The diabetes diagnosis
By Alan Cassels, September 2016
The war on blood glucose is stupid, costly and bloody.
AT 66, Sandra B. in Vancouver was feeling great. She lived a healthy lifestyle and was exercising. After the death of her mother a few years ago, however, she found herself inexplicably losing weight. The weight loss became noticeable and her partner suggested she go to the doctor and “get that checked out.”
She went to a walk-in clinic where the doctor sent her for a battery of tests. She wasn’t, however, prepared to hear the results.
“I got a call three days later and the doctor told me to come in and see her,” said Sandra. “So I went to the doctor and she looked at me and said: “You’re a diabetic.’”
It was unexpected for both of them. “The doctor said to me: ‘Geez, you’re in great shape, you walk, exercise, lift weights…’” and then began examining her.
“She looked at my feet, looking for gangrene,” Sandra said about her doctor, adding, “She completely reinterpreted who I was. She told me to get to an ophthalmologist, to get my eyes checked out, and I got a script right away for metformin.”
Thus began Sandra’s journey into the diabetes world, a journey which many of us will be navigating as we get older and face the common conditions that define aging. While a routine blood test is the start of the diabetes journey for many people, the cascade of interventions that typically follow will catch many people off guard. Type 2 diabetes, also known as adult-onset diabetes, involves frequent measurement and alteration of blood sugars, with the thought that high sugars will predispose you to a higher risk of heart attacks, strokes, kidney or eye problems. What many people don’t realize is how much about diabetes and “pre-diabetes” (its controversial precursor) is a minefield; much of what passes for wisdom is anything but wise.
The blood test that defined Sandra as a diabetic is a hemoglobin A1C or glycosylated hemoglobin test, a marker of how well one’s blood sugar has been controlled during the previous two to three months. If it is much higher than “normal,” it is appropriate for the doctor to suspect damage to the blood vessels in the legs, kidneys or eyes, as these represent the kinds of “microvascular complications” that are linked to diabetes.
The Canadian Diabetes Association Clinical Practice Guidelines say that lowering A1C values to below seven percent is important to prevent complications, while the ultimate reason to control your blood sugars are the more dreaded “macrovascular complications,” such as heart attacks or strokes.
The standard advice for anyone identified as having a high hemoglobin A1C level is to lose weight and manage the condition with diet and exercise. Controlling one’s diet—especially carbohydrates—and getting more exercise is the closest thing to a cure for most people identified as having high blood sugars. The exercise doesn’t have to be strenuous. In fact just daily walking can help many people traverse from “diabetic” to “non-diabetic” territory.
Yet for many people, exercise and dieting only goes so far, and has to compete against a powerful diabetes industry that demonizes blood sugars in order to sell blood glucose test strips, insulins, and, of course, a cornucopia of drug treatments.
Sandra, like most newly-diagnosed with diabetes, was immediately started on metformin, the standard treatment for type-2 diabetes, and later was given glyburide, a drug from a class of drugs called sulfonylureas. What was Sandra told about the metformin or the glyburide? (This is a question I always ask when people tell me what drugs they’ve been put on.) Her reply was a surprise: “Nobody told me anything. Nothing.”
Metformin is one of the oldest and most studied drugs for type-2 diabetes, yet it is also highly controversial. The simple fact is that when you consider all the major trials of metformin, you find it effectively lowers blood sugars, but it has almost no effect on “clinically relevant outcomes” (i.e. heart attacks and strokes). A January article in the British Medical Journal questioned the widespread use of metformin, noting that the UK Prospective Diabetes Study “found a significant 60 percent higher death rate in patients given metformin plus sulfonylurea compared with those given sulfonylurea alone.” Other studies have had similar findings.
Canadians spend nearly $750 million per year on prescription drugs that lower glucose, an amount that works out to about 628 prescriptions per 1000 people, about the same rate at which we consume antibiotics. In Canada in 2015 there were over 13 million prescriptions written for metformin, making it the fifth most prescribed drug in Canada that year.
In BC, according to a just-published letter from UBC’s Therapeutics Initiative, about 100,000 people take a single drug (mostly metformin) to lower their blood glucose. But that’s only the beginning: Nearly 65,000 BC residents take two or more diabetes drugs and nearly 30,000 take three or more. The costs of diabetes drug treatments in the province are staggering. The Canadian Diabetes Association has projected medications in BC to cost $115 million by 2020.
Yet here’s the kicker: Most of the people taking those drugs will not benefit from taking them. Sure, they may have lower blood sugars, but does that mean they will live longer or healthier lives? Not necessarily.
Cochrane is a global independent network of researchers, professionals and patients. Their information is considered the gold standard for trusted medical information. A 2013 Cochrane review examined almost 30 trials looking at “intensive glycemic control,” that is, trials that attempted to keep the hemoglobin A1C at or below the seven percent mark. Cochrane found that the incidences of cardiovascular death, non-fatal stroke and end-stage kidney disease—or any health-related death—were not improved by intensive glucose lowering. In fact, those who were subjected to intensive glycemic control had more serious adverse events, including severe hypoglycemia (which often resulted in hospitalization). In other words, the taking of multiple drugs to drive one’s blood sugars lower and lower comes with a costly toll.
Part of the problem here stems from how the drugs are approved. Many of the glucose-lowering drugs for people with type-2 diabetes are approved by Health Canada “without evidence that they reduce mortality or major morbidity,” according to the Therapeutics Initiative. The very basis for the approval of all the newer diabetes drugs—that are only proven to lower glucose but have no specific evidence they prevent heart attacks or strokes—should be seriously called into question.
Who stands to benefit from the war on glucose? One has to look no further than the latest edition of the Canadian Diabetes Association Clinical Practice Guidelines, which lists 12 pages of conflicts of interest between the doctors writing the guidelines and almost every drug company in Canada. In other words, the drug companies are putting their own people on the committees that are defining diabetes. Driving for lower and lower blood sugars is big money in Canada.
While there is little to be made flogging metformin or the sulfonylureas, which are mostly generic and cheap, the really big money comes from a smorgasbord of newer on-patent drugs that lower blood glucose, including the Gliptins—sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Trajenta), alogliptin (Nesina); the Tides—exenatide (Byetta), liraglutide (Victoza) and albiglutide (Eperzan), dulaglutide (Trulicity); and the Flozins—canagliflozin (Invokana), dapagliflozin (Forxiga), empagliflozin (Jardiance).
As for Sandra, her story continues. She has an appointment with a diabetes clinic which will teach her how to manage her condition. No doubt she’ll learn about these new drugs and be told to drive relentlessly for that “seven percent” target.
We end our discussion with her telling me: “So far, I’m following doctor’s orders, but I’m not happy that the doctor’s first step was to sign me up for a diabetes clinic with, as far as I can see, a lifetime of metformin (or possibly insulin), daily multiple (expensive) glucose test strips, and a new identity as a diabetic.”
Alan Cassels is a Victoria author and pharmaceutical policy researcher. He has written four books on the medical screening and pharmaceutical industry including the latest, The Cochrane Collaboration: Medicine’s Best Kept Secret.