Some Diabetes Treatments as Bad as the Disease

CHICAGO, Sept. 27 -- Treatment for type 2 diabetes may rival in inconvenience the complications of the disease, researchers here found.

Patients rated the burden of comprehensive diabetes care -- intensive control of diabetes, blood pressure, and other risk factors -- similar to having angina, diabetic nerve damage, or diabetic kidney damage (all P>0.04), reported Elbert S. Huang, M.D., M.P.H., of the University of Chicago here, and colleagues, in the October issue of Diabetes Care.

In their medical cost-effectiveness analysis, quality of life during intensive glucose control was likewise rated similar to having diabetic neuropathy (P>0.01).

The findings may have implications for compliance as well as for efforts to improve disease management, the researchers said.

"In the near future, the results of the Action to Control Cardiovascular Risk in Diabetes trial may actually lead to even lower risk factor goals that will require even greater use of medications to achieve them," they said, but "taking multiple medications on a routine basis represents a significant burden for many patients."

The researchers interviewed 701 adults with type 2 diabetes who were attending clinics in the Chicago area. Most participants were either black (38%) or Latino (24%). The mean age was 63.

Over their average 9.9 years with a diabetes diagnosis, a substantial proportion had experienced a microvascular complication (23%) and 30% reported having cardiovascular complications. Patients typically used only oral diabetes medications (61%), but 25% also used insulin and 14% did not take any glucose control medication.

In the face-to-face interviews, patients were asked their preference on quality-of-life tradeoffs for 10 years with a particular complication or treatment and a progressively shorter period of time in perfect health.

The researchers described the daily experience of each treatment, associated laboratory testing, and likelihood of side effects. Patients were asked to focus on quality of life effects of each treatment rather than its long-term benefit against complications.

Participants generally rated intensive treatment as worse than conventional treatment.

Patients thought 10 years of life during intensive glucose control treatment was worth only 6.7 years of in perfect health whereas 10 years of conventional glucose control was worth 7.6 years of perfect health (utility score 0.67 versus 0.76, P<0.01).

They rated quality of life best for diet and exercise therapy with no significant difference between the two (utility scores 0.88 and 0.89).

Patients rated quality of life lowest with comprehensive diabetes care treatment, which was described to them as intensive glucose control plus other medications. They thought 10 years of comprehensive diabetes treatment was equivalent to 6.4 years with perfect health.

The polypill, described as the same treatment regimen with a lower pill burden, didn't appear to make comprehensive treatment much easier (utility score 0.66 versus 0.64, P=NS).

In fact, comprehensive diabetes care with or without the polypill was rated similar to having angina, diabetic neuropathy, or diabetic nephropathy (utility score 0.64 and 0.66 versus 0.64, 0.66, and 0.64, all P>0.04).

Intensive glucose control, which got the lowest utility score of all the individual treatments, was rated similar to having diabetic neuropathy (utility score 0.67 versus 0.66, P>0.01).

Thus, "this quality-of-life burden appeared to arise from the prospect of multiple daily insulin injections rather than the prospect of multiple oral agents," Dr. Huang and colleagues wrote.

Overall, 10% to 18% of patients were willing to lose eight out of 10 years of perfect health to avoid diabetes treatments altogether.

By comparison, 12% to 50% of patients would make the same trade to avoid life with complications.

The researchers acknowledged that their participants, all of whom had an established professional relationship with a physician, might have been more adherent than most patients with diabetes.

Nevertheless, the findings suggest treatment-related quality of life would likely improve if health care providers can "simplify or modify current treatments through treatment innovations," they said.

But even without this, patient concerns may still be allayed through early patient education, incorporating patient preferences into treatment decisions, and by acknowledging quality-of-life concerns in public health efforts, they concluded.