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Teachable Moment | Less Is More

Intensive Glycemic Control in Type 2 Diabetes Mellitus—A Balancing Act of Latent Benefit and Avoidable Harm A Teachable Moment

Rene Rodriguez-Gutierrez, MD1,2; Kasia J. Lipska, MD3; Rozalina G. McCoy, MD, MSc4,5
[+] Author Affiliations
1Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
2Endocrinology Division, Department of Internal Medicine, University Hospital “Dr Jose E. Gonzalez,” Monterrey, Mexico
3Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
4Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
5Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
JAMA Intern Med. 2016;176(3):300-301. doi:10.1001/jamainternmed.2015.8320.
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This Teachable Moment provides an example of how patient-centered care and shared decision-making require a comprehensive and transparent discussion between patient and physician of known risks, benefits, costs, and burden of available and reasonable treatment options.

Article InformationCorresponding Author: Rozalina G. McCoy, MD, MSc, Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, 200 First St SW. Rochester, MN 55905 (mccoy.rozalina@mayo.edu).

Published Online: February 15, 2016. doi:10.1001/jamainternmed.2015.8320.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Lipska receives support from the National Institute on Aging (NIA) as a Paul Beeson Career Development awardee and from Centers for Medicare & Medicaid Services (CMS) to develop and maintain publicly reported quality measures. In addition, this work was made possible with the support from the NIA as a Paul Beeson Career Development awardee and from the CMS to develop and maintain publicly reported quality measures.

Role of the Funder/Sponsor: The NIA and CMS had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIA.

Additional Contributions: We thank the Patient Advisory Group, a voluntary group of patients with diabetes mellitus from the community; since 2004, they have met with researchers from the Knowledge and Evaluation Research (KER) Unit at Mayo Clinic to aid and direct their work on what matters to patients. The discernment developed herein would not have been possible without their generous contribution to the science of patient-centered healthcare. We thank the patient for granting permission to publish this information.

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Overall suboptimal care
Posted on April 3, 2016
Daniel Weiss MD CDE FACP PNS CPI
Your Diabetes Endocrine Nutrition Group, Inc.; Ohio University Heritage College of Osteopathic Medicine
Conflict of Interest: The author serves on multiple pharmaceutical speaker bureaus that market medications for both Type 1 and Type 2 diabetes.
This 55 year old man with Type 2 Diabetes was treated with 2 agents that are limited by the risk of hypoglycemia. It is surprising that his diabetologist failed to offer alternatives that might provide even better glycemic control without the risk of hypoglycemia. Newer agents such as sodium/ glucose co-transporter 2 inhibitors and the GLP-1 receptor agonists would do just that. In fact 1 agent in each of these classes, thus far, has been demonstrated to reduce mortality and cardiovascular events. In addition, these agents promote weight loss and not the weight gain seen with sulfonylureas. And newer basal insulins, as well as the older insulin U-100 insulin glargine, have been shown to cause less nocturnal hypoglycemia than that seen with NPH insulin. No foundation appears to have been provided as to what his primary care doctor should do when his glycemic control deteriorates further, as it surely will. Clinical practice guidelines would dictate, given his age and current health status, much better glycemic control than what was provided by his doctors. This man, in my view, was offered suboptimal care from all his physicians. As an endocrinologist who teaches residents and students, I always engage my patients in shared decision making but I discuss all options.
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