Who to listen to?• Metaguideline• Guideline• Review• Study• Preceptor’s Unsourced Opinion• Google
Who to listen to?• Metaguideline• Guideline Putting evidence into practice requires• Review more guesswork and judgement than you might think as a 3rd year. Less about facts, more about hunches.• Study• Preceptor’s Unsourced Opinion• Google
Lifestyle Management• Why does a chocolate chip cookie, with its warm, sumptuous mounds of chocolate, have such power over us? — David Kessler
Guilt• We probably react like rats here. Oral glucose has measurable affects on dopaminergic responses in the Amygdala for 7 days. Gastric infusion doesn’t.• Changing Diet is harder than giving the advice.
Lifestyle Management• Patient-centered: Motivational counseling• Systems-approach: Reminders• Support Group• Group Visits
3 month intervention, SMSMessagesPatients with SMS messages had 1.16%drop in A1c compared to controls. Diabetes Res Clin Pract. 2011 Aug
Medications • Metformin (Even ER, $4/month) • Glyburide ( $4/month) • Contrast: Januvia ($200/month), Actos ($300/month) Since I include the prices, here, I’m guessing you have a hunch about my opinion.Only oral meds on WHOs Model List of Essential Meds: Metformin, Glyburide.
Insulin• “The most dangerous drug I prescribe”• Key to management: Matching patients glucose patterns.• Glargine, NPH, 70/30, Regular: It depends.
Glucose Monitoring• Somewhere between continuously and never.• Test Strips are typically $1 each• Testing in stable diabetics correlates with depression (Unactionable result?)• 10 years ago, I was taught 2x Daily. My practice now trends toward 0x Daily.
A1c in a tweet• Your A1c is like a candy coating on your blood cells. It gives an average of the sugar in your blood over the 3 months blood cells live.• Or just use the estimated glucose instead? ~A1c x 29 As fundamental as A1c is, how many patients don’t grasp it?
Metabolic Syndrome• With Diabetes, the risk of CVD doubles.
35,000 patients (mean age, 62) receivedeither intensive orstandard glucose-lowering treatment.After a mean follow-up of 5 years,intensive glucose lowering was notassociated with lower risks forall-cause mortality and CV death BMJ 2011 Jul
Statins effective in CVDprevention20-30% reduction in major coronaryevents, strokes, revascularizations withsimvastatin. Lancet 2003.
Medication Cage Match in rm fo etM Vs. in at st va Sim
Let’s not get too Doctor-centered• Medication adherence probably matters more for reducing CVD. Apparently, the statin only works if the patient swallows it regularly.• Cost is still a major factor for patients.• Wouldn’t we get more bang from getting at the 1 out of 3 diabetics that isn’t diagnosed?
The future of Diabetes Low Agency High Agency Diabetes is our Map for treatingCertain destiny diabetes Who knows what Let’s build theUncertain we’ll do someday future of diabetes