Blog | Monday, April 30, 2012

An HgbA1c goal of 7 is sometimes dangerous


Recently we had a patient admitted for hypoglycemia. He had long standing type II diabetes mellitus being treated with metformin, glyburide and twice daily 70/30 insulin. He had had several hypoglycemic episodes previously at home.

The admission and management caused no problem and the patient was ready for discharge the next day. However, we then asked the most important question: Why?

Why did this patient develop repeated episodes of hypoglycemia?

I suspect that his primary care physician was trying desperately to achieve an HgbA1c of less than 7. I doubt that the physician added drugs because he thought the patient needed them, but rather because someone (an insurance company or a clinic manager) told him that the patient's HgbA1c was too high.

This patient likely represents one of the problems with poorly considered performance measures.

Achieving a low HgbA1c or blood pressure or LDL has challenges. Often we must use more medications. Usually we are not treating the patient as much as we are treating the patient.

Adding drugs to try to achieve a goal does increase the rate of complications. The more drugs, the more complications. The higher dose of drugs, the more complications.

PRIMUM NON NOCERE!

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.