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Treatment burden outweighs health improvement for some patients with type 2 diabetes
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Patients with type 2 diabetes do not always perceive a lifetime health benefit from glucose control due to the burden of treatment modalities, according to a new model published in JAMA Internal Medicine.
“For people with type 2 diabetes, the goal of managing blood sugar levels is to prevent associated diabetes complications, such as kidney, eye and heart disease, but it is essential to balance complication risks and treatment burdens when deciding how aggressively to treat blood sugars,” Sandeep Vijan, MD, MS, professor of internal medicine at the University of Michigan Medical School and research scientist at the Center for Clinical Management Research at the VA Ann Arbor Healthcare System, said in a press release. “If you’re a patient with fairly low complication risks, but are experiencing symptoms from low blood sugar, gaining weight or find frequent insulin shots to be disruptive to your daily life, then the drugs are doing more harm than good. Prescribing medicine isn’t just about reducing risks of complications, but also about helping patients improve their quality of life.”
Vijan and colleagues used a previously published Markov model of diabetes to estimate the health benefits of glycemic control, along with data from randomized and observational studies and simulated patients with type 2 diabetes from the National Health and Nutrition Examination Survey. To examine the burden of treatment, researchers used the concept of utility; for example, previous studies pinned a disutility of 0.02 to 0.12 on insulin treatment, equivalent to the loss of 7 to 44 days of quality of life per year, according to the study. Other disutilities considered were weight gain and gastrointestinal adverse effects, but did not account for out-of-pocket expenses.
Despite “optimistic” estimates of beneficial treatment, Vijan and colleagues reported that the best-case scenarios of improved insulin treatment were canceled out by the treatment burden (0.05) commonly put on insulin treatment, with the model predicting these patients would lose between 0.653 and 0.818 quality-adjusted life years. Even a small measurement of treatment adverse event would “result in net harm in older patients,” the researchers wrote, since glycemic control produces only “modest benefits.”
These risk–benefit scenarios varied depending upon age at diagnosis, medication used, pre-treatment HbA1c levels, patient view of treatment burden and cardiometabolic complications, the researchers wrote. They suggested that their outcome-specific absolute risk reduction estimates for myocardial infarction and end-stage renal disease may be more useful to practitioners.
“Drugs that lower blood sugar levels are extremely beneficial in some patients but offer almost no benefit for others. These results have major implications for the millions of people who are currently being told that they need to increase medication in order to achieve their ‘glucose goal,’” Rodney Hayward, MD, professor of medicine in the University of Michigan Medical School and senior research scientist at the Center for Clinical Management Research at the VA Ann Arbor Healthcare System, said in the release. “Current quality measures do not allow doctors and patients to make good decisions for each patient because they emphasize reaching targets instead of thinking of the risks and benefits of starting new medications based on individual circumstances and preferences.”
Disclosure: The researchers reported no relevant financial disclosures.
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