Clarity on control (American Diabetes Assn. Scientific Sessions)

Unraveling the complexities of insulin intervention

Faced with an ever-widening epidemic of type 2 diabetes, leading diabetes experts are urging physicians to pursue aggressive treatment, including early initiation of insulin, to bring hemoglobin A1c levels below 7%.

But they also acknowledge that major hurdles still must be overcome in convincing doctors and patients that the advantages of insulin therapy outweigh the disadvantages.

Traditionally, insulin has been considered a last option for controlling type 2 diabetes, so moving it up to a primary therapy requires a major shift in thinking.

Many patients fear insulin and are unwilling to use it as part of their treatment regimen if alternatives exist. Physicians also are reluctant in some cases to introduce insulin because of its complexity and additional self-care requirements.

Nevertheless, insulin remains the most potent drug for reducing blood glucose levels and should be considered an early treatment option for type 2 diabetes, said David M. Nathan, MD, director of the General Clinical Research Center and of the Diabetes Center at Massachusetts General Hospital and a professor at Harvard Medical School in Boston.

For some patients, insulin therapy may be indicated as early as diagnosis or shortly thereafter, Dr. Nathan said. He spoke during a symposium on insulin initiation in type 2 diabetes that was held at the American Diabetes Assn. Scientific Sessions June 22-26 in Chicago. The session attracted an overflow audience of physicians and other health care professionals.

Dr. Nathan walked the audience through a treatment algorithm for type 2 diabetes -- heavily weighted toward insulin therapy -- that was published as a consensus statement in 2006 by the ADA and its European counterpart.

Dr. Nathan, who chaired the expert panel that produced this document, pointed to studies showing that insulin, when combined with metformin, is more powerful than oral medications and can reduce A1c levels by about 2.5%.

Physicians also need to make sure that patients on insulin are getting adequate amounts of it, he said. "For primary care audiences, I tell them, 'I don't care exactly how you give the insulin as long as you give enough.' ... We tend to undertreat these patients."

He also urged doctors to try to reduce patients' anxiety about insulin therapy. Too often patients are told that if they don't lose weight, they'll have to go on insulin, he said. "If we stop threatening our patients with insulin, maybe they'll stop being so scared of it."

Drawbacks remain

But there also are significant downsides to using insulin therapy, said Robert R. Henry, MD, professor of medicine at the University of California at San Diego and director of the Center for Metabolic Research at the Veterans Administration Medical Center in San Diego.

Although many in his practice are treated with insulin, patient resistance can be a major barrier, he said. Studies have found that up to a quarter of patients with type 2 diabetes refuse this approach. "Some people will accept it without much problem at all, but others will try to do anything to get away from using insulin."

Another issue, particularly for primary care doctors, is the complexity and variety of these regimens. "Things are changing so rapidly, even with insulin, that it really takes specialized folks to use insulin," he said.

Some practices also do not have the necessary resources and staff to move patients successfully onto insulin.

Dr. Henry noted that the consensus algorithm, including its insulin therapy recommendations, is extremely complex and time-consuming.

"The intensive insulin treatment algorithm, I think, is an excellent algorithm for the knowledgeable diabetes care provider who has ample resources for patient education and close patient follow-up," he said. "I think it's impractical, though, and of modest, and perhaps minimal, clinical value for the majority of diabetes care providers with little in-depth knowledge of diabetes or the resources or the time to institute this complex algorithm."

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Treatment tips

Here are some treatment tips from the meeting:

Patients at risk for type 2 diabetes need the help of their physicians to set realistic goals for physical activity, healthy eating and weight loss, according to researchers and physicians involved with the National Diabetes Education Program. And an important message to convey to patients is that, when it comes to weight loss, a little can make a big difference.

Many patients set themselves up for failure by dramatically overestimating the amount of weight they need to lose, said David Marrero, PhD, professor of medicine at Indiana University School of Medicine in Bloomington, and a member of the NDEP Health Care Professionals Working Group.

"When you ask people, 'What would be the ideal weight loss?' they usually pick something between 25% and 30% of their body weight," he said. "That is a lot."

One of the conclusions of the Diabetes Prevention Program, a major clinical trial for which findings appeared in the Feb. 7, 2002, New England Journal of Medicine, was that the health promotion and risk reduction aspects of weight loss occur with fairly modest reductions, he said. But not enough patients hear this. A recent NDEP survey found that only about half of patients diagnosed with pre-diabetes or at high risk of diabetes had been advised to control or lose weight.

The NDEP has developed a "Game Plan Toolkit" to help physicians talk with patients about steps they can take to reduce their risk of diabetes. It is available through the NDEP's toll-free number (800-438-5383) or online ndep.nih.gov/resources/health.htm.

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Research findings: Seasonal fluctuations in A1c levels; diabetes' impact on hearing

A large-scale analysis of diabetic patients' A1c values found that blood glucose levels can fluctuate significantly depending on the time of year, generally peaking in the winter (January-March) and falling in the summer (July-October).

Seasonal differences are most apparent in patients older than 80 and those with A1c levels at 9% or higher, according to an analysis from the Quest Diagnostic Health Trends Report on Diabetes, presented at the American Diabetes Assn. 67th Scientific Sessions.

The report is based on findings from 22.7 million de-identified hemoglobin A1c tests performed between 2001 and 2006 on nearly 5 million patients with diabetes.

According to study authors, patients' A1c levels should be measured in late spring and autumn to minimize the impact of seasonal fluctuations on the interpretation of test results.

Another study presented at the meeting identified hearing impairment as a complication of diabetes.

People with diabetes are 76% to 91% more likely to have hearing problems than those without, according to a recent analysis of data from the National Health and Nutrition Examination Survey by researchers from the National Institute of Diabetes and Digestive and Kidney Diseases.

The potential mechanisms underlying the association still need explanation. But study authors say that screening diabetic patients for hearing impairment would likely yield a high number of diagnoses.

Meanwhile, the number of patients with diabetic eye diseases is expected to soar during the coming decades. The Centers for Disease Control and Prevention estimates that cases will triple from 7. 1 million in 2005 to 21.4 million in 2050, with increases especially pronounced among patients who are 65 and older, patients who are Hispanic, and those who have glaucoma and cataracts.

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