As an internist with a busy office practice and a large number of patients with type 2 diabetes mellitus, I was flabbergasted to read the Commentary by Havas1 on the lack of evidence supporting pharmacologic control of blood glucose levels and his recommendation that metformin be the sole oral agent used. Achieving a hemoglobin A1c (HbA1c) level below 7.0% is considered the sole measure of adequate diabetic control, and failure to achieve that mark is considered failure to adequately care for the patient. In fact, Medicare has included HbA1c control as one of its core measures for diabetes care in the recently enacted Physician Quality Reporting Initiative.2 Patients are routinely treated with multiple oral agents at a great expense, which only increases when we add injectable agents to the mix to achieve that elusive goal of an HbA1c level less than 7.0%. They endure adverse effects like nausea and diarrhea, which we pass off as nuisances, and risk hypoglycemia, which could have catastrophic effects. When we suspect that patients are not adherent with their prescribed treatment regimen and have an HbA1c above 7.0%, we consider discharging them from our practices so our data do not look bad. And yet Dr Havas now advocates controlling blood glucose for only the most extreme cases and concentrating our efforts on blood pressure and cholesterol control.
Hirsch R. Changing the Diabetes Treatment Paradigm. Arch Intern Med. 2009;169(13):1241–1247. doi:10.1001/archinternmed.2009.185