Treatment or cure?

Pre-emptive strikes are all the fashion these days. Got a pesky middle-eastern dictator hiding weapons of mass destruction? A first strike should sort him out. Got a bit of a global financial crisis on the horizon? Head it off by giving everyone a new plasma TV.

But first strikes don’t always work out so well (just ask George Bush). Early last year a medical pre-emptive strike was abandoned because it was killing too many people.  The US National Institutes of Health stopped part of an ongoing clinical trial on diabetes because it was clear that the patients receiving the treatment had a 22 percent higher risk of death than the people who weren’t.

The study involved aggressively treating high blood sugar with medication. Type II diabetes is caused by persistently high blood sugar. The standard treatment for high blood sugar (and therefore diabetes) is a prescription of ‘eat less fat and exercise more’. When that doesn’t work (as it almost never does) the prescription is changed to a combination of drugs.

There are a few different types of medication but the ones most commonly used in Australia work by stimulating the body to produce more insulin. Insulin is the hormone we naturally produce to clear sugar from the blood. But when there is too much fat in the arteries, the body becomes less sensitive to insulin and the sugar doesn’t get cleared. If blood sugar stays high for a long time, damage starts to occur in places where we have lots of small blood vessels, such as our kidneys, our eyes and eventually our hands and feet.

The drugs squeeze that little bit more insulin out of our pancreas to help clear the blood sugar. As you might expect, putting the pancreas on overdrive eventually results in it conking out completely. Then the only option is to start injecting insulin every day. By then, the drugs have converted a Type II diabetic (who produces insufficient insulin) into a Type I Diabetic (who produces none).

Unfortunately a side effect of the drugs is weight gain. Giving people more insulin (or having them produce it themselves) simply channels sugar out of the bloodstream and converts it into body fat.

The preferred long term measure of blood sugar is the haemoglobin A1c test. People without diabetes will have an A1c between four and six percent. The current treatment goal for people with diabetes is to manage the use of drugs so as to keep A1c less than seven percent.  The abandoned trial was an attempt to see if it would be possible to use even higher doses of drugs and push people back into the normal range. And it appears not to have been a very good idea at all. The side effect became a bit nastier than simply putting on a few kilos. Twenty two percent more of the patients died.

Giving more insulin to an insulin resistant person is like curing arterial blockage by increasing blood pressure. A smarter strategy is to remove the blockage. Unfortunately for diabetics the ‘blockage’ is high blood fats, something which can’t just be sliced out with the surgeon’s scalpel.

Diabetes now afflicts 13 percent of the US adult population with double that number estimated to be pre-diabetic (insulin resistant), a total of 40 percent. Australia is not there yet but we are tramping that path as fast as our fat little feet can carry us. When 40 percent of our adult population requires treatment with a lifelong course of drugs, we’d better start thinking about some serious tax increases to keep the health system afloat. Paying back the economic stimulus package will be the least of our worries.

The standard pharmacological treatment for diabetes doesn’t cure anything. It merely offers an invidious trade-off between avoidance of kidney damage, blindness and gangrene today and weight gain and permanent pancreatic damage tomorrow.

If you ejoyed this post, get free updates by email or RSS.