Screening May Not Reduce Mortality Rates in Patients at High Risk of Type 2 Diabetes
Screening for type 2 diabetes in high-risk patients does not appear to affect overall mortality rates, according to a new study published on Oct. 3 in The Lancet.
The randomized trial, which assessed the number of deaths over 10 years in a group of more than 20,000 patients between the ages of 40 and 69 across 32 general practices in Eastern England, found that one round of screening did not reduce all-cause mortality over a median 9•6 years in patients at high risk for diabetes. Similarly, invitations to screenings were not associated with reductions in deaths from cardiovascular disease, cancer, diabetes-related illness, or other causes. According to the study authors, "results from the parallel cohort analysis were similar to those from the main trial analysis, suggesting that population-based screening for diabetes is not associated with a reduction in all-cause, cardiovascular, or diabetes-related mortality within 10 years in this age group."
"The high proportion of undiagnosed cases of diabetes, the substantial number of patients with complications at clinical diagnosis, and the long latent phase of the disease are strong arguments for screening," said Simon Griffin, MD, of the MRC Epidemiology Unit at Addenbrooke's Hospital in Cambridge, UK. "However … it seems that the benefits of screening might be smaller than expected and restricted to individuals with detectable disease."
According to Griffin, benefits to the population could be increased by including the detection and management of cardiovascular risk factors alongside the assessment of diabetes risk, performing repeated rounds of screening, and improving strategies to maximize the uptake of screening.
Meanwhile, the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) on Oct. 2 released new, updated guidelines on the treatment of type 2 diabetes that incorporate new information on the benefits/risks of glycemic control; recent evidence concerning efficacy and safety of several new drug classes; the withdrawal/restriction of other drug classes; and an increasing focus on patient-centered care.
The new recommendations include, for the first time, a focus on not only individualised interventions in type 2 diabetes, but also the need for individualised goals. While past recommendations regarding the intensiveness of glycemic therapy have focused on a HbA1c target below 7 percent, the updated guidelines recommend that the precise glycemic target should take into account several factors including a patient's attitude and expected treatment efforts, potential risks associated with glycemia and other adverse effects, disease duration, life expectancy, other co-morbidities, established vascular complications, and the patient's own resources and support system.
Other key recommendations include:
- Continued focus on diet, exercise and education as the foundation of any type 2 diabetes treatment program.
- Use of metformin as the optimal first-line drug, unless there are prevalent contraindications.
- Use of combination therapy with an additional one or two oral or injectable agents after metformin. (Guideline authors note that this treatment is reasonable, despite limited data available.)
- Recognition that many patients will require insulin therapy alone or in combination with other agents to maintain glucose control.
- Need for comprehensive cardiovascular risk reduction as a major focus of therapy.
"The new position statement is less prescriptive than previous guidelines, advocates more patient involvement and gives guidance on the rational approach to the choice of therapy," the EASD and ADA note in their press release. "This choice will now combine the best available evidence from literature with the clinician's expertise and the patient's own inclinations."
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