Episode 137: Putting the patient back into the diabetes guidelines - the VA perspective

Submitted by JPM on Fri, 2011-08-12 10:20

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Comments

Quality of Life; A1c Hides Some Evidence

Submitted by Anonymous on Wed, 2011-08-17 08:35.

Thank you for examining the quality of life issue from a more holistic perspective (i.e., how high is your quality of life if you are spending ALL your time managing your diabetes and burning out on that management; how effective are therapy recommendations if they are not followed because of other priorities such as jobs/food/family?)

One of the issues we are concerned about in the Diabetes Online Community (patient-activists) is the contrast of target A1c with standard deviation -- i.e., the amount of time blood glucose readings are within target range. Largely, we understand that it's less the A1c itself (or sustained highs) than it's the peaks and the dips in BG that are responsible for cardiac stress and some of the long-term complications.

That said, it's hard to get a true round-the-clock picture without a CGM, which is generally not an available therapy for people without hypo unawareness. (I have, in several venues, advocated the use of CGMs as diagnostic tools -- use one sensor-life's worth of data to tune, or fine-tune, an individual's diabetes therapy. Of course, this suggests the patient has access to, and can make use of, the services of an RD/CDE.)

Evidence for CGM

Submitted by JPM on Wed, 2011-08-17 10:44.

Thanks for your comments - I have little if any experience with CGM but I would doubt that your comment "Largely, we understand that it's less the A1c itself (or sustained highs) than it's the peaks and the dips in BG that are responsible for cardiac stress and some of the long-term complications." is really based on solid enough evidence that it has an important cinical relevance but please correct me if I'm way off base. There may be a slightly better association with peaks etc than A1c but that in no way means correcting that will improve outcome. We had a great association between post MI PVCs and increaed mortality yet when we reduced the PVCs mortality actually went up 

In taking a quick look at the evidence it appears there are no RCTs that have looked at long term outcomes and that most of the evidence is for type 1 diabetes. Our podcast was dealing strictly with type 2 diabetes. I guess it could provide value in brittle diabetes or patients with hypoglycemia unawareness but mcuh of that can be dealt with by lower doses and better education etc. In type 2 diabetics regular glucose monitoring has been shown to be of little if any benefit so I'm concerned that CGM may add an expense and complexity with out much clinical benefit. But on the other hand it would be great if it did improve outcomes and make peoples lives better. Please let me know what evidence has convinced you that it is of value. Thanks again.

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