Tuesday, August 19, 2008

Type 2 diabetes, hospital medicine and primary care

A post and comment thread over at Musings of a Dinosaur provides much food for thought on these subjects. Briefly, one of Dino’s patients with DM-2 and CAD was admitted to the hospital with chest pain. Here’s Dino’s account:

Very nice 60-something patient with coronary disease, hypertension, hyperLDL, gout(the usual) and relatively mild diabetes. A1c's over the last two years ranged from 7.3 to 7.8%; ie, not perfect, but not horrible, MANAGED WITH DIET AND EXERCISE*. Already taking eight different meds for coronary disease, hypertension, hyperLDL, gout (the usual), so I was emphasizing exercise, diet and lifestyle management. Certainly considering adding some metformin at the next office visit.

At the first follow up visit Dino, who doesn’t round at that hospital and received no information from there, learns that the patient was placed on Januvia, metformin and glyburide all at once. Dino is critical of the hospital’s approach. An angry exchange with his commenters follows.

The crux of the matter is whether Dino should have been more aggressive in turning to drugs to push the patient’s A1c to the magic number of 7. Although Dino could have been kinder and gentler with his hospital colleagues I tend to side with him in this debate. The arrogance of some of his commenters is unbelievable.

To discuss benefits of pharmacologic treatment intelligently we have to distinguish between the effects of glycemic control on micro and macro vascular disease. This patient’s greatest risk, in the short term, is from macro vascular disease. What evidence is there that pushing the patient’s A1c to the magic number with drugs will improve macro vascular outcomes? Zilch. Drug therapy may even lead to macro vascular harm. I discussed that issue here and elsewhere.

What about micro vascular disease? The UKPDS suggests benefits of treatment, and that’s where we got the magic number of 7. Before you get too excited, though, read this and decide for yourself how meaningful those modest benefits are and whether they justify the downsides in your patient. (Especially if your patient is already on multiple other drugs to help control the macro vascular disease). So what was Dino to do? It’s not a slam dunk as some of his commenters seem to believe.

Were hospitalists involved in this mess? If so they were probably functioning as admitologists and roundologists in deference to the subspecialists. (That’s known as comanagement these days). This story raises an important question for hospitalists. How much should we fiddle with patients’ long term medications? It’s appropriate in some instances, but I tend to avoid it unless it’s really necessary. When we do fiddle, it’s all the more important to keep the PCP in the information loop.

1 comment:

#1 Dinosaur said...

Thanks for the props. I agree that some of my commenters went overboard, but that's just par for the course. I stand by my diabetes management; glad to see there's some support for it in the evidence-based world.