Optometric Management Supplements

June 2015

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THOMAS A. ALBINI, MD: It's fairly uncommon for me to see a patient with diabetic retinopathy who doesn't already have a medical professional manag- ing his diabetes. If it does occur, I refer patients to the diabetes center at the University of Miami. DR. PIZZIMENTI: Do you counsel your patients on diabetes management? DR. ALBINI: Typically, I don't, as that's not my area of expertise. However, I would like to ask Dr. Goldberg about a situation I sometimes encounter. Occasionally, I see a patient whose A1c always hovers around 8, and the physician managing the patient's diabetes care seems comfortable with that. This is a diffcult situation for me, because I'm unsure if I should refer the patient to another physician or just follow the current plan. Usually, in my note to the physician, I state that the patient's chance of developing retinopathy is higher if his hemoglobin A1c remains at this level, and I ask if anything can be done to lower it. I understand there may be good medical reasons why, in a particular patient, tighter control isn't reasonable, but occasionally, I recommend that a patient obtain a second opinion. Are there signifcant variations in physician- recommended target A1c levels? DR. GOLDBERG: Over the last decade, the average A1c of people with diabetes in the United States, based on representative samplings, has decreased. 8 The median A1c has decreased by 0.5-1.0% and the proportion with an A1c > 8% has dropped from 40% to 23% of those with diabetes over the 15 years, which is important, because even a 0.5% change in the A1c may make a signifcant difference in a patient's long-term health. 9 As Dr. Albini suggests, however, a wide vari- ance exists among different patients with different providers, and the patient you described exasper- ates me, as well, particularly if a high A1c level is indicative of medical lethargy. If a patient is taking two oral agents and has an A1c of 8 that has not come down, you would be right to question the physician who is handling his diabetes care. DR. PIZZIMENTI: Are there patients who shouldn't try to achieve the lowest A1c possible? DR. GOLDBERG: Yes, absolutely. The ACCORD trial compared the effects of combinations of standard and intensive therapy in patients with type 2 diabetes who were at high risk for cardiovas- cular disease events. 10 The researchers found that the patients who had intensive control had worse mortality. Although the reasons for these outcomes aren't fully understood, it appears patients who are elderly, have multiple complications and comorbidi- ties, and a history of severe hypoglycemia should not be targeted for low A1c levels. Unfortunately, that presents a problem for patients with progress- ing retinopathy. DR. DUNBAR: How diffcult is it for patients to reduce their A1c from 8 or 9 to 6 or 7? DR. GOLDBERG: That's a complex question, because there are multiple agents with varying effcacy and tolerability. In general, it is easier for patients to maintain good control early in the disease process when they are using fewer medica- tions. Conversely, the longer a person has had diabetes, and particularly once he or she needs insulin, the disease becomes more diffcult to control. Type 1 diabetes represents the extreme of diffculty. People 4 ¥ INTEGRATED CROSS-DISCIPLINARY APPROACHES TO THE MANAGEMENT OF DIABETIC EYE DISEASES

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