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Conquering Diabetes

with Michael Dansinger, MD

This blog has been retired. We appreciate all the wisdom and support Dr. Dansinger has brought to the WebMD community.

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Thursday, April 15, 2010

Are Diabetics Overmedicated?

The WebMD Diabetes Exchange is all about helping people understand diabetes and how to live with it.

Of course, that means eating right, exercising and aiming for a healthy weight. But it also means learning how to work closely with your medical team regarding medication decisions. Over 80% of people with diabetes take medications for glucose control, including 100% of patients with type 1 diabetes (who require insulin medication for survival).

My professional focus is lifestyle coaching for type 2 diabetes reversal. I have consistently and passionately urged people with type 2 diabetes to do all they can to maximize the power of lifestyle change by learning how to adopt an ambitious eating and exercise strategy, aiming to achieve remission (normal glucose without medication) or get as close to remission as possible.

Having said that, I’d like to discuss my philosophy about medication for type 2 diabetes, especially because it has been an emotional topic on the Diabetes Exchange recently in “Diet, Medications and More.”

In my view, when glucose levels cannot be adequately controlled (A1c greater than 7%) by eating right and exercise (and if “diabetes reversal surgery” is not an option), then medications are crucially important for reducing the risk of diabetic complications such as visual loss, kidney failure, neuropathy, foot ulcers, limb amputation, stroke and heart attack. We know from clinical trials that using medication to lower the A1c down to 7% helps reduce the risk of such complications, and helps prolong survival in certain patients. We also know from clinical trials that using multiple medications to push the A1c much below 7% has diminishing returns, although there may be advantages in certain patients.

I also feel strongly that it is a mistake to conclude that there is no point pushing the A1c below 7%. Observational studies suggest diabetics with A1c around 7% are still at about double the risk for complications as diabetics with an A1c below 6%. Unfortunately, using drugs to achieve that improvement is a limited strategy. In my opinion, lifestyle change, aiming to push the A1c below 6%, is almost certainly worth striving for whenever possible.

Most people with diabetes need cholesterol drugs to reach the optimal levels. We know from clinical trials that if the LDL (bad) cholesterol is over 100 mg/dL (or the C-reactive protein level, a marker of atherosclerosis, is over 2.0 mg/L), patients with diabetes live longer and/or have fewer heart attacks if they use statin drugs to push the LDL (bad) cholesterol well below 100 mg/dL, and the ideal may be around 70 mg/dL or lower.

So I really have mixed feelings about whether diabetics are “overmedicated” because we have two simultaneous problems. On the one hand, we have a large proportion of people who are “undertreated” because they are not meeting A1c and cholesterol targets. On the other hand, I am concerned about the common scenario where drugs serve as an excuse to avoid eating right and exercising.

It is very easy for health care providers and patients to rely on medications to get the numbers in line, without paying due attention to lifestyle change. The drugs can easily mask the problems that could be and should be addressed by lifestyle change. It is important to recognize that this is a very different situation than when a patient is making concerted lifestyle efforts, and seeing good results, but the health goals are still not being met.

Lastly, I would just like to acknowledge that we often use drugs and other treatments that have little or no benefit as reported in USA Today. Pharmaceutical companies sometimes exaggerate the benefits and downplay the risks of their products, and may do so via the design and interpretation of clinical trials that doctors, patients and the FDA rely on to assess the risks and benefits of drugs. For example, the makers of the diabetes drug Avandia have come under fire recently for unethical practices that were intended to downplay possible safety risks.

So, in summary, my job and my mission is to help people avoid unnecessary medication, but often medication is truly necessary to live life to the fullest.

- Michael Dansinger, MD

Ask your questions and post your feedback on the Diabetes Exchange.

Posted by: Michael Dansinger, MD at 7:05 am

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