UKPDS update: Bagful of medications needed
Control of sugars and hypertension key goals
Type 2 diabetics need as many as 11 drugs to maintain glycemic control and reduce the risk of complications over the average 24 years they live with the disease, researchers analyzing results of the United Kingdom Prospective Diabetes Study (UKPDS) said at the Scientific Sessions of the American Diabetes Association (ADA) in San Diego in June.
British UKPDS investigator Robert C. Turner, MD, from the University of Oxford in England, says intense therapy on a regular basis is the key to maintaining glycemic control and preventing the onset of complications.
Turner says after following the changes of glycemic control in his study participants, it became apparent that drug therapy was effective for about five years. Then the patients get thirsty, problems with blood sugar resurface, and doctors have to move on to using other medication strategies. What may happen, Turner says, is doctors can use up their options and have to go to insulin sooner in the course of treatment, simply because other options have been exhausted. But as a relief to many, insulin therapy did not seem to lead to any increase in the risk of developing cardiovascular disease.
The dramatic results in HbA1c soon began right after treatment started. But after only three months, HbA1c began to creep back up again in patients controlling their disease with diet and exercise alone, while it continued to fall with the drug therapy group.
Turner suggests this course of therapy to keep chasing down indicators of glycemic control (such as HbA1c levels) after diet and exercise alone no longer keeps patients under control:
• Begin with metformin and monitor carefully to see if the effectiveness begins to drop.
• Add sulfonylureas. One small study suggests there may be an increase in complications if the two are used together, but it will take larger studies to establish if the risks exist.
• Go to insulin when HbA1c levels begin to rise again uncontrollably or there are indications of other problems with glycemic control, such as thirst or frequent urination.
Turner’s study did not include the use of thiazolidediones.
Another important goal is to control blood pressure to 135/85 or lower. The UKPDS showed that ACE inhibitors and beta blockers work equally well for this purpose.
Control and/or prevention of hypertension is another key area of concern raised by the UKPDS. Commenting on the hypertension indication of the study at the ADA meeting, James S. Sowers, MD, noted a study adjunct to the UKPDS showed that Type 2 patients under tight control had 44% fewer strokes and 58% fewer fatal strokes. In addition, tight control brought systolic blood pressures down 10 mm Hg and diastolic pressures down 5 mm Hg.
Sowers also noted that hypertension is unique in diabetic patients because blood pressure does not decline at night like it does in nondiabetics, so diabetics are subject to longer periods of sustained hypertension.
Limitations of the UKPDS were noted by David M. Nathan, MD, from Massachusetts General Hospital in Boston. "Therapeutic crossovers made comparisons of individual therapies problematic at best," says Nathan, who continued by noting it is hard to determine which therapies brought which results, since many patients were treated with medications beyond what they started with in order to bring their conditions under control.
He also noted that complications were lumped together, so it would be difficult to determine, for example, how many patients went on to develop a specific complication, like retinopathy, over the long course of the study. "This study has been going on since the time of Moses," Nathan quipped, noting that in reality, Jimmy Carter was president when the 20-year trial began.
UKPDS Drug Shopping List
Here’s the shopping list of drugs needed to control diabetes and limit complications, according the UKPDS study presented to the 59th Scientific Sessions of the American Diabetes Association in San Diego:
| Condition To Control |
|
| Glycemic control
Hypertension Lipids Risks of cardiovascular disease Smoking |
3 1-2 1 (aspirin) 1 (nicotine patch) |
The UKPDS study indicates these goals for diabetes caregivers to set with their patients:
- HbA1c below 7%
- Blood pressure less than 135/85
- LDL below 100 mg/dL
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