New strategy for diabetics ‑ start early on insulin
DIABETICS here may soon benefit from a treatment plan developed in the United States,
which has managed to get more patients to keep their blood at ideal levels than in any other country.
A week ago inBangkok, the American Diabetes Association (ADA) shared its strategy with more 600 doctors from the Asia‑Pacific region. Dr Richard Kahn, ADA's chief scientific and medical officer, said half the diabetic patients in the US have blood sugar levels at 7 per cent or less ‑ the target for good control.
Only one‑third of patients in Singapore achieve that, a level that is already the envy of many. In China and India, for example only 17 per cent hit that target.
Some of the features in the new ADA guidelines ‑ set late last year ‑ are already practiced by doctors here, but the big difference is in the early use of insulin in the US.
Professor John Buse, chief of endocrinology at the University of North Carolina, described insulin as the “most powerful” diabetic medicine. After stringent lifestyle changes, it has the best results in bringing sugar levels down.
The pancreas of diabetics has difficulty producing enough insulin to deal with the sugar in their blood that comes from eating. Giving patients insulin relieves the stress.
But some doctors and diabetics here and in several other countries are resistant to insulin - which has to be injected into patients.
Dr Lee Chung Horn, an endocrinologist in private practice, said general practitioners and polyclinic doctors "are sometimes reluctant to start patient on insulin" as they may not know enough about its use to be comfortable prescribing it. They fear that, administered incorrectly, insulin could lead to hypoglycaemia, where blood sugar is so low, a patient could end up in a coma.
In the primary care setting here, only 5 to 10 per cent diabetes patients are on insulin.
There is also a common misconception that a patient who needs insulin has severe diabetes. Dr. Lee, who chaired the team that produced Singapore's guidelines on treatment of diabetes, said: "People still think using insulin is the death knell, when it actually gives them a fresh lease of life."
At least one doctor here - endocrinologist Stanley Liew of Raffles Hospital ‑ is now thinking of prescribing insulin earlier after hearing the ADA presentation. Among his patients and at public specialist outpatient clinics about one in four is already on insulin. He said perhaps more could benefit from earlier use of insulin.
Other Singapore doctors at the Bangkok meeting agreed that increased use of insulin could make a difference, but it will take a lot of education, of both doctors and patients.
Dr Kahn stressed that the important thing is to get a patient's sugar level to 7 per cent or less. He said: "Exactly how you go about doing it is not as important. "
When doctors are not aggressive enough, the patient continues to suffer the complications of diabetes, which can be life‑threatening.
The ADA guidelines have helped doctors in the US wade through the nine classes of diabetic medicines, each with a, different effect on the body.
This strategy, developed last year in discussions with Europeans and Canadians, has this take-home message: Achieve good control of blood sugar, and do it fast, even if it means piling on a range of medicines.
There are exceptions, however, such as the elderly and very sick.
Extracted from The Straits Times, July 16, 2007
