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Teachable Moment
Less Is More
March 2016

Intensive Glycemic Control in Type 2 Diabetes Mellitus—A Balancing Act of Latent Benefit and Avoidable Harm: A Teachable Moment

Author Affiliations
  • 1Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
  • 2Endocrinology Division, Department of Internal Medicine, University Hospital “Dr Jose E. Gonzalez,” Monterrey, Mexico
  • 3Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 4Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
  • 5Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
JAMA Intern Med. 2016;176(3):300-301. doi:10.1001/jamainternmed.2015.8320

A 55-year-old construction worker diagnosed as having type 2 diabetes mellitus 5 years ago, with current glycosylated hemoglobin (HbA1c) level of 7.4% of total hemoglobin, was referred to the diabetes clinic to optimize glycemic control. He was obese and had hypertension, dyslipidemia, and obstructive sleep apnea, but no known cardiovascular disease. He was prescribed metformin, 1000 mg twice daily; sitagliptin, 100 mg daily; glimepiride, 4 mg daily; and NPH insulin, 20 U at bedtime. (To convert HbA1c to a proportion of total hemoglobin, multiply by 0.01.)

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    1 Comment for this article
    Overall suboptimal care
    Daniel Weiss MD CDE FACP PNS CPI | Your Diabetes Endocrine Nutrition Group, Inc.; Ohio University Heritage College of Osteopathic Medicine
    This 55 year old man with Type 2 Diabetes was treated with 2 agents that are limited by the risk of hypoglycemia. It is surprising that his diabetologist failed to offer alternatives that might provide even better glycemic control without the risk of hypoglycemia. Newer agents such as sodium/ glucose co-transporter 2 inhibitors and the GLP-1 receptor agonists would do just that. In fact 1 agent in each of these classes, thus far, has been demonstrated to reduce mortality and cardiovascular events. In addition, these agents promote weight loss and not the weight gain seen with sulfonylureas. And newer basal insulins, as well as the older insulin U-100 insulin glargine, have been shown to cause less nocturnal hypoglycemia than that seen with NPH insulin. No foundation appears to have been provided as to what his primary care doctor should do when his glycemic control deteriorates further, as it surely will. Clinical practice guidelines would dictate, given his age and current health status, much better glycemic control than what was provided by his doctors. This man, in my view, was offered suboptimal care from all his physicians. As an endocrinologist who teaches residents and students, I always engage my patients in shared decision making but I discuss all options.
    CONFLICT OF INTEREST: The author serves on multiple pharmaceutical speaker bureaus that market medications for both Type 1 and Type 2 diabetes.