Following yesterday’s marathon blog of a day in my life, I thought it would be worth tallying up the totals to see just how many times I checked my glucose levels and thought about Diabetes.
Why?
To understand where I fall in the concept of Intensive Therapy.
Why is this important?
Well the DCCT and EDIC studies found that those undertaking Intensive Therapy had noticeably reduced complications compared to those who didn’t. And NICE has set a target Hba1C of <6.5% as a sledgehammer mechanism for reducing the risk of complications, and yet, as discussed here, only 7% of T1Ds in the UK achieve this and only 27% achieve the older 7.5% target.
So let’s start by taking a look at what the DCCT study considered to be “Intensive Therapy” and apply this to the T1D population of the UK. This will involve a number of assumptions, so bear with me! And if you don’t want to read through the summary of the DCCT stuff and recent NICE changes, click here to read my conclusions.
You can read additional “Days in the life” on the diabetes.co.uk forum.
DCCT and EDIC Studies
The DCCT study indicates that intensive therapy is:
“Intensive therapy included the administration of insulin three or more times daily by injection or an external pump. The dosage was adjusted according to the results of self-monitoring of blood glucose performed at least four times per day, dietary intake, and anticipated exercise.”
And that’s what we classify as Multiple Daily Injections (MDI) in the majority of the western world. The summary of the DCCT and EDIC studies was that intensive therapy reduced Hba1C levels and reduced average blood glucose levels as in the below chart:
In the study, this demonstrates a reduced incidence of complications by between 35% and 70% depending on complication as an added benefit, and as a result, it is easy to see why MDI became the recommended approach for treating T1. It’s worth noting that the average Hba1C under intensive therapy in this cohort study remains at around 7%.
NICE Recommendations
Now why did NICE recommend 6,5% as the level at which it would set a target Hba1C rather than the older 7.5%?
Well, you might consider that this was because it would reduce the amount of complications that people suffered. And this wouldn’t be bad interpretation, especially if you look at a number of studies, such as this one, which state that there are a number of threshold Hba1C levels at which different complications are reduced, and below which there is effectively no improvement in risk. This level is 6.5%. If you dig through the appendices of the new NICE guidelines, you might find some interesting points. To quote the “Summary of Results” on page 511 of Appendices H-U of the clinical guidelines:
“Achieving a target of 6.5% HbA1c compared to a 7.5% target is associated with a gain of 0.554 quality adjusted life-years (QALYs) and a reduction in healthcare costs of £3,524, when only the consequences of the HbA1c reduction in terms of reduction of complications are considered.“
So the real driver for the Hba1C reduction is a gain of 0.554 in the the number of years lived at a utility function of health. This could be half a year in perfect health or more than a year in poorer health. It is also a reduction in health-care costs of £3,524.
In response to the former, would it perhaps not be better to be dead than to live for five years bed ridden and in pain with a health utility that registers at 0.1? But that is an ethical question, and not one for statistics. For the latter, over the lifetime of a person, £3,524 doesn’t seem like a large sum to be saved.
Moreover, given the average value of Hba1C of Diabetics in the UK (according to the National Diabetes Audit) was 9.3%, this all seems somewhat of a moot point.
Very interesting, Tim. I think at some point it becomes part of our subconscious and therefore feels like less work even though there are more 'tasks' per day.
I've only been on a Dexcom G4 CGM for only 6 weeks, so still doing investigations on pre-bolus & a few alternative foods to reduce the spikes.
Prior to that I've been T1 for 46 yrs on MDI and was at 7.5% to 8% for most of first 43 yrs. Then three years ago I taught myself carb count & bolus based on ratios etc, and this reduced it by a full one percentage. So last few A1cs have been in 6.3% to 6.5%, which makes me one of the 7% of T1s that meet the <6.5% target. I also have no complications which I believe is due to running in good BG control.
So I've shown that you don't necessarily have to use CGM, or a pump, to achieve that level.
I'd agree Kevin. It's very much a habit that I find I do subconsciously. I was quite surprised as to how how many times I had checked throughout the day. It's almost autonomous!
Congratulations Jon, that's very impressive. I freely admit that I struggled to get enough of a view with SMBG to get myself all the way down, and I wonder how many more of us there are out there. The LIbre was a revelation for me and has made a huge difference. As you say, you've shown it can be done, but it appears, based on the National Diabetes Audit data, that it is somewhat difficult to achieve the new target using SMBG alone.
I agree about the pump though. I recently started to use a pump, so my last two Hba1C results have been achieved with MDI.
I wonder how these changes will affect either the target or the mechanisms available to get hold of CGM (and potentially pumps). Is it the kind of requirement that can be used to encourage the NHS as one of the largest businesses in the UK, in terms of resources consumed and people, to use its buying power with suppliers and act as some sort of UK wide intermediary to make these tools available at a significantly reduced cost? I'm not asking for "On prescription", rather a top up model similar to most health insurances.