Treatment of Type 2 Diabetes: One Extreme to Another
In
his article, Dr Havas1
recommends to ignore hyperglycemia in patients with type 2
diabetes mellitus until it becomes symptomatic, and even then
he allows the use of metformin only, in addition to diet and
exercise. I strongly disagree with his recommendations. I
would like to ask Dr Havas if he would prescribe any medicine
if a patient has a fasting blood glucose level between 250 and
300 mg/dL (to convert to millimoles per liter, multiply by 0.0555)
while following a regimen of diet, exercise, and metformin therapy
but is asymptomatic? Roughly what percentage of his patients
with diabetes adhere to weight loss and exercise? For how long
has he put his strategy into practice, and what kind of results
is he seeing on the complications of diabetes in his patients?
I
find the Action to Control Cardiovascular Risk in Diabetes
(ACCORD) trial interesting. To me, the message is clear: if
you focus on reducing blood glucose level by any means without
paying attention to treating insulin resistance, the root cause
of type 2 diabetes, you will have disappointing results in the
prevention of coronary artery disease (CAD) events because insulin
resistance plays a major role in the pathogenesis of CAD. In
the ACCORD trial, physicians were allowed to use any combination
of drugs. When a thiazolidinedione agent was used, it was mostly
rosiglitazone. Compared with rosiglitazone, pioglitazone has
been shown to be not only safe2
but also beneficial for CAD.3-4
Dr Havas seems to ignore these excellent studies on pioglitazone.
He recommends a strategy that is the opposite extreme of that
used in the ACCORD trial, and to me it appears just as harmful,
if not more.
The
results of the ACCORD trial have not changed my practice
pattern at all. For a long time, I have been treating type 2
diabetes by treating insulin resistance. I use a 5-component
strategy that consists of diet, exercise, stress management,
vitamins, and medications, mainly the insulin sensitizers metformin
and pioglitazone. I occasionally use sulfonylurea agents,
meglitinides, exenatide, or sitagliptin, and only as an
add-on to the insulin sensitizers. I almost never use
insulin. With this strategy, I achieve an HbA1c
level of less than 6.5% in the majority of my patients with
type 2 diabetes. I rarely encounter hypoglycemia. Severe
hypoglycemia due to insulin and sulfonylurea agents is one of
the plausible explanations for the unexpected increase in
cardiovascular disease events in the ACCORD study. In contrast
to the ACCORD findings, I see a notable decrease in cardiovascular
disease events. Other complications of type 2 diabetes are also
remarkably decreased.
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Correspondence: Dr Zaidi, Department of Internal Medicine, Jamila
Diabetes and Endocrine Medical Center, 1429 E Thousand Oaks
Blvd, Ste 105, Thousand Oaks, CA 91362 (sjzaidi@verizon.net ).
REFERENCES
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1. Havas S. The ACCORD trial and control of blood glucose
level in type 2 diabetes mellitus: time to challenge conventional
wisdom. Arch Intern Med. 2009;169(2):150-154.
FREE
FULL TEXT
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2. Lincoff AM, Wolski K, Nicholls SJ, Nissen SE. Pioglitazone
and risk of cardiovascular events in patients with type 2 diabetes
mellitus: a meta-analysis of randomized trials. JAMA.
2007;298(10):1180-1188.
FREE
FULL TEXT
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3. Dormandy JA, Charbonnel B, Eckland DJ; et al, PROactive
investigators. Secondary prevention of macrovascular events in patients
with type 2 diabetes in the PROactive Study (PROspective pioglitAzone
Clinical Trial In macroVascular Events): a randomised controlled trial.
Lancet. 2005;366(9493):1279-1289.
FULL TEXT |
WEB OF SCIENCE |
PUBMED
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4. Nissen SE, Nicholls SJ, Wolski L; et al, PERISCOPE
Investigators. Comparison of pioglitazone vs glimepiride on progression
of coronary atherosclerosis in patients with type 2 diabetes. JAMA.
2008;299(13):1561-1573.
FREE
FULL TEXT
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Arch Intern Med. 2009;169(13):1246-1247.
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