Diabetes drugs may do more harm than good
“First do no harm” is the maxim that doctors try to live by. For people with type 2 diabetes, this could mean a rethink of the treatment they receive.
The side effects of diabetes medication and the necessity for frequent injections mean that taking the drugs could be counterproductive, especially for older people, suggests a study published yesterday.
The researchers conclude that doctors should stop automatically recommending drug treatment for the two-thirds of diabetics whose blood sugar is only slightly raised. Instead, patients should be able to decide for themselves if they think the hassle and side effects are worth it.
“We need to rethink our whole treatment strategy,” says Richard Lehman, a family doctor in Banbury, UK, who was not involved in the study.
Type 2 diabetes usually develops in middle age, often in people who are overweight, when their bodies stop responding properly to insulin. This hormone controls the amount of glucose in the blood, so when things go awry, blood sugar levels can skyrocket. People with the condition are more likely to suffer heart attacks, kidney and nerve damage, and blindness.
If people can’t lose weight through diet and exercise to regain their insulin function, doctors usually prescribe an oral drug called metformin. If this doesn’t lower blood sugar sufficiently, insulin injections and drugs called incretins are also prescribed.
Hypo danger
Metformin’s side effects tend to be mild and temporary but insulin and incretins can cause longer-term problems, such as weight gain and nausea.
More dangerously, they can also cause “hypos”, when blood sugar drops too low, causing disorientation and fainting. In severe cases, people can fall into a coma. “More people are now admitted to hospital in the US for low blood sugar than for high,” says John Yudkin of University College London, who co-authored the latest work.
People taking insulin also have to inject themselves several times a day, as well as carry out regular finger-prick tests of blood sugar, a burden that can weigh heavy on some people, says Lehman.
Despite these issues, doctors have increasingly prescribed insulin and incretins over the past decade, reflecting the consensus that blood sugar levels should be kept under tight control.
For example, in the UK, the number of people with type 2 diabetes injecting insulin increased from 37,000 in 1991 to 277,400 in 2010.
However, there is little evidence that strict blood sugar control prevents health problems linked with diabetes. One trial showed the approach reduced heart attacks by 15 per cent, but the participants were younger on average than a typical person with diabetes. Three trials done in relatively older people have shown no benefits. One even showed the approach increased deaths.
Net gain for life?
In the latest study, a team led by Sandeep Vijan at the University of Michigan, Ann Arbor, used the data from those four trials, as well as other information about the drugs, to work out the net gains or losses to people’s quality of life.
Their model suggests that a 45-year-old with only slightly raised blood sugar who begins drug treatment would gain up to 10 months of healthy life. A 75-year-old, on the other hand, would gain only about an extra three weeks.
Age matters because the chance of an older person, with perhaps five years of life ahead of them, developing one of the health complications of diabetes is lower than that of a younger person with, say, 35 years. Therefore older people taking diabetes medication get less benefit from taking it, but all the side effects and hassle. “The person who’s best able to decide whether or not [the extra weeks or months of lifespan] are worth years of pills and injections is the patient,” says Yudkin.
“This study highlights the importance of looking at the individual needs of the person with type 2 diabetes, rather than adopting a blanket approach,” says Simon O’Neill, director for health intelligence for Diabetes UK. “It also underlines how vital it is that healthcare professionals and people with diabetes work closely together to jointly decide what the best treatment options are for that person and weighing up the potential benefits and side effects, which will vary from person-to-person”.
The previous studies had aroused the suspicion people were being overmedicated, says Lehman. This latest meta-analysis could be the clincher. “This really will change practice,” he says.
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