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samedi 24 novembre 2012


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.
Are diabetes management guidelines applicable in 'real life'?
Luciana V VianaCristiane B LeitãoMaria de GrilloEnnio P RochaJuliana 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).


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
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