Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, September 03, 2006

Not Yet Evidence Based Medicine

Don't get me wrong; I'm a huge fan of EBM. Call it silly, but I do think the things we do and recommend to patients should actually work. Let me also say that as a rule I am not what is known as an "early adopter." I prefer not to be the new guy on the block with new drugs and treatments. Let other doc's patients find out the hard way that Vioxx causes heart attacks.

That said, as new evidence from research comes down the pike, there are times when a pattern can be seen emerging distinctly, and following the curve ahead a bit feels like a good idea. So let me tell you about some of the non-evidence based ways I am treating type 2 diabetes.

For starters, I am explaining to patients that I no longer think of diabetes as a "spectrum" from non-diabetic to pre-diabetes to borderline diabetes to full blown diabetes. I'm check a lot of A1Cs with so-called "screening" blood work; anyone with a family history of DM, anyone who has been told their "sugar was a little high", and any woman with a history of any degree of gestational diabetes. Anyone with a glycated hemoglobin over 6.0% has "it".

Insulin resistance, potential diabetes, whatever. What it says to me is that if/when they eventually develop DM according to whatever the future standards might be (because they have been tightening relentlessly over the last 20 years) whatever damage to the blood vessels in their hearts, brains, kidneys and eyes will have already been going on for who knows how long. So I have decided to get ahead of the curve, even though there's no "evidence" formally promulgated as of yet.

As we all know, the metabolic syndrome is more than just DM ("glucose intolerance"; whatever.) So what my diagnosis if "it" does is raise the bar for BP and cholesterol control. What do I do with someone with an A1C over 6% but under 7%? Even if I call them "diabetic", they're still "well controlled" by whatever lifestyle modifications they've already implemented. Many of them already have an optimal exercise regimen and diet.

What it does is change the targets for blood pressure and cholesterol control. I try to get their BP down below 110/70 instead of 120/80, preferable with an ACEI or ARB. I'll try to push their LDL down below 100. I don't give them all metformin, but I'm sure someone somewhere is researching it.

Evidence based? Not really. Not yet, anyway. But it's what I would do if my A1C were over 6%. And I tell patients that up front. Your BP is 118/78; why do you need lisinopril? Because I think 10 years from now the "guidelines" will have changed (again), and I'd rather they get the 10 extra years of protection for their endothelium.


At Sun Sep 03, 08:58:00 PM, Blogger anonymous47842 said...

Excellent post! A couple of years ago my fasting glucose was 99, A1c 5.2 -- and postprandial glucose frequently over 200. Since glucose tolerance tests are "unnecessary" this would never have been discovered had I not felt seriously unwell and purchased a glucose meter on a hunch. Waiting to take action until some arbitrary, official criteria are met strikes me as insane.

Perhaps you might consider carbohydrate restriction as the next step in the progression of your thinking. Advise these "pre" diabetic patients to dump the empty sugar and starch calories and to eat in a way more consistent with the diet of our hunter-gatherer ancestors. Following the ADA diet and piling on the medications to treat the resulting metabolic abnormalities also strikes me as insane.

At Mon Sep 04, 03:25:00 PM, Blogger #1 Dinosaur said...

Re: Carb restriction:

Oh, I totally do that!! I tell them to think of themselves as "allergic" to carbohydrates and offer them the choice of Atkins, South Beach, SugarBusters, or The Carb Addicts diets, whichever they find resonates best with their philosophy and food preferences. Some people think Atkins is too "out there" although I find "diabetics" (including pre- and potential ones) do beautifully with it.

I had included it in an earlier version of the post, but somehow edited it out for flow.


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