Re: “Controlling the complications of diabetes: It’s about the sugar.” 1 The controversy regarding glycemic control is further than ever from resolution. Type 2 diabetes mellitus (T2DM) is a common and growing primary care disease that attracts strong attention from the pharmaceutical industry. While management of T2DM, including diagnosis, treatment, monitoring, lifestyle and long-term patient–doctor relationship, is a primary care field, official guidelines originate from specialists and diabetologists without benefit of a strong primary care perspective. We in the field have repeatedly seen study results interpreted to support more interventions. The research use of relative risk, surrogate and composite endpoints does little to engender faith at the coal face of medicine. The hallmark of good primary care of a T2DM patient comes with understanding the care of the whole patient. Many of our patients are poor, uneducated, obese and suffer from multiple comorbidities. We must accept them as and where they are, moving forward at their pace. This means we need to keep it simple. Metformin and NPH (neutral protamine Hagedorn) insulin adjusted on 3 monthly A1c measurements is doable for most patients. On the other hand, frequent home glucose monitoring, highly advertised by a variety of entertainers at the behest of for-profit companies, is not supported by evidence. Most patients may be better served by discussing a different set of numbers: how many cigarettes they still smoke, the number of minutes of walking or exercise they achieve, how affordable their medications are. As things stand today, with the advertising being married to the clinical practice guidelines, those patients with T2DM who do not frequently measure their blood glucose are made to feel irresponsible at best, despite any evidence to support this. In the long term, this will work against the best interests of many patients.
Footnotes
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For the full letter, go to: www.cmaj.ca/cgi/eletters/181/6-7/357#206053
REFERENCE
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