The Effect of Changing Regular Care Provider in Type 2 Diabetes Mellitus: A Retrospective Study.

INTRODUCTION: Several studies have demonstrated the benefits of having a regular care provider on the control of chronic diseases. Our study intends to clarify the effects of the transition to a new diabetologist on metabolic control in type 2 diabetes patients followed-upin a tertiary care setting. MATERIAL AND METHODS: Retrospective study performed in an endocrinology outpatient clinic. We randomly selected 50 type 2 diabetespatients for a control group and 50 for a study group. In the study group, we registered the last evaluation before the physician change (year 0) and at the end of each year (year 1, 2 and 3) with the new doctor. Evaluated variables - body mass index, blood pressure, HbA1c and lipid profile - were compared yearly between groups. RESULTS: There was a decrease in mean HbA1c levels (0.4% - 0.5%, p < 0.05) in year 1 and 2 when compared to year 0 in the study group, but not in the control group. This reduction was superior (0.5% - 1.4%, p < 0.05) in patients whose baseline HbA1c was greater than 7%. The other studied variables did not vary significantly throughout follow-up in either group. DISCUSSION: In our study the transition to a different type 2 diabetes physician was associated with a decrease in mean HbA1c and this difference was greater in less well controlled patients. CONCLUSION: Switching to a new physician may not be harmful and may actually have benefits for the glycemic control of some type 2 diabetes patients.

Introdução: Vários estudos já demonstraram ser benéfico para o controlo de várias doenças crónicas manter seguimento com um mesmo médico assistente de forma prolongada. O nosso estudo pretende esclarecer os efeitos no controlo da doença associados à transição para um novo médico diabetologista em doentes diabéticos tipo 2 seguidos em cuidados de saúde terciários. Material e Métodos: Estudo retrospetivo realizado num serviço de consultas externas de Endocrinologia. Seleccionámos aleatoriamente 50 doentes diabéticos tipo 2 para um grupo controlo e 50 para um grupo estudo. No grupo estudo, registámos a última avaliação antes da mudança de médico (ano 0) e no fim de cada ano (ano 1, 2 e 3) com o novo médico. As variáveis avaliadas ­ índice de massa corporal, tensão arterial, HbA1c e perfil lipídico ­ foram comparadas anualmente entre os grupos. Resultados: Verificou-se uma diminuição na média da HbA1c (0,4% ­ 0,5%, p< 0,05) no ano 1 e 2 por comparação com o ano 0 no grupo estudo, mas não no grupo controlo. Esta redução foi maior (0,5% ­ 1,4%, p < 0,05) em doentes cuja HbA1c basal era superior a 7%. As outras variáveis estudadas não variaram significativamente em qualquer um dos grupos. Discussão: Neste estudo, a transição de doentes diabéticos tipo 2 para um novo médico diabetologista assistente associou-se a uma diminuição na média de HbA1c, de forma mais marcada em doentes com menor controlo metabólico. Conclusão: A mudança para um novo médico diabetologista assistente pode não ser prejudicial e inclusivamente associar-se a benefícios para o controlo glicémico de alguns doentes diabéticos tipo 2.

Renal function markers and metformin eligibility.

BACKGROUND: Metformin is the cornerstone of the pharmacological therapy for type 2 diabetes mellitus (T2DM). It belongs to the biguanide class of drugs and it improves hepatic insulin resistance and enhances GLP-1 and peptide YY secretion. Despite being considered safe regarding hypoglycemic risk, renal dysfunction remains the main obstacle to its use due to the underlying risk of lactic acidosis. In the recent past many authors used creatinine values as the decisive marker when it came to choose between pharmacological agents in DM. Serum creatinine values equal or above 1.4 and 1.5 mg/dL were considered contraindications for metformin use in women and men respectively. Nowadays, creatinine is not the only surrogate of renal dysfunction and formulas such as the MDRD and CKD-EPI, that besides serum creatinine also include variables such as gender, age and race, have replaced serum creatinine as the standard for renal function assessment. Furthermore, since the associations between metformin and lactic acidosis in renal disease are not straightforward, its use has been considered safe down to creatinine clearances of 30 mL/min/1.73 m2. The authors describe a population with T2DM being treated with metformin and evaluate the impact of the solo evaluation of serum creatinine or CKD-EPI on biguanide prescription. METHODS: Retrospective, observational, single-center study. All type 2 diabetic patients with regular follow up in a Central University Hospital Endocrinology-Diabetology Outpatient Clinic who were being treated with metformin and had at least 2 creatinine and estimated glomerular filtration rate (eGFR) measurements in the last decade were included. Patients were stratified according to renal function-based metformin contraindication criteria: creatinine group included patients with serum creatinine levels above 1.4 and 1.5 mg/dL in women and men respectively, and eGFR group included patients with eGFR below 30 mL/min/1.73 m2. The entire population and both groups are described and compared regarding comorbidities, demographic and laboratory data. The authors report the impact of each renal function marker (serum creatinine or eGFR) when used solo regarding metformin prescription eligibility. RESULTS: A total of 2218 patients (61.3% females) with a mean age of 70±12 years is studied. Mean diabetes duration was 11.8±8.8 years. No cases with an eGFR below 30 mL/min/1.73 m2 were identified. On the other hand, in patients with GFR greater than 30 mL/min/1.73 m2, creatinine alone would contraindicate therapy in 274 patients (12.4% of the study population). Comparing Stage 3 chronic kidney disease patients without creatinine contraindication criteria with those with creatinine based contraindication, the data reveals that a higher prevalence of males, with longer diabetes duration, higher target organ damage (cerebrovascular disease, peripheral artery disease, heart failure, neuropathy and retinopathy) and with worse glycemic control were prevalent more in the elevated creatinine group. The use of serum creatinine as the single marker for renal function would significantly reduce metformin eligibility (OR=0.88, 95% CI: 0.8-0.95, P=0.002). CONCLUSIONS: Metformin is the first line pharmacological agent in type 2 diabetes mellitus patients, being associated with significant HbA1c reductions and improvements in both micro and macrovascular outcomes. Avoiding its use due to imprecise renal function markers would potentially render the patient deprived of optimal pharmacological therapy for T2DM. Creatinine contraindication criteria alone are associated with unnecessary under prescription of metformin.