WASHINGTON — Even in a private subspecialty endocrinology practice, most patients with type 2 diabetes still aren't meeting American Diabetes Association goals for hemoglobin A1c, blood pressure, and lipids, Pardis Dana, M.D., reported in a poster at the annual meeting of the American Association of Clinical Endocrinologists.
“Clearly, a need exists for more aggressive, detail-oriented [diabetes] management with use of far more resources and improved patient compliance, along with more efficacious and better-tolerated pharmacologic considerations,” according to Dr. Dana of the Endocrine and Diabetes Center, Vienna and Woodbridge, Va.
In a report published last year that included data from the 1999–2000 National Health and Nutrition Examination Survey (NHANES), only 7% of 441 study participants with type 2 diabetes met all three goals: hemoglobin A1c below 7%, blood pressure below 130/80 mm Hg, and total cholesterol below 200 mg/dL (JAMA 2004;291:335–42).
Dr. Dana and his associates retrospectively compared outcomes for 334 of their own type 2 diabetic patients with those of the NHANES study, as well as with the American Diabetes Association's guidelines of HbA1c below 7%, BP below 130/80 mm Hg, LDL cholesterol below 100 mg/dL, HDL cholesterol of at least 40 mg/dL, and triglycerides below 150 mg/dL.
The 185 men and 149 women had all made at least three visits per year from January 2000 to December 2003. Statistically significant changes that occurred with subspecialty management included reductions of 1.87 percentage points in HbA1c, 2.56 mm Hg in systolic blood pressure, 29.32 mg/dL total cholesterol, 17.87 mg/dL in LDL cholesterol, and 113.03 mg/dL in triglycerides. Changes in diastolic blood pressure, HDL cholesterol, and BMI were not significant, they reported.
But despite the improvements, only 2% of the patients had achieved all three target goals of the NHANES study at the time of their most recent office visit. For the ADA guidelines, 9% reached all five, 28% reached four, 28% reached three, 22% reached two, 10% reached one, and 3% reached none.
Lack of medication was not the reason: Of the 334 patients, 59% were taking metformin, 40% insulin, 38% thiazolidinediones, 36% sulfonylureas, and 16% nonsulfonylurea secretagogues (8% repaglinide and 8% nateglinide). Of these, monotherapy was used in 25%, two glucose-lowering drugs in 41%, three in 22%, a three-drug regimen plus insulin in 6%, and lifestyle modification in 5%.
As for antihypertensive drugs, 53% were receiving angiotensin-converting enzyme inhibitors, 28% diuretics, 17% angiotensin II receptor blockers, 14% β-adrenergic blocking agents, 12% calcium channel blockers, and 1% α-adrenergic blocking agents. Of these patients, 42% were taking one, 23% two, 8% three, and 3% more than three, while 24% were not taking any antihypertensive drugs.
In the lipid-lowering category, statins were taken by 61%, fibrates by 10%, ezetimibe by 9%, and niacin by 1%. Most (63%) were on monotherapy, while 9% were taking two drugs and 28% weren't taking any, they reported.