I have never been a great fan of
“Guidelines” issued by Professional Medical Bodies, especially for Chronic
Diseases where a substantial profitability exists for Pharmaceutical companies.
The guidelines have changed at the whims of
the “experts” who never apologize when their expertise goes wrong and kills
many patients. Some mayvens insist on a HgbA1c of less than 6.5% in patients
with Diabetes and as studies have pointed out, there is truly a chance of death
of the patient if you are that enthusiastic! My healthy scepticism was founded
early in my career, when I was training to be an Endocrinologist, I attended an
International meeting where a flamboyant “expert” suggested that: Not putting
your women patients on Hormone Replace Therapy amounts to malpractice. Few
years and few deaths later, now the reverse is the accepted practice, unless
you have a very serious reason to do so. I wonder which drug company he
belonged to. As the Government funds dried up or the number of mediocre people
practising “science” rose among the doctors, they walked into the den of
wolves: pharamaceutical companies with money to burn as long as nothing too
wrong was said about their products and of course, they would be pleased if you
recommended their products as being superior to what is currently available.
The field of Diabetes Management (type 2)
is undergoing such a convulsion at the moment. Most of these people who travel
the country at the expense of the drug companies promoting their drugs have
very little exposure to every day life of doctor and patient, if so they are
very carefully screened and pampered patients who attend these trials for drug
companies.
The Late Dr Howard Lessner who mentored me
for a few months during my stay at Jackson Memorial Hospital, said to me once:
Read only things you pay for, don't believe in materials that are sent to you
free.
Currently my mailbox is full of stuff,
published in a very polished fashion, courtesy of an Educational Grant from
some drug company or other. There are lots and lots of very honest researchers
out there in this world, so I really don't have to listen to people who take
money from drug companies, the greedy ones from many companies.
I also tend not to read articles written by
Medical Journalists who are used as proxies for medical researchers (who will
have to expose their drug company connections). Most of the medical journalists
are used by “throw-away” journals that are inundated to the offices of the
practising physicians. So a report may appear as balanced but when you delve
into it, the underlying interest becomes clear.
A busy practising clinician has no time to
do such detective work and is at the mercy of so much medical information that
my advice to them is, don't listen to the Pharmaceutical representatives or
read it in a free journal or go to drug company sponsored dinners. Pay your
hard earned money to get official journals of medicine and attend professional
meetings of your society, avoiding once again drug company sponsored dinners.
We are inundated with information about the
new forms of treatment for type 2 Diabetes, mainly DPP-4 inhibitors and
Incretin mimetic or GLP analogues, which are at best only marginally better (at
a extraordinarily high expense). I beg the doctors working in the developing
world not to indulge in these medications as none of them have shown to hold a
candle to minor changes in lifestyle. The presence of these drugs also give a
false confidence to the practising physicians that they can do something, write
a prescription, rather than counsel which they may not be good at. Also it is a
form of “turfing”, getting rid of a patient who is not showing improvements as
you would like. As such, using these drugs by Family Physicians is an admission
that their treatment has failed or their knowledge about treatment of Type 2
Diabetes is sadly behind the times, incongruously as it may sound.
The following study just published a few
days ago in November 2012 is of great importance to those of us who are
actually working with patients rather than just going around talking about
papers we have read in the journals, in fact talking about other peoples work and not based on your experiences to add to it.
Research
Are diabetes management
guidelines applicable in 'real life'?
Luciana V Viana, Cristiane B Leitão, Maria de Grillo, Ennio P Rocha, Juliana K Brenner,Rogério Friedman and Jorge L Gross
A one-year, single-arm
interventional study was conducted with type 2 diabetes patients in a primary
care unit. Intervention consisted of intensification of lifestyle changes and
sequential prescription of drugs based on ADA guidelines using the medications
available through the publicly funded Unified Health System (Sistema Unico de
Saude, SUS).
Results
Ninety patients (age:
62.7+/-10.4 years; diabetes duration: 8.2+/-9.1 years) completed the trial.
During the intervention period, increases were observed in number of oral
antidiabetic agent (OAD) classes per patient OAD pills per patient ,insulin
dosage and number of patients on insulin
but no improvement in or frequency of
patients on target, defined as HbA1c <7 b="b"> Patients with baseline HbA1c
<7 6.7="6.7" a="a" baseline="baseline" change="change" during="during" had="had" hba1c="hba1c" in="in" increase="increase" no="no" observed="observed" p="0.002)." small="small" such="such" the="the" those="those" trial="trial" vs.="vs." was="was" with="with">=7%.
It is interesting to
note that the medication usage increased if you followed the ADA
recommendations but not the measurements for the control of Diabetes. This
study is the first of its kind to question the advice of the “experts”.
What is very important
to note in this study is that the control of patients with Diabetes, from a
mostly lower socio economic group was BETTER in the non ADA recommendation than
ANY SUCH RESULTS in the USA, let alone from lower socio economic groups!
So you could re title
this blog to :
Poor Brazilians get
better medical care than well off Americans..
(the above is the reality. A1C less than 7% remain unchanged over the years)
I have looked into the
Control of Diabetes Type 2 around the world, unfortunately just looking at only
one measurement HgbA1c. What is amazing is the fact that regardless of the
context:
War Zone in Basra
Kabul
Private Practice of
Medicine in Malaysia
Expensive Tertiary
Medical Care in India
American Indian Health
Services
Endocrine practices in
Los Angeles,
33% of the patients do
just well regardless of the treatment or place, even if you have no place to
keep your insulin cold, or there is a possibility of death on a trip to the pharmacy
or your insurance is paying 300 dollars to the Endocrinologist or you are
getting all your medications free.
As an anthropologist,
I can only add: an individual body cannot be separated from the society it
lives in and the political forces that control that society.
If as a Primary Care Provider, you are not competent to do one or all of the above, please seek help from your colleagues.
On this day, I salute
the doctors who work at the Veterans Administration Hospitals and Indian Health
Services Clinics and Hospitals for their unselfish work to better the welfare
of these two well deserving groups of people. It is not well advertised that
some of the best diabetes care in America are in these two facilities
…
