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Daily Dose

How aggressively should doctors treat type 2 diabetes?

One of the biggest conundrums facing those with type 2 diabetes is how aggressively to treat soaring blood sugar levels. Should patients take a mild drug like metformin that might leave their glucose levels a little elevated, increasing their risk of diabetes complications like blindness, amputations due to nerve damage, or kidney disease?

Or should they inject themselves daily with the more potent insulin that could cause side effects like weight gain and hypoglycemia — a condition that causes irritability and light-headedness from low blood sugar.

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A new study published earlier this week in JAMA Internal Medicine could help patients and their doctors navigate the difficult decision. It used computer modeling to determine that patients over age 50 with mild to moderate type 2 diabetes — defined as having a hemoglobin A1C level of less than 9 percent — likely get a net negative effect from using insulin; that’s because the small protective benefits they get from lowering their blood sugar from, say, 8.5 percent to 7.5 percent are outweighed by the lower quality of life they experience from insulin’s side effects.

“We were trying to balance two sides of the coin,” said study leader Dr. Sandeep Vijan, a physician–scientist at the Ann Arbor VA Hospital in Michigan. “The benefits of intensive glucose management take a very long time to become apparent so younger patients may benefit from more aggressive therapy than older ones.”

The American Diabetes Association recommends that doctors try to get patients hemoglobin A1C levels — a blood test that’s a more accurate long-term measurement of blood sugar levels — down to about 7 percent using drugs if lifestyle counseling doesn’t work. But many endocrinologists who treat diabetes now believe that’s an over-simplified recommendation.

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Dr. David Erani, director of medical programs at Joslin Diabetes Center, said he’s seen diabetes patients who experience horrible symptoms from hypoglycemia when their A1C levels go below 8 percent and emphasized that doctors need to treat patients as individuals considering their age, personal preferences, and how they respond to a new medication when it comes to selecting a drug they’ll likely be on for the rest of their lives.

“Doctors have to weigh the risks and benefits of each drug they prescribe when determining how aggressively to treat,” he said. They can also consider a wide variety of drugs that lower blood sugar level before moving on from metformin to insulin injections.

Each of the seven different categories of diabetes drugs — such as pioglitazone (Actos) and glimepiride (Amaryl) — has its own list of side effects and its own potential to lower blood sugar. Doctors should be able to explain all the pros and cons of all these options, Erani added, along with making recommendations on lifestyle changes like weight loss and increased physical activity to lower blood sugar levels.

Deborah Kotz can be reached at Follow her on Twitter @debkotz2.
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