Primary Care Research

A protocol for adjusting diabetes medications can improve diabetes management and patient blood-sugar levels

People with diabetes must control their blood-sugar levels through diet, exercise, and/or medication in order to avoid serious complications such as eye or kidney disease. Yet doctors don't always intensify patients' medication when their blood glucose levels remain high on their current medication regime. However, a new protocol encourages better diabetes management and improves patient blood-sugar levels, according to a new study. The protocol for adjusting diabetes medications is based on a patient's current therapy and their glucose levels at the time of the visit, and is called a glucose algorithm.

The algorithm was tested at a diabetes clinic in Georgia that serves a predominantly black indigent population. The physicians measured plasma glucose at each visit and hemoglobin A1c (average blood-sugar level) every 3 months. Both test results were available to the providers each time a patient was seen. If adequate glycemic control was not attained after 2 months of lifestyle modification and perhaps medications, then medication therapy was either begun or increased. Medication therapy was advanced using a stepped-care approach, beginning with a single oral agent (for example, metformin) and then progressing to combination oral agents, oral agents plus bedtime insulin, and finally, multiple-dose insulin regimens.

Goals for glycemic control included an A1c level below 7 percent (the American Diabetes Association goal), a random plasma glucose level below 150 mg/dL, and a fasting plasma glucose level below 125 mg/dL. The researchers assessed patient management 7 months before and 7 months after initiation of the algorithm. When the algorithm was available, providers were 45 percent more likely to intensify therapy when indicated and increased therapy by a 20 percent greater amount. The A1c level at followup was 90 percent more likely to be less than 7 percent in the algorithm group, even after adjusting for patient clinical and sociodemographic differences. The study was supported in part by the Agency for Healthcare Research and Quality (HS09722).

More details are in "Use of a glucose algorithm to direct diabetes therapy improves A1C outcomes and defines an approach to assess provider behavior," by Christopher D. Miller, M.D., David C. Ziemer, M.D., Paul Kolm, Ph.D., and others, in the July 2006 Diabetes Educator 32(4), pp. 533-545.

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