In the Modern Approach to Diabetic Management, What Does ‘Good Control’ really Mean?

Nov 23, 2020 at 01:26 am by pj

“In Other Words” with Matthew Shlapack, MD

 In the Modern Approach to Diabetic Management, What Does ‘Good Control’ really Mean?


Dr. Matthew Shlapack is a Board-Certified Endocrinologist who has been practicing in Florida for nine years and has recently established his practice, Orlando Endocrinology, on Lake Underhill Rd. in Orlando,

Shlapack completed both his Internal Medicine Residency and his Endocrinology Fellowship at The University of South Carolina, School of Medicine, and was awarded his Doctor of Medicine from Ross University Medical School. He graduated from The University of Maryland, College Park with bachelor’s degrees in both Neurobiology, Physiology, as well as Psychology.

During his years working in Florida, Shlapack has been part of several community outreach programs focusing on a range of endocrine-related health issues. He specializes in a wide range of endocrine conditions, including diabetes, thyroid disease and cancer, osteoporosis, and parathyroid disease.

“Being a physician means providing compassionate care with every visit and always staying at the cutting edge, to ensure that my patients benefit from the newest breakthroughs,” said Shlapack.

In keeping with Dr. Shlapack’s passion for care, and continuing development of best practices, we wanted to use this space for him to discuss an updated approach to managing diabetes.  


In Other Words with Matthew Shlapack


In the Modern Approach to Diabetic Management, What Does ‘Good Control’ Really Mean?


There was a time in the more distant history of medicine when the intentional bleeding of patients, a practice known as bloodletting, was considered a routine part of treatment for a range of medical conditions. Largely regarded as a crude and medieval practice today, the physicians who performed this procedure probably did have the best interests of their patients in mind. Fortunately, once it was determined that this practice was detrimental to the patient, it was abandoned.


This example parallels our ever-changing body of knowledge regarding the best practices for the management of diabetes and the evolving target goals of blood glucose control. As a medical community, we have come a long way from the narrow focus of merely driving down the A1C into the ‘normal’ range. A multitude of studies has shined light upon the reality, that strict glucose control is not without its risk.


With this in mind, as providers, we are left with the open-ended question of what level of glucose control should we be striving to achieve? If uncontrolled diabetes increases the risk of diabetic complications and tight glucose control increases the risk of hypoglycemia with associated mortality, where is the proverbial Goldilocks zone?


While the debate on this issue is still raging and probably will for some time, a consensus among medical professionals has begun to emerge. First and foremost is the realization that not all patients have the same target glucose range for optimal diabetic control. A newly diagnosed diabetic with no established complications, especially at a younger age, is still probably a candidate for tight glucose control. In contrast, an elderly patient, especially one with multiple comorbidities, is rarely a candidate for tight control.  


In practice, however, there is considerable “grey area” as not all patients fall into these two clear-cut extremes. What about middle-aged patients who already have a documented history of CAD? When trying to chart a path for these patients, I ask myself the question “what are the expected benefits of strict glucose control for my patient versus their risk associated with recurrent hypoglycemia?”


Another important consideration among the medical community involves the methods for how we measure glucose control. While seeing an optimal A1C result brings satisfaction to both the patient and the provider, we must not lose sight of what the A1C is: an average. With the advent and increased implementation of continuous glucose monitoring (CGM), we are now able to see what providers have always really wanted to know, how much of the time do our patients spend with their glucose values where we want them.


One development that cannot be emphasized enough, is that research has consistently shown us that the tools that we use to control glucose have a tremendous impact on the health of our patients. Medications such as SGLT-2 and GLP-1 agents have proven to be effective in staving off the progression of CKD and reducing cardiovascular events in those diabetics with mild preexisting renal disease and CAD. At the same time, concerns have been raised regarding the possibility of increased mortality with agents such as Glyburide and osteoporosis with medications such as Pioglitazone.


On the subject of tools for glucose control, the development of insulin pumps and glucose sensors seem to be moving at the speed of light! Sensors are getting smaller and less expensive. Insulin pumps are becoming not only smaller but also smarter.  


On the surface, it can often seem that these advances make the treatment of diabetes even more complicated. As providers, it can be easy to get lost in the vast array of choices and competing brands. Especially in a world of direct to consumer advertising, it is challenging to make sense of what treatments are best for our patients.  


While acknowledging the complexities associated with the modern treatment of diabetes, it is important to remember that now, more than ever, we can do more to safeguard the health of our diabetic patients.


The timeless adage ‘treat the patient, not the labs’ remains true. As providers, we want the very best for our patients. To achieve this, we must be willing to challenge the status quo and question ingrained practice patterns. As physicians, we must remain open and allow ourselves to accept new evidence and expand on our medical knowledge. In doing so, we can better promote the health of those patients who have been entrusted into our care.