Re: Insulin for T2 and prevention of complications.

[Guest guest]

> But does it mean that everyone progresses to

> keep getting worse? or can people really just be

> controlled the rest of their life?

That is the question that has been bothering me for

a long time and I now believe that the answer is:

It all depends on how old you are and how long the

particular complication you are planning to get

(sorry, joke!) takes to develop. In other words,

hard as it sounds, you may not live long enough for

a particular complication to become a consideration.

The younger you are or the better your life expectancy,

the more chance you will have to get any particular

complication. Some time back, I read of a German

diabetic who was 95 years old and had had diabetes

for over 50 years and his physicians had confirmed

that to a certain extent he had every complication

in the book but was still going strong and insisting

on managing his own diabetes.

In the literature about microalbuminuria (which is

my favorite complication) I found the following

statement:

" Prognosis

Microalbuminuria has prognostic significance. In 80%

of people with type 1 diabetes and microalbuminuria,

urinary albumin excretion increases at a rate of

10–20% per year, with development of clinical proteinuria

(>300 mg albumin/day) in 10–15 years. After development

of clinical grade proteinuria, most (>80%) patients go

on to develop decreased glomerular filtration rate and,

given enough time, end-stage renal disease.

In type 2 diabetes, 20–40% of patients with micro-

albuminuria progress to overt nephropathy, but by

20 years after overt nephropathy only about 20% develop

end-stage renal disease. In addition, patients with

diabetes (type 1 and type 2) and microalbuminuria are

at increased risk for cardiovascular disease.

....

....

Microalbuminuria rarely occurs with short duration of

type 1 diabetes or before puberty. Thus testing is less

urgent in these situations. Although the difficulty in

precisely dating the onset of type 2 diabetes warrants

initiation of annual testing early after diagnosis of

diabetes, older patients (age >75 years or life expectancy

<20 years) may never be at risk for clinically significant

nephropathy in view of a projected life-span that is

too brief for renal dysfunction to develop. In such

patients, the role of treating microalbuminuria is far

from clear, and the need to screen for it is, thus,

uncertain at best. " (NACB: Guidelines and Recommendations

for Laboratory Analysis in the Diagnosis and Management

of Diabetes Mellitus)

http://www.nacb.org/lmpg/diabetes/9_diabetes_microalb.doc

So you see that it is never a certainty, it is just a

matter of the odds. The longer you live, the worse are

the odds that you will be able to avoid a particular

complication. Most diabetics die of cardiovascular

disease but a good proportion of non-diabetics do too.

So your strategy has to be: Do everything possible to

improve your odds of avoiding the various complications,

e.g. to increase your chances of not having an amputation,

take the best possible care of your feet. Keeping a low

average BG (HbA1c) is therefore also a good strategy. It

does not guarantee you freedom from complications but

it sure does improve your chances!

Regards

Thornton

[Guest guest]

This kind of lockstep thinking by the German medical establishment only

reinforces your wife's notion that insulin is the last step before The

End. No wonder she's loathe to start it.

I've said it before and I'll say it again: For a type 2, taking insulin

doesn't mean you've failed. Insulin is a tool best used long before it

becomes a " last resort " .

Vicki

Re: Insulin for T2 and prevention of

complications.

>

>

>> My only argument is with your final statement.

>> Pills are not the only next logical place to go

>> after diet and exercise aren't controlling

>> diabetes adequately. Starting insulin early is

>> cited as being advantageous in several articles

>> I have in my archives, and there are people on

>> this list who started insulin earlier rather

>> than pills. And some here tried pills but found

>> insulin to be less odious and more effective for

>> good BG control.

>

> Yes, I guess so but that is not the way the health

> system works over here. We have progressive

> " treatment stages " and a recent study showed that

> of the 5.8 million diagnosed German diabetics:

>

> 16.4% are at treatment stage: 'Insulin'

> 11.2% are at treatment stage 'Insulin + oral meds'

> 44.4% are at treatment stage 'Oral meds'

> 28.0% are at treatment stage 'Diet and exercise'

>

> I believe that the stages are arranged in order of

> the direct cost of materials required in each stage

> and it is usual to move up through the stages as

> the physician determines the necessity (if the

> state health insurance is paying, that is). That

> is probably one of the reasons why some people are

> shy of the " insulin stage " - it is clearly the " end

> of the flagpole " in that way of looking at it!

>

> Thornton

[Guest guest]

Hey, we agree !

Vicki

Re: Insulin for T2 and prevention of

complications.

>

>

>> The quibble is this: With type 1 the reason we

>> " suddenly " do not produce enough insulin is

>> cause of an autoimmune attack. In LADA, it's not

>> sudden at all, as it is with type 1 in children -

>> it can take months (like for me) or years (like

>> for ).

>

> Yes, you are right, Vicki, " suddenly " was not the right

> word. " In a relatively short time " would have been

> better, relatively short in comparison with the

> 10-15 years that it is said that a full-blown type 2

> can take to develop from nothing.

>

> Thornton

> (I am getting confused myself now with some other

> s on this list! Maybe the others could add their

> last names, too?)

>

>

[Guest guest]

> In so many studies of DM, people are treated

> as though there are no differences in control.

> When they start doing studies on well-controlled

> diabetics (or poorly controlled diabetics for

> that matter), I will pay closer attention.

Yes, I know what you mean but there is the point

that " well-controlled " and " poorly-controlled "

are really a matter of definition and depend on

the criteria adopted by the researcher.

Naturally, it is going to be more difficult to

get sensible results from a study using subjects

whose diabetes is all over the place. A lot will

depend on the object of the study.

All this mentioned just to suggest to you that you

won't see the terms " well controlled " and " poorly

controlled " in study reports because they are not

clearly defined terms, they are subjective terms,

and you have to look at the way that the subjects

are classified into groups numerically in terms

of their treatment targets and their compliance

with the treatment.

One person's " well " could easily be another persons

" poorly " !

Regards

[Guest guest]

> I saw my GP(UK) Tuesday and he quoted a price of

> 30pence ( 51cents) for a test strip and thought

> this expensive, but from the Dx put me on Metformin

> and Glimepiride as they were cheap. He also said

> insulin treatment was costly too - so it looks as

> though economics rule here in the UK too.

Yes, I am sure that it does everywhere! The idea of

putting everybody on insulin right away sounds good

- if you don't have to pay for it! And a lot depends

on the accounting method and which budget it comes

out of. We are only talking about cents but if those

are several times a day for life and multiplied by

millions of patients, the bottom line is usually

quite a lot of money.

I imagine that putting all diabetic patients directly

onto the most expensive treatment with the object of

reducing the risk of them getting complications in

20 years' time would break the back of most health

care systems. And telling a mother that it is best if

she pays out money she does not have now for a treatment

that might or might not help to prevent complications

that she might or might not get in the remote future

has to be weighed against the certainty that her children

might have to go without school lunch right now, and the

whole family without a vacation, to pay for it.

And a physician can tell all his/her patients that an

intensive treatment with many BG readings a day plus

insulin doses matched to readings is the best for them

but if most of them are not going to have the patience

or the interest or the time to comply with his treatment

then it is going to be a shocking waste of money.

The graduated system in which the treatment goal is

matched to the present severity of the disease and

the physician prescribes the least expensive treatment

to enable that goal to be achieved seems to me to be

a more reasonable way to handle the situation.

Regards

Thornton