Monday, November 12, 2018

Putting the "family" in family physicians' care of children with type 2 diabetes

- Jennifer Middleton, MD, MPH

The current issue of AFP includes a review on Type 2 Diabetes Mellitus in Children, reviewing current guidelines for screening, diagnosis, and treatment. Children with type 2 diabetes mellitus (DM2) have optimal success with their treatment regimens when their families are engaged in their care. This engagement is crucial to success with both lifestyle and pharmacologic treatments.

Improving nutrition and exercise can lower A1Cs and improve clinical outcomes in children with DM2. Physicians can guide these changes by providing dietician referrals, exercise prescriptions, and screen time limits. Just as children and adolescents with DM2 tend to be obese, their families also tend to have similarly elevated body mass indices along with "high fat intake, minimal physical activity, and a high incidence of binge eating." Encouraging the entire family to work together to improve their nutrition and exercise improves the pediatric diabetic patient's chance of success with these changes. 

Sometimes, though, engaging children and families in the office alone is insufficient. Interdisciplinary interventions, such as multi-systemic therapy led by a trained family therapist, lowers A1Cs, reduces hospitalizations, and reduces costs in children with type 1 diabetes mellitus; though these interventions have not been systematically studied in children with DM2, it seems reasonable to assume that they would be similarly effective. Interestingly, parents often under-estimate their children's health-related quality of life; it may be that these interdisciplinary interventions help younger diabetic patients better understand the severity of their disease and, consequently, increase their adherence.

Unfortunately, children initially prescribed only lifestyle change after a DM2 diagnosis rarely succeed at sustained blood sugar improvement; lifestyle measures alone only effect meaningful change in hemoglobin A1C values in 10% of pediatric DM2 patients. As such, the American Academy of Pediatrics recommends that all children be started on metformin, in addition to lifestyle counseling, at the time of diagnosis. Pairing medication taking with daily family routines significantly increases medication adherence, as does multi-systemic therapy as outlined above. Encouraging parents to adopt a more permissive parenting style may be another technique to increase adherence to both lifestyle and medication recommendations; "[y]outh with T2DM who perceive more autonomy (less parental control) in day-to-day and diabetes tasks are more likely to adhere to medication regimens." 

Working collaboratively with families and other disciplines are strengths of our specialty and can greatly benefit our younger patients with DM2. You can read more about DM2 in the AFP By Topic on Diabetes: Type 2, which includes both further reading for physicians and patient resources.

Tuesday, November 6, 2018

For mild hypertension in low-risk adults, harms of drug therapy outweigh benefits

- Kenny Lin, MD, MPH

Prior to publication of the controversial 2017 ACC/AHA clinical practice guideline, stage 1 or "mild" hypertension was defined as a systolic blood pressure of 140-159 mm Hg and/or diastolic blood pressure of 90-99 mm Hg. Although guidelines have recommended that persons with mild hypertension receive anti-hypertensive drug therapy if lifestyle modification does not lower blood pressure below 140/90, a Cochrane review found that such therapy did not reduce cardiovascular disease (CVD) events, stroke, or mortality compared to placebo. A 2015 meta-analysis that included high-risk persons (patients with diabetes and/or who had received prior antihypertensive treatment) suggested that drug therapy for mild hypertension may prevent CVD events, but others have argued that this analysis mixed apples with oranges and did not establish benefits for adults at low CVD risk.

A retrospective cohort study recently published in JAMA Internal Medicine sought to clarify the benefits and harms of drug therapy in low-risk adults with mild hypertension using data from 40,000 patients in an electronic health records database in the United Kingdom. The authors compared the outcomes of persons aged 18 to 74 with mild hypertension who were prescribed anti-hypertensive medications within 12 months of diagnosis to those in similar untreated persons. Persons with a history of CVD, left ventricular hypertrophy, atrial fibrillation, diabetes, chronic kidney disease, or a family history of premature heart disease were excluded from the study.

After a median follow-up duration of 5.8 years, there were no differences between the groups in all-cause mortality, stroke, myocardial infarction, acute coronary syndrome, or heart failure. However, the treated group had an increased risk of hypotension (number needed to harm = 41 at 10 years), syncope (NNH = 35), electrolyte abnormalities (NNH = 111), and acute kidney injury (NNH = 91).

Although ideally the findings from this observational study should be confirmed in a randomized, controlled trial, it is unlikely that a trial will ever be performed due to the large number of participants that would be needed in order to provide enough statistical power to detect a difference in mortality or rare CVD events in this population. In the meantime, the best available evidence suggests that the harms of drug therapy outweigh benefits for low-risk adults with a systolic blood pressure of 140-159 mm Hg and/or diastolic blood pressure of 90-99 mm Hg (recently redefined by the ACC/AHA as stage 2 hypertension). In these patients, family physicians and other primary care clinicians should emphasize nonpharmacologic management strategies such as a diet with a high intake of vegetables, fruits, and whole grains; moderating excessive sodium intake and alcohol consumption; and at least 150 minutes per week of moderate-intensity aerobic physical activity.