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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Monday, August 20, 2007

    Those Stupid Family Doctors: As portrayed, once again, in the New York Times:

    Nearly 73,000 Americans die from diabetes annually, more than from any disease except heart disease, cancer, stroke and pulmonary disease.

    Yet, largely because of a misunderstanding of the proper treatment, most patients are not doing even close to what they should to protect themselves. In fact, according to the federal Centers for Disease Control and Prevention, just 7 percent are getting all the treatments they need.

    ....In part, the fault for the missed opportunities to prevent complications and deaths lies with the medical system. Most people who have diabetes are treated by primary care doctors who had just a few hours of instruction on diabetes, while they were in medical school. Then the doctors typically spend just 10 minutes with diabetes patients, far too little for such a complex disease, specialists say.

    Oh, my. "Just a few hours of instruction on diabetes while they were in medical school?" That beggars belief. The average medical student learns about diabetes in anatomy, pathology, physiology, and biochemistry during the basic science years. Then, they encounter it again during their clinical rotations. They learn to treat it and diagnose it during their internal medicine and pediatric rotations. They see complications of it during their subspecialty rotations. And then, when they go to their residency training (at least if they go into primary care), they learn to diagnose and treat it even more. Medical school isn't like high school or college, where every topic is given its fifteen minutes of attention and it's off to the next topic. It's more of an integrated educational experience.

    It also beggars belief that that the average internist and family physician doesn't understand the importance of blood pressure control and cholesterol management in diabetics. I assure you, we do. It appears that the model patient in the story, however, didn't:

    Mr. Smith, a 43-year-old pastor in Fairmont, Minn., tried hard. When dieting did not work, he began counting carbohydrates, taking pills to lower his blood sugar and pricking his finger several times a day to measure his sugar levels. They remained high, so he agreed to add insulin to his already complicated regimen. Blood sugar was always on his mind.

    But in focusing entirely on blood sugar, Mr. Smith ended up neglecting the most important treatment for saving lives — lowering the cholesterol level. That protects against heart disease, which eventually kills nearly everyone with diabetes.

    He also was missing a second treatment that protects diabetes patients from heart attacks — controlling blood pressure. Mr. Smith assumed everything would be taken care of if he could just lower his blood sugar level.

    Is it true that lowering cholesterol in a diabetic is more important than controlling blood sugar? No, and again no. One comes away from the Times article thinking that treating diabetics with a statin and a couple of hypertensive pills is better than treating the diabetes itself. That would be malpractice.

    Diabetes is a complex disease that often goes hand in hand with other diseases (high cholesterol, high blood pressure) that affect the heart and other small blood vessels in vital organs. This is why diabetics (and hypertensives, too), run the risk of kidney failure and blindness and strokes and peripheral vascular disease, in addition to heart disease. Diabetes, high cholesterol, and high blood pressure each act to damage blood vessels, in effect aging them at a faster rate than occurs in a healthy body. It only makes sense to treat each condition aggressively when they are present in an unholy trinity, which they often are.

    However, if one were to rank the diseases from the highest risk for the above complications to the lowest risk, diabetes would be number one, hypertension number two, and high cholesterol dead last. It is rare to find someone who has kidney failure on the basis of untreated high cholesterol alone. It is all too common a complication, however, of untreated diabetes and untreated hypertension.

    That entire article reads like an advertisement for statins. Maybe it is.

    posted by Sydney on 8/20/2007 09:55:00 PM 2 comments


    Pushing the A1C down for Type I DM has good evidence of benefit.

    A critical reading of UKPDS data, however, does not support the idea that we meaningfully alter important clinical outcomes in Type 2 diabetes by pushing down the A1C. The A1C is a marker of disease severity, pushing it down does not seem to affect the underlying disease risk of important health outcomes. Thus the emphasis on blood pressure/statins, etc, which has good evidence of benefit (at least blood pressure control) from the UKPDS studies.

    You may want to look into this topic a little more. It is extremely important when taken in context of many of the misguided P4P targets physicians are being rated on.

    Some papers on the topic:

    Shaughnessy, A.F., et al, Br Med J 327:1, August 2, 2003

    Ewart, R.M., et al, Br Med J 323:854, October 13, 2001

    By Anonymous Anonymous, at 6:29 AM  

    All hail the statin.

    As a business person I have followed the statin story for years. After their introduction sales were not meeting expectations. Standards were lowered and sales increased. Another lowering and another sales increase. Today we have target LDL numbers lower than the national averages and surprise, surprise, multiple statins are given with the idea they will bottom out the LDL number with no side effects.

    Starting at 48 I have been told how I need a statin, no test needed. In one case I was told I would be required to take a statin to maintain my health insurance. This doctor knew that the insurance companies would see the benefit of medicating the entire population over 50.

    Today we see marketing plans to do combo pills with generic statins and another drug in order to maintain a drug patient, and newer is always better.

    With statins being the most sold drug ever I have to question is the driver in their use financial or patient need? I am voting financial.

    Steve Lucas

    By Anonymous Anonymous, at 8:53 AM  

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