Monday, August 05, 2013


The management of diabetes has improved by leaps and bounds. We now have so many agents to fine tune our control of diabetes. The controversy remains that diabetologist remain fixated on numbers, HbA1c, fasting sugars, 2hr PP sugars, 1hr PP sugars, whereas cardiologist focus on outcomes, MACCE.
Now with their good treatment regime, in an attempt to get optimal control and normalise blood sugars, diabetologists have run into a new problem. ( well no so new ). The issue is one of hypoglycemia. In the ADVANCE and ACCORD, a significant number died from hypoglycemia.
Just to emphasize this point, the 30th July issue of the British Medical Journal carried an article by a consortium of workers who looked into the issue of serious hypoglycemia and the risk of CV disease. The researchers led by Dr Mitsuhiko Noda of Tokyo, from the National Center for Global Health in Medicine, looked into 6 large clinical trials, through Medline, Embase, and Cochrane Library database. They were looking into the relationship between severe hypoglycemia and CVS disease.
After reviwing the records of 903,510 patients with 5 years followup, on diabetic treatment, they found that severe hypoglycemia was associated with a relative risk of 2.05 of CVS. The p value was 0.001.
Looks like the presence of hypoglycemia, in patients on oral hypoglycemics and insulin, carries a high risk of more CV events.Some possible explanation includes the presence of increase SNS tone and so more stress on the CV system. There will obviously be increase inflammatory molecules with hypoglycemia.
On a personal level, I have seen somediabetologist trying to advocate almost hour to hour sugar monitoring and 3 x a day rapid insulin on top of oral hypoglycemics and also basal insulin ( just saw one such ptient last Friday ). I must say that I am very worried for this patient. His sugars are swinging from 7 - 4 mMols / L. Of course he has episodes of hypoglycemia. I think that it is crazy. Of course I began preaching my lesson for reasonable control.
This hypoglycemia thing is a real problem in the real world. I wish that my diabetoogist colleagues will have better evidence before advocating normalising blood sugars, to see the benefit, and not just use UKPDS alone.
I worry for normalising blood sugars in diabetics.

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