HgbA1c goal of 7 – dangerous

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Category : Medical Rants

Recently we had a patient admitted for hypoglycemia.  He had long standing type II diabetes mellitus being treated with metformin, glyburide and twice daily 70/30 insulin.  He had had several hypoglycemic episodes previously at home.

The admission and management caused no problem and the patient was ready for discharge the next day.  However, we then asked the most important question – why?

Why did this patient develop repeated episodes of hypoglycemia?

I suspect that his primary care physician was trying desperately to achieve a HgbA1c of less than 7.  I doubt that the physician added drugs because he thought the patient needed them, but rather because someone (an insurance company or a clinic manager) told him that the patient's HgbA1c was too high.

This patient likely represents one of the problems with poorly considered performance measures.

Achieving a low HgbA1c or BP or LDL has challenges.  Often we must use more medications.  Usually we are not treating the patient as much as we are treating the patient.

Adding drugs to try to achieve a goal does increase the rate of complications.  The more drugs, the more complications.  The higher dose of drugs, the more complications.

PRIMUM NON NOCERE

Comments (2)

It is not the goal of an HgbA1c of less than 7 (or actually under 6.5 as recommended by the American Association of Clinical Endocrinologists) which was the danger. The dangerous act which probably caused the hypoglycemia was trying to reach this goal with inappropriate medications, such as using a mixed insulin. (Adding Glyburide to such a regimen was also a mistake, but it is also possible that such a patient on insulin might not have even had enough beta-cell function left for the Glyburide to do much. )
When insulin is used properly (using a long acting insulin separately from short acting pre-meal insulin) it is not difficulty to achieve a HgbA1c under 6.5. Using insulin in this manner not only results in better control of blood sugar–it also carries a far lower risk of hypoglycemic reactions. Using 70/30, a patient is most likely to alternate between high and low readings.

Dr Centor I cant agree more. I saw a patient in clinic today with the same problem but "his performance measure" was on goal.

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