Type 2 diabetes

T2D game plan need to look beyond glycaemic targets for those with suboptimal control

A change in the current model of care might be warranted for patients with type 2 diabetes with suboptimal glycaemic control, according to a study from a specialist diabetes clinic.

The study, published in the Internal Medicine Journal, reviewed outcomes in 284 patients who attended the Royal Melbourne Hospital diabetes clinic for at least 12 months between 2008 and 2013.

Overall, HbA1c improved from a median of 8.4% at baseline to 7.5% at one year.

However the improvement depended on baseline HbA1c.

“Thirty seven, 62, 99 and 86 patients, respectively, had 1-year HbA1c values of >9%, 8–9%, 7–8% and <7%,” the study said.

“Patients with HbA1c >9% at 1 year initially improved before deteriorating, whereas the other groups had similar starting points that decreased divergently over the year of follow up.”

The study found as well as baseline HbA1c, the factors associated with 1-year HbA1c were use of antidepressant or antipsychotic medications; low treatment adherence; higher bodyweight; and recommendations to intensify treatment during the first year.

“One effective approach to address this would be to employ diabetes ‘case managers’ to provide mental health support and assistance to overcome treatment barriers,” the study authors said.

The investigators also suggested relaxing the HbA1c target (e.g. to 7.5 or 8.0%) in cases where the HbA1c exceeded 9% at baseline and could not be reduced to the conventional target of 7% despite treatment adherence.

Senior investigator on the study Associate Professor John Wentworth told the limbic that most of the improvement in HbA1c occurred during the first few months of clinic attendance.

“There are people who are seemingly refractory to what we do,” he said.

“Moving beyond a set HbA1c target is appreciating that really the game plan for type 2 diabetes is vascular risk reduction, and blood pressure and cholesterol are more important one would argue than glucose control in that equation.”

Associate Professor Wentworth, from the department of diabetes and endocrinology at Royal Melbourne Hospital, said their findings certainly flagged the need to do things differently.

“Looking at our glucose results, it’s pretty clear that we know after six months whether we have had a win or not and currently in our clinic we are hanging onto patients for years. We’re probably best to have that short, sharp interaction early and then get them out of the clinic [back to their GP].”

He said intractable issues such as obesity, mental health and disengagement probably required targeted resources.

“I think there is so much poor diet going around that makes it impossible to medicate effectively with type 2 diabetes. If there was some way to reform what people are eating, that would be really powerful. But it’s difficult for people with entrenched habits. Lots of people can’t even cook for themselves.”

“If they don’t want to change and don’t see any need to change because they feel well despite a high HbA1c, then it’s pretty difficult.”

“If we really want to make a metabolic impact for these people, we need proper resourcing to support people in difficult social situations and with significant mental health issues.”

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