The current management of type 2 diabetes is ignoring some individuals and over-treating others, says a Sydney-based endocrinologist who advises clinicians to consider using a ‘staging’ process to individualise care.
Presenting at the recent ADEA-NSW Branch conference, Dr Soji Swaraj from the Concord Hospital in Sydney said there were four stages that encompassed the entire insulin resistance spectrum, starting with prediabetes and insulin resistance, where there is a significant opportunity for intervention and prevention, through to the ‘late career’ stage where the focus should move to avoiding harm.
Stage 1 – Prediabetes
This stage presents a significant opportunity for intervention and prevention but is largely ignored, Dr Swaraj told the audience. This is despite the fact that these individuals may have an equivalent cardiovascular risk to those with type 2 diabetes.
He recommends an aggressive approach with medical lifestyle prescription encompassing goal setting and motivation, diet and increased physical activity (both aerobic and resistance training). Metformin may also be considered for some individuals (off-label). The focus should be on fat loss and muscle gain and Dr Swaraj prefers to measure waist circumference than weight.
Stage 2 – Early career type 2 diabetes
Based on the findings of the UKPDS, showing a ‘legacy effect’ from early intensive treatment of type 2 diabetes, Dr Swaraj recommends aggressive treatment of both glycaemia and other cardiovascular risk factors at this stage, starting with lifestyle modification and metformin.
Again, the lifestyle ‘prescription’ should incorporate diet and physical activity, including both aerobic and resistance training. And this doesn’t need to be complex or require a gym membership – he asks his patients to do 1 hour of walking daily and 20-30 biceps curls before each meal.
Stage 3 – Post-event type 2 diabetes
As the ACCORD study has shown us, there is a potential danger of tight glycemic control in those with existing cardiovascular disease. The focus for this stage is active avoidance of hypoglycaemia and managing co-morbidities, Dr Swaraj told delegates. Higher HbA1c targets should be considered, depending on individual risk.
Stage 4 – Senior ‘celebratory’ diabetes
The emphasis at this stage is Primum non nocere (first, do no harm), recommends Dr Swaraj, who explained that there is no efficacy data for intensive glycemic control in older individuals (those over 75 years are excluded from these studies) but there is evidence of harm, including an increased risk of dementia. The focus should be on preventing hypoglycemia, avoiding overly intensive treatement and monitoring regimes and most of all, improving quality of life.
The key to individualised treatment
While individualisation of care for people with diabetes is the gold standard, Dr Swaraj said that we still commonly see a lack of intensity of treatment in the early stages of diabetses and overly intensive treatment in the elderly. By ‘staging’ individuals, and re-negotiating goals as they move through these stages, we can provide more holistic care and prevent iatrogenic harm, he told delegates. And this will become increasingly important as more people with diabetes are living for longer.
For those unable to attend the conference, a recording of Dr Swaraj’s talk (along with the other presetners) is available for purchase through ADEA and provides CPD points for credentialling – for more details visit https://learning.adea.com.au/