Discussing targets with patients

One of the reasons for flexible HbA1c guidelines is that health risks of tight control with intensive insulin treatment may be dependent upon the duration of the disease and other factors that are not always well understood.

“We do not want any person markedly over- or under-treated, but individuals need to make their own decisions when potential benefits and harms are less clear,” says Pogach. For example, he pointed out, many individuals with Type 2 diabetes will need insulin therapy at some point — especially as they get older — “And it is the second most dangerous drug in the U.S.”  Two articles on dangerous drugs support this assertion. One, “Serious adverse drug events reported to the Food and Drug Administration, 1998-2005,” in the Archives of Internal Medicine in 2007, ranked insulin second behind estrogens under drugs responsible for “disability or other serious outcome.” The second, “Medication use leading to emergency department visits for adverse drug events in older adults,” published in the Annals of Internal Medicine in 2007, ranked insulin second behind Warfarin under drugs ”not always potentially inappropriate” but responsible for adverse events.

That issue presents a “reality check” for physicians, Pogach noted.

“We’ve come up with a risk communication tool in developing a new VA/DoD tool kit for providers,” adds Pogach.

 VA and DoD recently have completed a comprehensive toolkit for multiple healthcare disciplines — physicians, nurses, dieticians, psychologists, pharmacists — and patients. The tools cover important health information about all aspects of diabetes management, as well as a summary FACT sheet for clinicians with key guideline points. A new feature currently planned will be pictorial representations of the benefits of glycemic, blood pressure and cholesterol control to facilitate clinician understanding and informed discussions with patients. Additionally, there will be a pictorial representation of the accuracy of A1c test results that will be helpful in interpreting the results (See the example below).

“This, in essence, addresses the issue that not everyone with diabetes needs tight control — especially if they have reasons for decreased life expectancy, such as co-morbid conditions,” says Pogach. In 2003, The American Geriatrics Society echoed this sentiment in their “Guidelines for Improving the Care of the Older Person with Diabetes Mellitus,” citing the importance of individualized goal-setting in light of co-morbidities and other chronic conditions in this population.

Slight variation in A1c levels is usually not a problem, according to Pogach, “This is what we’re moving toward in the toolkit. People get upset sometimes about small changes, and they need to know not to be upset.”