Exploring Glycemic Challenges With Experts in T2DM
Learn about the early damage that can be caused by hyperglycemia in this video hosted by Dr. Robert Busch. Also, did you know that delays in treatment intensification can leave patients with elevated glucose levels for many years?
One of the important themes of this video series is the need to understand the underlying pathology of diabetes when patients are not meeting their glycemic goals. As we know, prolonged hyperglycemia can lead to serious consequences. Even before their diagnosis, many patients have already faced years of high blood glucose levels. In addition, treatment delays may cause many patients to continue to experience lengthy periods of hyperglycemia. Let’s look at just how early hyperglycemia affects the body. By the time a patient with type 2 diabetes is diagnosed, they may have already experienced years of negative consequences related to their hyperglycemia.
Data from the United Kingdom Prospective Diabetes Study, or UKPDS, point to this early damage. The data generated implies that β-cell damage due to hyperglycemia was evident approximately 10 years before diagnosis. Their observations suggested that about 50% of β-cell function is lost before diabetes is typically diagnosed in patients.
Furthermore, a separate study of patients with retinopathy of unknown etiology suggested that some patients may experience hyperglycemic damage to their eyes for as long as 4 to 6 years before diabetic retinopathy is diagnosed.
While there’s no way to prevent the damage done by hyperglycemia before our patients are diagnosed with diabetes, after diagnosis we act. We monitor our patients regularly. We encourage lifestyle modifications like healthier eating, weight control, increased physical activity, and diabetes education. We prescribe pharmacotherapies.
We do all of these things to help patients meet their glycemic goals. Maintaining appropriate glucose levels can help reduce the risk of microvascular and macrovascular complications associated with hyperglycemia. Even so, a large proportion of treated patients are not meeting the A1C goals recommended by the guidelines.
In fact, patients often experience prolonged periods of elevated A1C before the intensification of their treatment regimens. Illustrating this is a large, retrospective cohort study of patients with type 2 diabetes who were taking 1 oral antidiabetic and were not reaching typical glycemic targets—between 7% and 8%. Despite their elevated A1C, treatment was not intensified with an additional OAD for 1.6 to 2.9 years. The same study revealed even longer delays to initiate insulin, finding that patients uncontrolled on 3 or more OADs were not initiated on insulin until 6 to 7 years after exceeding their A1C targets.
The potential result of this prolonged exposure to high blood glucose is the risk of negative consequences. As we’ve seen, damage can start during the decade before diagnosis, and risk may be elevated during years of treatment, if they remain uncontrolled.
Therefore, recognizing the potential impact of prolonged hyperglycemia, we want to do all that we can to help manage type 2 diabetes in our patients. In doing so, we may consider different approaches to help patients reach their glycemic targets. The ADA and AACE guidelines recommend the use of combinations of oral therapies, and combinations of injectable therapies in appropriate patients. A treatment approach that employs timely treatment intensification with such regimens may help us along the journey.
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