2019 ADA Standards of Diabetes Care Unpacked for Primary Care Providers. February 8, 2019

2019 ADA Standards of Diabetes Care Unpacked for Primary Care Providers by Jay H. Shubrook, DO; Neil S. Skolnik, MD
 https://www.medscape.com/viewarticle/908075?nlid=127744_381&src=WNL_mdplsnews_190208_mscpedit_wir&uac=164666HZ&spon=17&impID=1879857&faf=1

The statement comprises two important themes. The first is individualization of care and how to pick medicines. The second is what to use as the first injectable. There are major changes in each of these areas.

      What does ADA mean under 'individualization of care'? I really lost. Does any medical care is not individual for every patient? We all do have something in common when we are healthy or ill. Flu has one set of symptoms, diabetes type 2 has another symptoms. Still, flu and diabetes type 2 can be at the same time, and so it means that treatment must be for this diabetic type 2 with care for flu condition. I understand, maybe I am not clear in writing, but it is obvious that there is no universal therapy for everyone.
       At the same time I wish to say, diabetics type 2 also all different. One has level of sugar in blood 700+ mg/dl, and another diabetic type 2 has 130 mg/dl. Is it is not obvious that they must have different care?  Not so fast. As I see in this publication, there is no such understanding as stages of diabetes, and so ADA never consider that diabetics are not the same, every one is different.
       Now about 'injectables', what does it mean? Many diabetic patient have no one idea that Lantus is Insulin, but every one diabetic know, Insulin is only in injections. So, there is the trick. Naive diabetic type 2 will inject any medicine if it was said that it is insulin and it is good to keep him healthy and well. It is not. In present time there are more and more medicine developed to be injected rather then in tablets. Also insulin come under so many different names that diabetic simple has no one idea that Novolog is insulin and what is difference between Novolog and Lantus or Lantus Solo Star. All three are insulins, all in injections, but two come in pan and one is different administration.
      There are a lot of programs to educate diabetics I name them: To Brain Wash Diabetics. If one will say that Insulin, Lantus Solo Star would prolong function and life, in contrary with SU which will destroy insulin secreting beta cells, then more reasonable diabetic will prefer to take insulin rather then SU. This education never in the program. In program all what medical care team needs, Brain Washing. Why not? Diabetes is wonderful disease, very profitable for medical care team. They all wish to keep it as it is.

The first aspect of individualization of care is choosing the A1c goal. It should be around 7% or less for most patients. But remember: For younger patients with few comorbidities, it can be a lot lower than 7%, and for older patients who have multiple comorbidities, we can be more lenient than that usual 7% goal. An A1c above 8% may even be appropriate for many of our geriatric patients.

      Another interesting aspect of individualization. Normal A1c =4.5%. What is all that dancing around choosing goal? Why goal is not normal level of sugar in blood? As I posted above, diabetic must stay in line, to stay diabetic, to walk from one clinic to another, and carry papers of referrals to every one fellow of prime care team.
       Another important aspect of this goal is that with treatment such as SU and even without treatment for diabetes but with different season, level of sugar in blood will drop. So, it is easy to present that doctor done good job. Now it is not 12. 4% but 10.9%. So, keep going, and sugar will drop down to 7%. It never will. 12.4% is way too high. Without insulin diabetic will not last for long. Still, there are a lot of profit for medical care providers. It is the goal.

Let's move on now to choosing medicines. The first-line medicine, metformin, hasn’t changed. Why?

         Really why? Diabetic in office with A1c = 12.4%. He is first time in office of this provider. So, it is first line of medicine. You must be kidding!!!!!!!!!!! It is ADA. As it is just said, there is nothing changed one year after another. Who really need any changes? Walks for "Stop Diabetes" are most profitable, and healthy BRW. There are donations and grants. Millions $$$$$$$$$$$.

Because it's inexpensive, well tolerated, doesn't cause weight gain, has a low incidence of hypoglycemia, and data show that it has good glucose-lowering efficacy.

       Every diabetic has Metformin in medical box. Most not diabetic also do have Metformin as medicine to prevent weight gain. All pre-diabetics take Metformin. Now, what  Mortality Table of CDC show? Diabetes is number 7 cause of death. Every year 80,000 diabetics die because of diabetes, 100% preventable deaths. About 200,000 diabetics die due to all cause of mortality. As I wish to say, Metformin is very effective medicine to reduce aging human population.

What we all struggle with is what to choose as our second medicine, and this is where the new guidelines provide some very clear advice.

      Sorry about interruption. I did not get the point. Why choose second medicine if first medicine is effective? Just add dose of it, and there is no need in second medicine.  Also, if medicine is effective, rally what does it mean? How it was proved that medicine is effective? For instance, if antibiotics are effective to kill virus then there is no death because of flu. In big scale at least. As it was presented above, Metformin is effective medicine to fight diabetes and to improve diabetic's medical condition. Still, ADA sure, disbetic type 2 will need another medicine, second line. Then third line. And finally very wide coffin.

We start by asking: Does the patient have established cardiovascular (CV) disease, congestive heart failure (CHF), or renal disease?

        Sorry, I still do not get, is this comedy? Whom you are gong to ask, what patient has?  Let me to be clear. At first treatment  was Rx-ed, Metformin, first line medicine. No one question was asked, if patient has healthy liver, or kidney or heart. Now, the question is, how medicine was Rx-ed without testing and knowing the vitals, and whole blood panel? Why there is no any discussions who is diabetic to whom any medicine must be Rx-ed? In my naive mind at first MD must run blood test and see if there are kidney problem. Second, diabetic's kidney all the time effected by diabetes. with or without second line of anti-diabetic medicine. The same as liver and heart. Looks like discussions lead by man without any understanding of subject. But probably it is highly paid job, so.... why not. Every one know all about diabetes type 2.
        I prefer to skip this part. I name all that Cooking Book medicine, first line medicine, and every one next lines medicine by one expression: Junk Medicine. I take no one. Insulin only, Lantus Solo Star. I like that it is easy to administer, it come in pen and easy to carry everywhere I go. It is easy to inject everywhere I am in. It is long acting insulin, easy to find dose and adjust it when I need it.

And if someone has established renal insufficiency, then an SGLT2 is preferred.

      Now, when one come to medical clinic take a look at the legs of ladies (men legs are not open as ladies legs.)  What do you see? Severe edema. Ask those ladies if they take water pills. They do. All elderly people take water pills. They do lost weight. What cause? BTW with time kidney stop to work, and dialyses is only option.
     Thanks a lot. I prefer to carry on my 400 pounds, but be on my legs. Invokana is most severe diuretic.When start to take Invokana pay attention to the heart beat. It will start to beat irregularly. Just prediction. I do not take diuretics. It is too difficult to fight edema.

Shubrook: That is a lot of information. I want to make sure I can summarize this in a way that is useful for our audience. First, we're going to start treating our patients with metformin and lifestyle changes. We're going to individualize our goals. That's not new, but it is important. Second, if someone has CVD, we're going to look at the GLP-1RAs or SGLT2s that have evidence that they reduce CVD. If someone has renal disease—and this is a very important new addition—the SGLT2s have good evidence that they help protect against the progression of renal disease. We also know that the SGLT2s have robust data in support of their use in treating heart failure, above and beyond their effect in diabetes. Is that correct?

       One more to bear in mind. Invokana is very expensive.  But right now it is one of the most popular and hardly advertised medicine to kill diabetics type 2. Families of those who lost type 2 diabetic sent letters to stop Invokana. People who take Invokana die because of CDC. Sometimes there are Black Box in labile for the medicine. There is block Box in labile for Invocana and Metformin. These Black Box come in and then come out.

A fourth key take-home point: If your patient is worried about hypoglycemia, avoid sulfonylureas and insulin.

So, if there is no one medicine to reduce level of sugar then what? Sugar getting up to the hill.

A final key take-home point: If cost is the major issue, think sulfonylurea, metformin, or a TZD.

If you think about money then take what ADA suggest.  If you think about health and well being, try to buy insulin, Lantus Solo Star is bets choice. SU eventually will kill all beta cells wich work now. Metformin will lead to many complications in future. The choice is yours.

via Ravenvoron