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Dr. Bill's Commentaries

Dr. Bill Quick began writing at HealthCentral's diabetes website in November, 2006. These essays are reproduced at D-is-for-Diabetes with the permission of HealthCentral.

Endocrinologists vs Diabetologists   (October 15, 2012)

A friend of mine was recently diagnosed with type 2 diabetes by an endocrinologist who is employed at a nationally-known medical center. My friend asked me to comment upon the information in the consultation report, a copy of which had been sent to him. I was surprised at the gaps which were apparent in the report, and told him so. My comments to my friend are paraphrased below.

Sorry to hear that you've joined the type 2 diabetes club. You requested I review the endo's report. My thoughts after reviewing the report:

You should have been seen by a CDE (Certified Diabetes Educator) nurse educator and a CDE diabetes dietitian, or arrangements made for you to see them both after your endo visit. This may be possible to do in your hometown, or at the medical center otherwise.

The CDEs should instruct you 1:1 on dietary changes and home glucose monitoring as well as other basic skills. You and your wife should also go through a formal diabetes education program that meets the ADA standards -- see Find a Recognized Education Program in your area by Zip Code to find one.

Sorry, but I disagree with the physician’s comment that you "almost” meet the criteria for “mild type 2 diabetes mellitus." IMHO, you do have diabetes. Per the ADA's Standards of Medical Care in Diabetes—2012 "In 2009, an International Expert Committee that included representatives of the American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD) recommended the use of the A1C test to diagnose diabetes, with a threshold of 6.5%, and ADA adopted this criterion in 2010."

Hence, if you had an A1C of 6.7, the experts say you do have diabetes. At the most, a second A1C done in the next few days to confirm the elevated value will suffice for diagnosis, and your borderline-high glucose values (124 mg/dl) becomes irrelevant to the diagnosis if both A1C values are high.

Third, his comment that you have "mild" T2DM is a value judgment and inappropriate. It's like having a "mild" case of pregnancy.

Next: Waiting 6 months to reassess A1C after starting diabetes therapy is too long - it should be in 3 months to assess the effectiveness of your therapy.

You should be started on metformin, as I do not see any contraindication (e.g., no impaired renal function). Dosing of metformin should be by a diabetes specialist (maybe your CDE nurse educator in concert with your internist) to minimize GI side effects. Again quoting the ADA Standards: "Therapy for type 2 diabetes. Recommendations. At the time of type 2 diabetes diagnosis, initiate metformin therapy along with lifestyle interventions, unless metformin is contraindicated."

Your physical exam should have included examination of the lower extremities for neuropathy and vascular status. If, as you said to me, you were not asked to remove shoes and sox for examination, the exam was inadequate.

A microalbumin value should have been mentioned from prior lab if it had been previously done, or one should be ordered. This is a test that can be done on a "spot" urine, not a 24-hour sample.

An EKG should have been commented upon or advised if no recent one has been done.

A baseline ophthalmologic exam should be recommended.

It might have been helpful for the physician to explain to you and your personal physician that you have many components of the "metabolic syndrome" (as you have hypertension, obesity, T2DM, high lipids, and probable fatty liver) and its implications for your care. See this discussion of Metabolic Syndrome online.

Most important, you should have been advised whether your antidepressant medication is associated with hyperglycemia. See Antidepressant Medication Use, Weight Gain, and Risk of Type 2 Diabetes . This association does not mean your antidepressants must be discontinued, but that you and your prescribing physician should decide whether a trial without them might be appropriate.

I understand that my friend will take my recommendations to his internist, and together with the local CDEs, they should be able to handle his care. But if my friend needs to see an endocrinologist again, I suggested it should be one who specializes in diabetes (what’s called a “diabetologist”), rather than a general endocrinologist who’s not up to date about diabetes.

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