Are Older T2D Patients Overtreated?

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Gys de Jongh

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Jan 24, 2018, 3:24:53 PM1/24/18
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"Dutch researchers reported"

So,
this can't be fake news

<https://www.medpagetoday.com/endocrinology/diabetes/70707>

Endocrinology > Type 2 Diabetes
Are Older T2D Patients Overtreated?
Possible benefits to de-intensifying glucose-lowering treatment

Older patients with type 2 diabetes may be overtreated, which could lead
to complications, Dutch researchers reported.

In an assessment of level of personalized diabetes treatment for older
patients in primary care, 38.8% of adults, ages ≥70 with type 2 diabetes
and a target HbA1c of >7% were "overtreated," accounting for nearly 20%
of all older patients, according to Huberta Hart, MD, of the University
Medical Center Utrecht in the Netherlands, and colleagues.

Older patients with a target HbA1c of >7% had a significantly higher
rate of complications, they stated in a brief report in Diabetes,
Obesity & Metabolism. They were also more frail compared with those with
a target HbA1c ≤7% (P<0.05 for all):

Microvascular complications: 54.0% versus 35.2%
Macrovascular complications: 33.3% versus 17.7%
Use ≥5 medications: 87.3% versus 53.2%
Frail prevalence: 44.2% versus 13.9%
"The beneficial effects of stringent glycated hemoglobin (HbA1c) goals
in older patients with long-existing type 2 diabetes and vascular
complications are not proven," the authors wrote, adding that "the risk
of harm associated with an HbA1c target lower than the conventional 7%
(53 mmol/mol) seems to outweigh the possible benefits for adults aged
≥70 years."

Remus Pohl

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Jan 24, 2018, 7:54:03 PM1/24/18
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On 1/24/2018 3:24 PM, Gys de Jongh wrote:
> "Dutch researchers reported"
>
> So,
> this can't be fake news
>
> <https://www.medpagetoday.com/endocrinology/diabetes/70707>

Why is it bad to overtreat?

Andrew B. Chung, MD/PhD

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Jan 24, 2018, 8:21:51 PM1/24/18
to
Remus Pohl asked:
> Gys de Jongh wrote in part:
>> "Dutch researchers reported"
>>
>> So,
>> this can't be fake news
>>
>> <https://www.medpagetoday.com/endocrinology/diabetes/70707>
>
> Why is it bad to overtreat?

For T2D patients, overtreating increases the risk of hypoglycemia (low
blood glucose) which can be lethal.

Nonetheless, I am wonderfully hungry ( http://bit.ly/Philippians4_12 )
and hope you, Remus, also have a healthy appetite too.

So how are you ?




... because we mindfully choose to openly care with our heart,

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--
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2016 & upwards non-partisan candidate for U.S. President:
http://bit.ly/WonderfullyHungryPresident
and author of the 2PD-OMER Approach:
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which is the only **healthy** cure for the U.S. healthcare crisis

F00

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Jan 24, 2018, 9:02:23 PM1/24/18
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It really has to do with the method(s) used to treat the condition.

Increasing medications, whether that is insulin or other drugs,
in order to accommodate overeating and/or eating badly leads to
the results that have been reported. This is quite simply a
variation on "correlation is not causation."

I had a PCP, now retired, to swore by some studies that seemed to
indicate that fat/grease was the primary problem that leads to heart
attacks, when later, better, studies have showed that carbohydrates
are the cardinal sin for everyone.

Even earlier I had a PCP who swore that eating more than 2 eggs a week
led to dire outcomes.

Such examples are endless. The old Shanghai-la model worked for the
people in the story, and it works exceptionally well for diabetics,
moderation! But even moderation needs to be realistic.

I don't buy that an A1c of 7.0 is a magic number for everyone under
all circumstances. There are far too many unresolved and unincluded
variables that make the "study" fake news. A *lot* of damage happens
at an A1c of 7.0, and actually even lower than that. But anyone who
is willing to pay the consequences can be happy with that number, so
long as they actually understand those consequences and know what is
going to happen to them.

Remus Pohl

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Jan 24, 2018, 10:15:29 PM1/24/18
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How can anyone "know" the consequences, when even the PCP's you cited
didn't get it right in what they were suggesting,

Bottom line is 1) outcomes depend on the individual, and 2) the best way
to prevent the bad consequences of uncontrolled T2DM is a combination of
a) control of food intake,
b) vigorous exercise, and c) medication.

T2DM has been know since antiquity. How did the Romans deal with it?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707300/

"Cacatio Matutina Est Tamquam Medicina." - Anonymous Roman Physician

The non-insulin medications have come about only in approximately the
last 75 years.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3714066/

Despite that, there are some who suggest that outcomes have already been
predetermined by genetics.

"Every man is the artisan of his own fortune." - Appius Claudius Caecus

"



Andrew B. Chung, MD/PhD

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Jan 25, 2018, 4:34:23 AM1/25/18
to
F00 wrote:
> Remus Pohl asked:
>> Gys de Jongh wrote:
>>
>>> "Dutch researchers reported"
>>>
>>> So,
>>> this can't be fake news
>>>
>>> <https://www.medpagetoday.com/endocrinology/diabetes/70707>
>>
>> Why is it bad to overtreat?

"For T2D patients, overtreating increases the risk of hypoglycemia
(low blood glucose) which can be lethal. "

Source:
https://groups.google.com/d/msg/alt.support.diabetes/MBrn-dnCF8Y/qsjgpgWTBAAJ

> It really has to do with the method(s) used to treat the condition.
>
> Increasing medications, whether that is insulin or other drugs,
> in order to accommodate overeating and/or eating badly leads to
> the results that have been reported. This is quite simply a
> variation on "correlation is not causation."

Actually, the medications are being increased to achieve a target
HgbA1c of less than 7.0% instead of "to accommodate overeating."

Sadly, few of my fellow physician researchers (aka medical scientists)
are aware of their own overeating much less whether their patients are
overeating.

Nonetheless, I am wonderfully hungry ( http://bit.ly/Philippians4_12 )
and hope you, F00, also have a healthy appetite too.

Gys de Jongh

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Jan 25, 2018, 3:37:24 PM1/25/18
to
Hi Remus Pohl welcome to Asd

In this contex "overtreated" means die sooner
which by some is regarded as "bad"

Gys

Andrew B. Chung, MD/PhD

unread,
Jan 25, 2018, 4:44:22 PM1/25/18
to
Gys de Jongh wrote:
> Remus Pohl wrote:
>> Gys de Jongh wrote:
>>
>>> "Dutch researchers reported"
>>>
>>> So,
>>> this can't be fake news
>>>
>>> <https://www.medpagetoday.com/endocrinology/diabetes/70707>
>>
>> Why is it bad to overtreat?
>
> Hi Remus Pohl welcome to Asd
>
> In this contex "overtreated" means die sooner

Correct.

> which by some is regarded as "bad"

All physicians are trained to regard dying sooner as "bad."

Nonetheless, I am wonderfully hungry, despite the morbid context, and
hope you, Gys, also have a healthy appetite too, despite the sarcasm.

Remus Pohl

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Jan 25, 2018, 9:03:07 PM1/25/18
to
What evidence supports the association of higher patient mortality
with over-treatment?



Andrew B. Chung, MD/PhD

unread,
Jan 25, 2018, 10:30:37 PM1/25/18
to
Remus Pohl asked:
> Gys de Jongh wrote:
>> Remus Pohl asked:
>>> Gys de Jongh wrote:
>>>
>>>> "Dutch researchers reported"
>>>>
>>>> So,
>>>> this can't be fake news
>>>>
>>>> <https://www.medpagetoday.com/endocrinology/diabetes/70707>
>>>
>>> Why is it bad to overtreat?
>>
>> Hi Remus Pohl welcome to Asd
>>
>> In this contex "overtreated" means die sooner
>> which by some is regarded as "bad"
>
> What evidence supports the association of higher patient mortality
> with over-treatment?

The earliest clinical research evidence of the "higher rate of
mortality" with overtreatment comes from the ACCORD trial:

"February 6, 2008 (Bethesda, MD) – The blood-glucose-lowering part of
the ACCORD trial in patients with type 2 diabetes at especially high
risk of heart disease has been stopped prematurely because of a higher
rate of mortality in the patients in the intensive arm vs that in the
standard arm [1]."

Source:
https://www.medscape.com/viewarticle/569835

Again, I am wonderfully hungry ( http://bit.ly/Philippians4_12 ) and
again hope you, Remus, also have a healthy appetite too.

So again, how are you ?

Gys de Jongh

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Jan 26, 2018, 2:50:51 AM1/26/18
to
In the now famous ACCORD Trial the research was baffled by the outcome.
In fact the trial was halted premature because it was decided unethical
to proceed.

3458 Citing Articles !!!!

The inhabitants of Asd discussed this trial intensively and concluded
that this would not happen to them and that the worse outcome was solely
due to the used medication. They would stick to Low-Carb diet and survive.

There are a lot of, free articles in Pubmed with ACCORD in their title
in the follow up studies. A clear reason was never found and hypo's
caused by insulin was excluded, Iirc

The Trial :

<https://clinicaltrials.gov/show/NCT00000620>

Action to Control Cardiovascular Risk in Diabetes (ACCORD)
Study Description
Brief Summary:
The purpose of this study is to prevent major cardiovascular events
(heart attack, stroke, or cardiovascular death) in adults with type 2
diabetes mellitus using intensive glycemic control, intensive blood
pressure control, and multiple lipid management.

The first publication of the trial :

<http://www.nejm.org/doi/full/10.1056/NEJMoa0802743>

25 References
3458 Citing Articles
1 Letter

Effects of Intensive Glucose Lowering in Type 2 Diabetes
The Action to Control Cardiovascular Risk in Diabetes Study Group*
June 12, 2008
N Engl J Med 2008; 358:2545-2559
DOI: 10.1056/NEJMoa0802743

Abstract
BACKGROUND
Epidemiologic studies have shown a relationship between glycated
hemoglobin levels and cardiovascular events in patients with type 2
diabetes. We investigated whether intensive therapy to target normal
glycated hemoglobin levels would reduce cardiovascular events in
patients with type 2 diabetes who had either established cardiovascular
disease or additional cardiovascular risk factors.

METHODS
In this randomized study, 10,251 patients (mean age, 62.2 years) with a
median glycated hemoglobin level of 8.1% were assigned to receive
intensive therapy (targeting a glycated hemoglobin level below 6.0%) or
standard therapy (targeting a level from 7.0 to 7.9%). Of these
patients, 38% were women, and 35% had had a previous cardiovascular
event. The primary outcome was a composite of nonfatal myocardial
infarction, nonfatal stroke, or death from cardiovascular causes. The
finding of higher mortality in the intensive-therapy group led to a
discontinuation of intensive therapy after a mean of 3.5 years of follow-up.

RESULTS
At 1 year, stable median glycated hemoglobin levels of 6.4% and 7.5%
were achieved in the intensive-therapy group and the standard-therapy
group, respectively. During follow-up, the primary outcome occurred in
352 patients in the intensive-therapy group, as compared with 371 in the
standard-therapy group (hazard ratio, 0.90; 95% confidence interval
[CI], 0.78 to 1.04; P=0.16). At the same time, 257 patients in the
intensive-therapy group died, as compared with 203 patients in the
standard-therapy group (hazard ratio, 1.22; 95% CI, 1.01 to 1.46;
P=0.04). Hypoglycemia requiring assistance and weight gain of more than
10 kg were more frequent in the intensive-therapy group (P<0.001).

CONCLUSIONS
As compared with standard therapy, the use of intensive therapy to
target normal glycated hemoglobin levels for 3.5 years increased
mortality and did not significantly reduce major cardiovascular events.
These findings identify a previously unrecognized harm of intensive
glucose lowering in high-risk patients with type 2 diabetes.
(ClinicalTrials.gov number, NCT00000620.)



Don Roberto

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Jan 26, 2018, 2:56:25 AM1/26/18
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Hi there! I see you are still asking silly questions

Don Roberto

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Jan 26, 2018, 3:11:31 AM1/26/18
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The same evidence that supports the association of higher mortality of a
Remus who has a brother named Romulus.
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