Effective diabetes care: a need for realistic targets
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7353.1577 (Published 29 June 2002) Cite this as: BMJ 2002;324:1577All rapid responses
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Dr Winocour’s article raises several points of interest; not all
related solely to diabetes. He should be commended for ascertaining real
life targets. It is important that realistic perspectives on such
guidelines are heard. One point I would raise though regards the
discussion of hypertension. The MICROHOPE study (2) and the recently
updated NICE guidelines (3) both highlight the benefits of ACE inhibitors
in diabetes. These extend beyond the benefits gained simply through
lowering blood pressure. Considering this, perhaps guidelines covering ACE
inhibitors could have been discussed in the article along with some
discussion of the MICROHOPE study.
The other main issue raised is more conecptual. Dr Winocour questions
the practicality of the NSF guidelines. By doing so, he is raising a
familiar issue. In the medical profession, we spend so much time looking
at what we should do that we often fail to focus on the reality of what we
could do. A lot of research is done with the aim of improving practice and
guidelines for best practice are produced based on this research. However,
for many areas of medicine, guidelines are not practical and are
consequently not followed. This manifests itself as widely varying
clinical practice. Surely, this is exactly what guidelines are meant to
avoid. Guidelines have value; of that there is no doubt. This often lies
in defining aims and ideals rather than being a manual for clinical
practice. Which leaves me wondering whether there should be a space for
practical guidelines in addition to the ideals?
1 Winocour P. Effective diabetes care: a need for realistic targets.
BMJ 2002;324:1577-80.
2 Effects of ramipril on cardiovascular and microvascular outcomes in
people with diabetes mellitus: results of the HOPE study and MICRO-HOPE
substudy. Heart Outcomes Prevention Evaluation Study Investigators.
Lancet. 2000 Jan 22;355(9200):253-9.
3 National Institute for Clinical Excellence. Management of Type 2
Diabetes - Renal disease, prevention and early management, February 2002
Competing interests: No competing interests
Editor,
Peter Winocour’s thought provoking article on targets in diabetes
care raises some interesting issues1. He argues that targets for
glycaemia, blood pressure and lipids are unrealistic as only 50% of these
targets were attained in clinical trials, and we know that clinical trials
are far removed from the “real world”. It is clearly worrisome that even
in a relatively affluent area such as Hertfordshire, Dr Winocour struggles
to convince his patients to comply with medication. The problem is
probably significantly worse in deprived inner city areas.
Diabetes care has benefited from the publication of large-scale
randomised controlled trials, so that we now have an abundance of evidence
that treating risk factors can reduce complications by up to 75%. We agree
wholeheartedly with Dr Winocour that targets for glycaemic control need to
be realistic, and individualised to the patient, according to age, other
risk factors, duration of diabetes and patient preference. For example, an
obese middle aged patient with diabetes for 10 years, hypertension,
hypercholesterolaemia, microalbuminuria and needle phobia who has improved
glycaemic control from an HbA1c of 11% to 9% on diet and three oral
hypoglycaemic agents, should not be classed as “failing”. Previously,
diabetes care has been distinctly glucocentric, but more recently, it is
accepted that other factors are perhaps more important.
We disagree, however, with Dr Winocours assertion that blood pressure
and lipid targets should be relaxed or made “more realistic”. Numerous
studies have demonstrated dramatic reductions in complications with
improved blood pressure, with a target blood pressure now being
We fully endorse Dr Winocour’s pragmatic approach to glycaemic
control, which should be encouraged, but we feel strongly that we are
failing our patients if we do not vigorously treat blood pressure, lipids
and try to address smoking.
Dr Tahseen A Chowdhury
Consultant in Diabetes and Metabolic Medicine
Mile End Diabetes Centre
Barts and the London NHS Trust
The Royal London Hospital (Mile End)
Bancroft Road
London E1 4DG
E-mail: Tahseen.Chowdhury@bartsandthelondon.nhs.uk
Dr Shawarna S Lasker
General Practitioner
Oakland Medical Centre
344 Long Lane
Hillingdon
Middlesex UB10 9NL
Competing Interests: None
References
1. Winocour PH. Effective diabetes care: a need for realistic targets. BMJ2002 (June 29); 324: 1577-80
2. Ramsey LE, Williams B, Johnson GD, MacGregor GA, Poston L, Potter JF, et al. Guidelines for management of hypertension: report of the third hypertension working party of the British Hypertension Society. J Hum Hypertens 1999; 13: 569-92
3. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering in 20536 high risk individuals: a randomised placebo controlled trial. Lancet 2002; 360: 7-22
Competing interests: No competing interests
Whilst I accept Dr Winocour’s arguments, the facts as observed in the
UKPDS, DCCT and other studies indicate that accepting blood pressures and
sugars considerably over the 130/80 and 6.5% targets respectively will not
prevent retinopathy, nephropathy or neuropathy.
In practice this means that a patient aged 60 with background retinopathy,
unless these targets can be met or nearly met, will go on to lose vision
from maculopathy.
In a wealthy area such as Sutton Coldfield, most patients can achieve or
nearly achieve these targets, and I therefore think it is unacceptable not
to aim and expect to reach/nearly reach these targets in most patients.
Those patients not reaching the targets develop very severe retinopathy;
these are patients whose diabetes is diagnosed late so they cannot
exercise, or who are poorly compliant despite excellent general
practitioner and practice nurse support, or who have complications from
many years or diabetes.
I realise this is time consuming and expensive. However, if the NHS really
wants to save money it has to start screening for insulin resistance,
screen all at risk patients for diabetes before complications develop, and
to tackle obesity or/and lack of exercise in its very early stages.
Competing interests: No competing interests
It is very refreshing to read Dr. Winocour's article which is very
realistic. Aiming for a target of 4mmol blood glucose level is in fact
harmful to the elderly diabetics due to high risk of hypoglycaemic
attacks. Such patients cannot afford to have hypoglycaemic attacks which
will further harm their already poor mental function.
I personally also feel that giving night dose insulin to elderly patients
to bring down the fasting blood sugar is also unrealistic due to increase
risk of hypoglycaemia at night which is even more harmful as patient will
not be aware of it. I am glad that more and more doctors are now accepting
the fact that post prandial blood sugar is in fact more important than
just the fasting blood sugar and I am glad that recent trials have now
shown that it is even more effective in bringing down Hba1c. I personally
rely more on 2 hr. post prandial blood sugar in managing Type 2 diabetes
especially the elderlies and have been doing so for the past 25 years as a
physician with good outcome.
Since bringing Hba1c down to 7% or below will also reduce macrovascular
complications, it will however be worthwhile trying for that target.
Competing interests: No competing interests
Editor
How refreshing to read a paper with the word 'Realistic' in its title1.
And how gratifying to hear a consultant physician articulating in an
authoritative and informed way the moans and groans I have been sharing
with my GP colleagues over the last few years. The imposed pursuit of
unattainable targets has significantly sapped the morale of those in the
front line - and we thought the situation could only get worse. Perhaps
papers like this will lead to the development of a National Institute for
Pragmatism thorough which all guidelines, NSFs and other intitiatives
should be filtered for reality checking. In which case, I'd like to
suggest it's headed by Dr Winocour.
Keith Hopcroft
General Practitioner
Laindon Health Centre
1 Winocour P. Effective diabetes care: a need for realistic targets.
BMJ 2002;324:1577-80.
Competing interests: No competing interests
Will failing to meet targets fail accreditation?
What a breath of fresh air to read a pragmatic article on management
of whole populations. The current move towards absolute figures which can
be measured and audited is fine at one level. It is hard to find reliable
evidence from primary care of what is consistently achievable with optimal
management in a resource limited health system. When that is known then we
should all aim to meet or better it. However there may be a very real
danger with the new GP contract and re-accreditaion that we may be set
targets based on short lived clinical trials in selected populations.
These may not be achievable. Then what? John Sharvill
Competing interests: No competing interests