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Experts say the balance between drugs, insulin and lifestyle needs to be considered when developing the treatment plan.
Treating type 1 and type 2 diabetes with medications is more complicated than you think.
And finding the right balance can be more difficult than expected.
A recent study concluded that some people with diabetes are overworked and that their treatment plan is too intense.
Some previous research has shown that the majority of people with type 2 diabetes are not treated aggressively enough and do not see an improvement in their blood glucose.
However, the most recent study indicates that a number of people taking insulin or other diabetes medications have hypoglycaemia (hypoglycaemia) severe enough to send them to emergency rooms.
The research found that when patients in the United States were receiving more medications than needed to reach their HbA1c goals, they directly contributed to 4,774 hospitalizations and 4,804 emergency visits in two years.
Research estimates that about 20% of adults with diabetes in the United States are over-treated, especially those with type 2 diabetes. This means that about 2.3 million people have been over-treated between 2011 and 2014, explained the study.
"It's not a revolutionary science," Dr. Rozalina McCoy, an endocrinologist and primary care physician at Mayo Clinic in Minnesota, and senior researcher at Healthline told Healthline.
"But this demonstrates the real human impact of too intensive a treatment in a diabetic patient," she explained.
"We know as clinicians that we should not over-treat older patients or those with multiple health problems, but other patients may also be over-treated. The consequences for a patient's life are real, especially if they end up in an emergency room. "
Although a person can take a medicine against oral or injectable diabetes or get insulin injected to treat diabetes, the way these drugs work is very different.
In addition, the amount of insulin a person needs for different times of the day or different aspects of blood sugar management varies.
The amount of medication or insulin a person needs is a function of a number of variables, including weight, age, activity level, diet, stress and overall function of beta cells.
These factors largely determine whether a person with type 2 diabetes will eventually need insulin.
"Even though type 1 diabetes is extremely difficult to live with and very complicated, we at least understand why hypoglycemia occurs," said McCoy, "and as clinicians, we generally know where to start to adjust their treatment so to reduce these serious and recurrent hypoglycemic events. "
She added, "With type 2 diabetes, it is much harder to pin down the exact problem, especially when A1c is still high, but patients have frequent hypoglycaemia and take multiple medications."
McCoy said that many clinicians do not realize how much a person with type 2 diabetes can easily suffer from hypoglycemia. Overall, the rate of hypoglycemia in people with type 2 diabetes is lower than in those with type 1, but its frequency in people with type 2 is higher than what we thought before.
"A problem that contributes to the problem is that the risk of hypoglycemia in a patient with type 2 diabetes does not come right after the diagnosis," McCoy explained.
"In the first place, they try to manage their diabetes through a diet, exercise and metformin, which can not cause hypoglycemia."
In a person with type 1 diabetes, McCoy said that hypoglycemia was expected and was essentially part of the diagnostic program.
A person with type 1 diabetes immediately receives information about the signs and symptoms of hypoglycemia, what may be causing it, how to treat it, and how to prevent it from occurring too frequently.
A person with type 2 diabetes will only be reimbursed financially through their health insurance plan if they meet a diabetes educator for a specific number of years after the initial diagnosis.
By the time they start taking more intensive medications for diabetes or insulin, the opportunity for extensive training on blood glucose management can be minimal because of the costs.
"Only a small fraction of type 2 patients receive adequate education because there are not enough diabetes educators, not enough time with practitioners and not enough financial reimbursement in the years to come when they start to take insulin, "said McCoy.
"The risk of hypoglycemia in a patient with a low A1c is actually very low, as they usually do not follow an intensive treatment plan," she added.
McCoy, says McCoy, the higher the risk of hypoglycemia is, because this person's doctor could intensify his treatment by increasing the dosage or adding drugs to lower his blood sugar level.
People with type 1 diabetes learn how to count carbohydrates and how to adjust their insulin dosage based on the amount of food they want to eat.
One unit of too much or too little can easily lead to high or low blood sugar, but people with type 1 are taught to wait for these fluctuations and encourage them to control their blood sugar several times a day to cope better to this type of challenge.
People with type 2 diabetes are not encouraged to routinely check their blood glucose levels. They may take their insulin as prescribed, but they may not understand how important it is for the amount of food they eat to match the insulin dose or how to adjust it. if they do not want to eat so much.
Too often, type 2 people are asked to take an amount of "X" insulin at each meal, which means that they will need to eat an "X" amount of carbohydrate to reach that insulin dose.
This creates an "insulin supply" problem, which can lead to overeating, weight gain, and dangerous fluctuations in blood glucose levels when you are not eating enough to meet the insulin dose.
"It is presumed that type 2 diabetes is easier to manage than type 1 diabetes, but as soon as a type 2 patient is prescribed insulin, we should start treating them more like patients with type 1 diabetes, "said McCoy.
"One of the most important things I do with insulin-like type 2 patients is to 'undo' the prescribed insulin dose and the amount of carbohydrate at each meal," McCoy said.
"Instead, if they do not want to learn how to count carbohydrates and adjust the insulin dose in particular, we are talking about the meal dosage in more general terms of" small "or" big "meal with insulin. options for each size. It is always better to force a patient to eat a certain amount of food to cover the amount of insulin he is supposed to take, anyway, "she explained.
Gary Scheiner, CDE, author and head of Integrated Diabetes Services in Wynnewood, Pennsylvania, agreed with McCoy's assessment … to some extent.
"Glucose targets need to be individualized based on the patient's capabilities, risks and limitations," Scheiner told Healthline.
"Tightening does not always mean better, for example in patients at risk of falls, such as the elderly or unconscious hypoglycemic agents during which they can not physically feel the symptoms of hypoglycemia, those who exercise a risky profession the children. "
Scheiner, meanwhile, argues that for some people, more intensive treatment is worth it and that the risks of lowering blood sugar levels are integral to the search for a healthier blood sugar level.
"For patients with diabetes complications such as retinopathy, patients in early pregnancy or patients seeking to optimize their athletic performance, for example, tighter control is usually desirable."
Scheiner added that one of the biggest mistakes in his opinion is to assume that strict control of blood glucose and a lower A1c automatically reduce the long-term risk of developing a complication.
"This is just not true," Scheiner said. "Many factors contribute to complications – not just blood sugar – and there is a time when there is no benefit in tighter control. It's like taking 10 aspirins for a headache instead of two.
"And of course, there is a point where the risks outweigh the benefits. For a person taking insulin, using a continuous glucose meter has "changed the curve" by alerting patients to the approach of their hypoglycaemia so that they can prevent more severe hypoglycemia. he noted.
Again, it's about individualizing the patient's treatment plan, which can not be done properly in a five-minute appointment.
"Managing diabetes with a unique approach will not work," said McCoy.
"I have the luxury of having 30-minute appointments at the Mayo Clinic and sometimes that's not enough yet. What does the patient's life look like? What are their resources and support system? How can we help them safely integrate their diabetes into their routine?
To actually reduce the number of hospital visits related to hypoglycemia, the most important problem to solve can go far beyond changing the way doctors prescribe insulin. Instead, they may need more time with their patients.
"An appropriate treatment plan," explained McCoy, "depends on a good relationship with the patient."
Ginger Vieira is an expert patient with type 1 diabetes, celiac disease and fibromyalgia. Find his books on diabetes on Amazonand connect with her on Twitter and Youtube.
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