Man with Type 2 diabetes puzzled by guidelines
Dear Dr. Roach: I’m a 72-year-old, otherwise healthy man who was diagnosed about three years ago with Type 2 diabetes. I am on the medication Amaryl (glimepiride), 2 milligrams twice daily. My last A1C was 7.5, and I had a prick test of 140. I don’t know the acceptable ranges for the A1C. My doctor desires the level to be below 6, but said that 7.5 is not terrible. I read that 8 is the new normal. Is there any actual “acceptable” or “normal” range? Is there a true danger point? It seems difficult, at best, to determine where the truth lies with medicine. It seems that a study one month says one thing and then a different study says something else. Is it possible to get truly accurate medical information?
C.A.
There are almost no absolute truths in medicine. Our knowledge is imprecise at best, and demonstrably wrong on many occasions.
In your particular case, there is even now some controversy. Some authors push for as normal a blood sugar as possible, and a normal A1C is below 5.7 per cent. People with lower A1C levels have a lower risk for eye and kidney diseases. That’s probably why your doctor is saying to shoot for below six per cent. However, in a group of people with Type 2 diabetes, who were at higher-than-average risk for heart disease, the group with a goal of seven per cent had less risk of heart disease than the group with a goal below six per cent. Unfortunately, some doctors have misinterpreted that study, in my opinion, and think that all people with diabetes should have an A1C near seven per cent. The reality is more complicated, and I think that a lower A1C is appropriate for younger patients with low risk for heart disease.
I do not agree with a goal of eight per cent, which is associated with too high a risk for eye and kidney diseases.
Dear Dr. Roach: I’m about to go on a new drug for treatment of rheumatoid arthritis. It’s related to quinine. Would this be a good choice for me? I am concerned because I have glaucoma and had a torn retina in my right eye, leading to loss of sight.
E.F.
There are two commonly used antimalarial drugs (related to quinine) that are useful in the treatment of rheumatoid arthritis: chloroquine and hydroxychloroquine. They work well for some people and not at all for others. But I think your question is about any bad effects these drugs might have on your eyes.
There are two ways these drugs can affect the eyes. The drug itself can get deposited in the cornea, and this can cause a sensitivity to light and the appearance of a halo effect on the vision. The deposits and symptoms go away when the medication is stopped.
The second is that the drug can affect the retina.
This can cause permanent vision loss, so while it is very worrisome, it fortunately is not common.
Only about two per cent of people will develop early changes of this condition in the first 10 years on the medication, but the risk goes up after 10 years.
People taking the medication should receive annual eye exams. I don’t think that your glaucoma or retinal tear puts you at higher risk for side-effects of this class of drugs for rheumatoid arthritis.