Type 2 Diabetes: The Tightrope of Intensive Blood Glucose Control. Part 2
Ian Jackson
Former National Health Service (NHS) Prescribing Adviser and Senior Lecturer in Clinical Pharmacology and Therapeutics at a UK Medical/Pharmacy School
Contact: ian.pharmacist@gmail.com
In a previous article we looked at whether intensive blood glucose control in type 2 diabetics was supported by the evidence. Two further questions we need to consider are:
1) Do we need to consider whether a mass nationwide screening programme is appropriate as many type 2 diabetics are undiagnosed?
2) What impact does tight blood glucose control have on a patient’s quality of life.
Screening for Type 2 Diabetes
The Diabetes Prevalence Model, produced by the Public Health England (PHE) National Cardiovascular Intelligence Network (NCVIN) estimates 1 in 4 people with diabetes are unaware of their condition. (1)
Screening for diabetes implies testing for diabetes in individuals without symptoms or who are unaware of their condition. The American Diabetes Association (ADA) recommend screening individuals above the age of 45 years; and at a younger age in the presence of risk factors for diabetes (2) . Emirates Diabetes Society Consensus Guidelines have adopted the ADA screening criteria but starting at a lower age of 30 years.
Perhaps, a national screening programme would be a good idea? Does the evidence support this?
33 practices in the East of England invited 15,089 individuals at high risk of prevalent undiagnosed diabetes in for diabetes screening. 11,737 attended, and 466 were diagnosed with diabetes. After a median follow up period of 9.6 years, it was found that screening in patients at risk of type 2 diabetes was not associated with a reduction in all-cause, cardiovascular and diabetes related mortality. (3) It is primary endpoints such as these that we need to focus on.
The authors concluded that the benefits of screening might be smaller than expected and restricted to individuals with detectable disease.
Quality of Life and Tight Blood Glucose Control
We also need to consider the impact on the patient and their quality of life. Newer treatments for type 2 diabetes such as glucagon-like peptide 1 (GLP-1) receptor agonists or GLP-1 analogues and more established treatments such as insulin therapies involve regular injections. For some older patients with reduced dexterity or declining cognitive function this could be an issue.
There have been very few studies looking at how intensive diabetes control can impact on a patient’s life. A small study of 701 patients found that they perceived comprehensive diabetes care as having significant negative effects on quality of life, and these effects were equivalent to life with several intermediate complications such as a minor stroke. The study concluded that perceived reduction in quality of life could be due to the prospect of regular insulin injections rather than oral medication. Something we need to consider when we aim for tight blood glucose control. (4)
Before going for tighter blood glucose control with therapies such as GLP-1 receptor agonists or insulin we need to consider patient factors such patient concerns about self injection and the impact on their lives.
Discussion
As we have seen from these two articles, intensive blood glucose control in type 2 diabetes may be suitable for some patients and not others.
We need to consider what impact intensive blood glucose control has on a patient’s quality of life. One study showed that comprehensive diabetes care has the same negative effects on quality of life as having a minor stroke. This is something we need to consider when offering older patients intensive blood glucose control.
Healthcare commissioners also need to reflect on whether funding local screening programmes for type 2 diabetes is an appropriate use of limited resources given the findings of the East of England study on diabetes screening.
References
- Public Health England, NHS England. 3.8 million people in England now have diabetes. September 2016. Available from: https://www.gov.uk/government/news/38-million-people-in-england-now-have-diabetes.
- American Diabetes Association. Older Adults: Standards of Medical Care in Diabetes—2021. Diabetes Care 2021;44(Supplement_1):S73–S84
- Simmons R, et al. Screening for type 2 diabetes and population mortality over 10 years (ADDITION-Cambridge): a cluster-randomised controlled trial. Lancet 2012;380(9855):1741-8.
- Huang E, et al. Patient perceptions of quality of life with diabetes-related complications and treatments. Diabetes Care 2007;30(10):2478-83.