Type 2 diabetes has reached epidemic proportions in the U.S., we are told. The high blood sugar levels that define this disorder are linked to a higher than normal risk of heart attack, stroke, and many nerve complications. Unfortunately, the drugs prescribed to lower this risk come with complications of their own. Aggressive lowering of blood sugar levels has severe, potentially fatal consequences. A recent study found that — of all medications—insulin and oral diabetes drugs are the second most common cause of emergency department visits and hospitalizations!
That the treatments for diabetes 2 might be worse than the disease has been an issue for years. click here So has the possibility that the treatments are prescribed too intensively. click here Then there’s the expanded definition diabetes 2 that, not surprisingly, had drug industry’s behind-the-scenes guidance. click here Today’s post, however, deals solely with the potential overtreatment of people, aged 65 and older. It is based on a new online first commentary in Archives of Internal Medicine.
A co-author David Aron, MD, Case Western Reserve University School of Medicine, Cleveland, explained in a telephone interview why a diagnosis of diabetes 2 in old age could be problematic: “The benefits of better glycemic [blood sugar] control takes roughly up to about ten years to develop, so it’s only beneficial to someone who has a longer life expectancy.” Put another way, the whole reason for diabetes 2 drug therapy is the lowering the diabetic’s increased risk for a long list of horrors including stroke, amputation, blindness, stroke, heart attack, and others. But the rate of these complications does not begin to drop until the diabetic has been on drug therapy for about ten years. Ever heard that before?
Intensive use of drugs to lower blood sugar levels is another problem for diabetics over age 65. The drugs prescribed for diabetes 2 range from metformin alone—thought to be the safest—to the riskier combination of insulin plus an oral drug class of medications called sulfonylurea. Age 65 is the point at which many people begin to develop other serious health problems that make them more likely to experience complications when the drug therapy causes the blood sugar to go down to dangerously low levels (hypoglycemia). Dr. Aron’s commentary identifies a list of conditions that put older diabetics at risk for hypoglycemia.
Ominously, at the top of the list is: treatment with the combination of insulin plus a sulfonylurea drug (click here for brand names). The list also includes “chronic kidney disease, cognitive impairment or dementia, neurologic conditions that may hamper the ability to speak or respond to a hypoglycemic event, and conditions associated with weight loss, appetite disturbances, or altered medication metabolism.” Yet Dr. Aron has this caution, “I wouldn’t want concerns about hypoglycemia to be seen as a license to avoid appropriate treatment for diabetes 2.”
Now for the test result at which overtreatment and hypoglycemia complications become a possibility: The diagnosis of diabetes 2 is based primarily on the hemoglobin A1C test, which can also measure how well the treatment is working. The A1C test shows the average blood sugar levels of the past three months. The A1C result is reported as a percentage. The higher the percentage, the higher a person’s blood glucose levels have been. For people without diabetes, a normal A1C level can range from 4.5 percent to 6 percent.
Dr. Aron and his co-author Leonard Pogach have identified 7 percent as the A1C level as significant for certain people with diabetes 2. Once the patient’s A1C level goes below 7 percent, they say, the potential for overtreatment kicks in for people over the age of 65 who are at high risk for hypoglycemia. Their commentary is part of the “Less is More” series published regularly by Archives of Internal Medicine, a medical journal with the mission of addressing the problems of unnecessary medical care.
Alarmingly, Drs. Aron and Pogach describe the A1C test as not very accurate (no matter the age of the patient), “There is even greater inaccuracy in many point-of-care A1C tests,” they wrote, referring to blood tests administered in a doctor’s office, as opposed to a free-standing laboratory.
Dr. Aron was asked for more information about how people would know whether their test results could be trusted as the basis for long-term drug therapy “Yes, it’s scary,” he said. When pressed further, “No test is 100% accurate,” he hedged, “And there is a National Standardization Project currently working on improvements (click here).”
Take-home messages: Pay attention to your A1C test results and keep copies. If your A1C goes below 7%, talk with your doctor about lowering the dose. Become an expert on diabetes 2, hypoglycemia and the controversies that dog both topics. Learn more about the drugs you are taking. Read the links within this post and “Related posts” below.
Non-pharmaceutical steps to take: Improve your diet by eating real food, as opposed to fast or processed foods (read “Food Rules“). Don’t forget regular aerobic exercise (read “You can be fat and fit“). Do both and you might be able to avoid drugs.
Maryann Napoli, Center for Medical Consumers©
Risks of diabetes 2 treatment A meta-analysis of 13 randomized controlled trials found that drug therapy does not reduce mortality and might, in fact, slightly increase mortality. Study participants were middle-aged and older. Drug industry’s role in expanded definition of diabetes 2 is described, so there is reason to think that overdiagnosis explains part of the diabetes 2 “epidemic.”
Weight loss and diabetes 2 Former American Diabetes Association official takes issue with the organization’s standard advice about weight loss and the disturbing trend toward labeling people as prediabetics.