ibr e ( such a s veg e t ab le s , frui t s , whol egr a ins and
legumes), low-fat dairy products and fresh fish should be
emphasised. High-energy foods, including those rich in
saturated fats, and sweet desserts and snacks should be eaten
less frequently and in lower amounts [50–52].
Click to expand...
 
Thank Pneu. Very interesting. It is something I have wanted to see for a very long time. The present one-size -fits -all approach often does more harm than good,

The problem now is , who is going to deliver this tailored care?
I have posted on another hread about the "downgrading " of care in my practice. It is by no means unique,

It may be different for T!s but many T2s are left to the not-so -tender mercies of the nurse . The doctors distance themselves from diabetes mattters in gerneral. Even if diabetes problems overlap with iothers hey still refer you to the nurse "as she goes on more courses"

At least this is a step in the right direction.

I think my Nurse must be comfortable with insulin management for T1s . Or more likely, she just continues wih the treatmen specified by the hoospitals as most would have been treated there initially.

I have absolutely no con fidence in her ability to mange T2 insulin therapy initiated in the practice.

I was just about to post a new opic related o this subject becaue I understand that very srict control articularly in the elderly can be counter productive.

I welcome this statement and hope that it is implemented soon but I do fear that the current system, target driven and , for T2s, downgraded will not be receptive to the message.

I am not implying that treatment of T1s is always perfect and appropriate . It is merely better established.

T2 is still seen either as one of the inevitable diseases of old age or as a self-inflicted condition. A doctor told me a while ago that present protocols for T2 treatment have not been successful and change was on the way. That was 3 years ago and this is the first sign of it i have seen. Thanks again Pneu.
 
xyzzy said:
Dietary advice must be personalised [49]. Patients should
be encouraged to eat healthy foods that are consistent with
the prevailing population-wide dietary recommendations
and with an individual’s preferences and culture. Foods high
in f ibr e ( such a s veg e t ab le s , frui t s , whol egr a ins and
legumes), low-fat dairy products and fresh fish should be
emphasised. High-energy foods, including those rich in
saturated fats, and sweet desserts and snacks should be eaten
less frequently and in lower amounts [50–52].
Click to expand...
Click to expand...

Firstly I haven't read it yet. But if that is the extent of the dietary advice then they seem to have "bottled it somewhat". Certainly it's better than "include starchy carbs with every meal" and "50% of your energy from carbs"', but instead it just dodges the whole issue. I still don't think that fruits and wholegrains (especially) are appropriate dietary choices for most T2s, except in very small doses.

Still, small progress is still progress I suppose.

I'll read it all later.
 
There is very little that's new in this, perhaps other than the concept of tailoring targets on an individual basis. It stresses the point that achieving tight control has little if any effect on CVD outcomes ( Presumably the ACCORD study) but that control might be desirable for certain categories ( no co-morbidities , high motivation, youth, etc) but that a higher range is acceptable for others. It is silent on diet other than general stuff and quite frank about the lack of data relating to appropriate drug regimes ( other than highlighting Metformin as the 'gold standard' in the first instance). It's worth reading.
 
I re-read this again and came away thinking that the self management bit is good but that overall like many of these things it misses the point. Simplistically treatment and recommended practices seem to be set by taking an average cross section of T2D's and coming up with a set of recommendations to best manage those average and usually uninformed or even ill informed patients.

Why does no one do a study of people who have successfully self managed their T2D and then try and base treatment and recommendations from that? Take recommendations from a successful sample not an average sample. If you are training to run the 100 metres or a marathon you look at the techniques of athletes who excel at it not just an average sample of runners.

Anyone know if any such study exists? That would be very interesting to read.
 
There might be some diffficulty in identifying suitable subjecs for such a study. In this country , for example ,the NHS eeem to be in denial about the possibility of self management. Leave it all to us etc.

Wouldn't they wish to claim the credit for any improvements {they already do so} ?
Their reasons for thie attitude are perfectly understandable given the way in which Diabetes care is organised and funded here..

I am surprised that companies engaged in production of diabees supplies are not interested in funding such research......
 
Why does no one do a study of people who have successfully self managed their T2D and then try and base treatment and recommendations from that?
Click to expand...
Any such study would be post hoc, and non verifialble.
There is such a research project on" long-term successful weight loss maintenance" in the US... but it's results are much criticised by people who don't agree with the findings :lol:
http://www.nwcr.ws/default.htm
 
On the third of your links mPhoenix, first post, I quite like the idea of the "scales" for judging people, according to things like attitude and motivation, life expectancy, self-care capabilities etc. and then prescribing appropriate drugs. I'd like to see the same thing used in determining things like HbA1c targets, rather than blanket statements like "less than 7" etc. and setting such targets across the board.
 
HCPs are already tld that they should set individual targets , The problem is that targets for the practice don't reflect this.
hey are given one overall target.. So.......
 
phoenix said:
Why does no one do a study of people who have successfully self managed their T2D and then try and base treatment and recommendations from that?
Click to expand...
Any such study would be post hoc, and non verifialble.
There is such a research project on" long-term successful weight loss maintenance" in the US... but it's results are much criticised by people who don't agree with the findings :lol:
http://www.nwcr.ws/default.htm
Click to expand...

Accepted Phoenix, just seems frustrating... What I'm getting at is that I would guess the majority of forum members however they control do better than the average patient "out there". To me that implies we have all learnt techniques that work so why aren't those techniques ever picked up as surely the entire worlds successful T2D patients aren't all members of this forum!

Makes you wonder that when the sample set of patients is being selected for this kind of stuff the statistical outliers i.e. people like successful forum members who manage their T2D effectively get rejected so the studies never get to see successful people. Probably just my paranoia though.

grazer said:
I'd like to see the same thing used in determining things like HbA1c targets, rather than blanket statements like "less than 7" etc. and setting such targets across the board.
Click to expand...

I interpreted the doc to mean it WAS advocating that idea. So for example if you have a very low life expectancy unrelated to your diabetes (maybe very old age) why make someone aggressively diet or aggressively aim for a low HBA1c, let them live out their life in peace. If you are newly diagnosed and up for it aim for as low an HBA1c as you can. Did I misinterpret that?
 
xyzzy said:
I interpreted the doc to mean it WAS advocating that idea. So for example if you have a very low life expectancy unrelated to your diabetes (maybe very old age) why make someone aggressively diet or aggressively aim for a low HBA1c, let them live out their life in peace. If you are newly diagnosed and up for it aim for as low an HBA1c as you can. Did I misinterpret that?
Click to expand...

Sort of. My reading was that the drug treatment wouldn't be so aggressive in terms of achieving good glycemic control, for those who couldn't adapt to it or had shorter life expectancy. But it didn't mention specific targets, and I'm sure a blanket "7" will still stay as a generality and be used for the vast majority of us. Currently, NHS are supposed to set individual targets - but has anyone here been told your target is ....6.5, or 6.0, or anything specific other than less than 7? I can see it staying because anything lower is likely to mean more people failing to achieve them, so NHS targets being missed even more - can't have that.
 
Grazer said:
xyzzy said:
I interpreted the doc to mean it WAS advocating that idea. So for example if you have a very low life expectancy unrelated to your diabetes (maybe very old age) why make someone aggressively diet or aggressively aim for a low HBA1c, let them live out their life in peace. If you are newly diagnosed and up for it aim for as low an HBA1c as you can. Did I misinterpret that?
Click to expand...

Sort of. My reading was that the drug treatment wouldn't be so aggressive in terms of achieving good glycemic control, for those who couldn't adapt to it or had shorter life expectancy. But it didn't mention specific targets, and I'm sure a blanket "7" will still stay as a generality and be used for the vast majority of us. Currently, NHS are supposed to set individual targets - but has anyone here been told your target is ....6.5, or 6.0, or anything specific other than less than 7? I can see it staying because anything lower is likely to mean more people failing to achieve them, so NHS targets being missed even more - can't have that.
Click to expand...

Ok, with you on that no one has ever discussed a target with me.

Perhaps when I see the DSN next week I'll ask what she wants my target to be now its 5.3% :lol:
 
They are supposed to agree individual targets WITH the patient. Mine once agreed to a target of 9.0 ! I had just thrown a very justifiable hissy fit though so she might have agreed to anything!

Patients on medication and experiencing problems with it are probably more likely to be involved in discussions about targets. As in "if levels rise to - we will do this , should they fall we will reduce/ wtihdraw them etc. Hopefully with agreement from the patient

I have read several studies which suggest that levels automatically increase with age and that too rigid control is counter productive - even dangerous, in the elderly.
I am not sure what the general definition of elderly might be.
I control my levels quite tightly because of my eye condition. I understand that it can take up to 3 years for improved control to improve the condition. To date it is only making it worse. . If it does indeed take 3 years it may well be too latefor me. My own experience and studies I have read ,suggest that only running at non-diabetic levels will be effective. While reducing my levels may protect from further complications. would running at these levels cause my aged self other problems.?
Its a puzzlement. I often feel that serious work is only now being done into researching T2". Probably because only the very ederly were diagnosed in previous years and it was not thought worthwhile.
 
re: ageing and bs levels.

I was told today that, in the 6 months since my first HbA1c and my latest one 8 weeks ago, my body has continued to age, and that is why it has gone up a point!!!

I managed to keep a straight face and not point out that that was when I followed their diet and wasnt testing and low-carbing. They still dont know about the meter I bought and the testing I now do : (

It doesnt feel right to be sneaky like this, but i have to.
 
Unbeliever
There's no evidence that tight control in and of itself is dangerous. there is the ACCORD study, whih is often cited as proof of this idea, but having read it, I feel it only proves that using polypharmaceutical treatment is dangerous.
If tight control of blood glucose was itelf danerous, where would that leave the non-diabetics who have it naturally?
In a fairly recent, discussion with my retired veterinary surgeon brother he told me that, when he was doing referrsal work, he was often presented with patients who were being treated with whole rafts of medications.. He would check the list and very often, admit the patient to his clinic and take away all medication for a coulple of days[ not insulin fo diabetics of course!] and monitor carefully. it was not unusual for the majority of those medications to be there simply to counteract the effects of each other. Someimes the original condition was gone.
He had among those patients a Jack Russell Terrier which came in on about 60 units of insulin per day split into 2 doses night and morning. Now even a FAT JRT doesn't seem to warrant that much insulin.
He had the dog in the clinic for a while and got it stabilised on 2 units night and morning. He concluded that the overdosing was causing a huge Somogyi effect [ a liverdump rebound effect]
Unfortunately the owner put it back on the high dose as soon as she took it home . He didn't see the dog again.
Hana
 
Thanks hanadr., That is very reassuring. I have a lot of sympathy with hat poor little Jack Russell. I can never get anyone to discuss my medication let alone change it I have to use my own judgement. I have beee with my present practice for 3years
and they would have changed nothing left o hemselves- just added insulin.

I notice in a fairly recent post you mentioned that you tend to take metformin every other day. Can I ask if you do this because you feel that this is all that is necessary for you or for some other reason.?
 
lucylocket61 said:
re: ageing and bs levels.

I was told today that, in the 6 months since my first HbA1c and my latest one 8 weeks ago, my body has continued to age, and that is why it has gone up a point!!!

I managed to keep a straight face and not point out that that was when I followed their diet and wasnt testing and low-carbing. They still dont know about the meter I bought and the testing I now do : (

It doesnt feel right to be sneaky like this, but i have to.
Click to expand...
Know what you mean LUcy bu its your disease. The HCPs are only following he guidelines they are given and sayinfg what they have been told to say. Doing their job in fact. They don't have to deal with the consequences and are not personally involved. find out what is right for you and do what you need o do,.
If not elling them what you are doing makes life easier for you then don't worry about it.
if you are an honest direc person hen this goes against the grain but its self preservation . It is important to acquire a sense of his when you have been diagnosed with diabetes.
 
It was the idea that my body had aged sufficiently over 3 months to affect my bs so much which made me smile. I must be ageing fast :lol:

I agree about keeping quiet. What they dont know wont hurt them, and why get into trouble needlessly?
 
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