TY - JOUR
AU - Hirsch, Ronald
AB - As an internist with a busy office practice and a large number of patients with type 2 diabetes mellitus, I was flabbergasted to read the Commentary by Havas1 on the lack of evidence supporting pharmacologic control of blood glucose levels and his recommendation that metformin be the sole oral agent used. Achieving a hemoglobin A1c (HbA1c) level below 7.0% is considered the sole measure of adequate diabetic control, and failure to achieve that mark is considered failure to adequately care for the patient. In fact, Medicare has included HbA1c control as one of its core measures for diabetes care in the recently enacted Physician Quality Reporting Initiative.2 Patients are routinely treated with multiple oral agents at a great expense, which only increases when we add injectable agents to the mix to achieve that elusive goal of an HbA1c level less than 7.0%. They endure adverse effects like nausea and diarrhea, which we pass off as nuisances, and risk hypoglycemia, which could have catastrophic effects. When we suspect that patients are not adherent with their prescribed treatment regimen and have an HbA1c above 7.0%, we consider discharging them from our practices so our data do not look bad. And yet Dr Havas now advocates controlling blood glucose for only the most extreme cases and concentrating our efforts on blood pressure and cholesterol control. As we have seen with recent studies of ezetimibe and torcetrapib, our reliance on surrogate end points as markers for risk reduction is flawed.3,4 His analysis seems to add to that skepticism. I would welcome efforts by Dr Havas to meet with other influential diabetologists and quickly work to change the treatment paradigm. Our patients would thank you and the clinicians like myself, on the front lines of diabetes care, would thank you, and you would only have to answer to the pharmaceutical companies who stand to lose billions of dollars that they have invested in the development of newer, and apparently ineffective, diabetes drugs. Correspondence: Dr Hirsch, Signature Medical Associates, 1710 N Randall Rd, Ste 200, Elgin, IL 60123 (rhirsch@signaturedoctors.com). References 1. Havas S The ACCORD Trial and control of blood glucose level in type 2 diabetes mellitus: time to challenge conventional wisdom. Arch Intern Med 2009;169 (2) 150- 154PubMedGoogle ScholarCrossref 2. Centers for Medicare and Medicaid Services, 2009 PQRI measures list. http://www.cms.hhs.gov/PQRI/Downloads/2009_PQRI_MeasuresList_030409.pdf. Accessed January 2009 3. Kastelein JJAkdim FStroes ES et al. ENHANCE Investigators, Simvastatin with or without ezetimibe in familial hypercholesterolemia. N Engl J Med 2008;358 (14) 1431- 1443PubMedGoogle ScholarCrossref 4. Cutler DM The demise of a blockbuster. N Engl J Med 2007;356 (13) 1292- 1293PubMedGoogle ScholarCrossref
TI - Changing the Diabetes Treatment Paradigm
JF - Archives of Internal Medicine
DO - 10.1001/archinternmed.2009.185
DA - 2009-07-13
UR - https://www.deepdyve.com/lp/american-medical-association/changing-the-diabetes-treatment-paradigm-dU0LmrCeSl
SP - 1241
EP - 1247
VL - 169
IS - 13
DP - DeepDyve
ER -