Getting it right – all the way

A journey of a thousand miles begins with a single step – so the saying goes. The diabetes journey begins with the diagnosis and to get that journey started in the right direction it has to be the right diagnosis, not only whether or not it’s diabetes but also exactly what type of diabetes is it? As articles in this Issue make plain, the wrong diagnosis will get that journey off to a very bad start.

Worst of all is for a child with type 1 diabetes to be misdiagnosed or to have the diagnosis significantly delayed. Many parents of type 1 children have felt reassured, then puzzled, then outraged by the clear signs and symptoms in their children being overlooked when a timely (and simple) blood or urine test would have taken things in the right direction. Too often, the initial diagnosis is made when the child is already in life-threatening diabetic ketoacidosis. This happened to the eight year-old son of Sarah Dyer Dana and to our Diabetes Voice Editor – two of this Issue’s “Diabetes Voices” contributors. They were eventually correctly diagnosed. However, in developing countries when other childhood illnesses are much more common, type 1 diabetes may not even be thought of, as Graham Ogle’s contribution illustrates. We have no real idea as yet how many children die in these circumstances.

Even when the diagnosis of diabetes seems straightforward, there are important subtleties – might it be LADA (latent autoimmune diabetes in adults), a form of type 1 diabetes which may seem initially to be type 2 or MODY (maturity onset diabetes of the young) a form of type 2 diabetes which may masquerade as type 1. Knowing for sure will make a difference in terms of therapy and may even provide some insight into the likelihood of distant complications.

When the diagnosis of diabetes has been made, there are a number of therapeutic options available and a number of evidence-based guidelines to provide the best sequence of these and the criteria for moving from one regime to the next. The ideal scenario is for patients and healthcare professionals to identify the need to move on (on the basis of inadequate or deteriorating HbA1c levels, for example) and to move on to the next therapeutic stage at once. Several recent studies show that this ideal is seldom realised. “Clinical inertia” and how to reduce it is the subject of the Time2DoMoreTM study featured in these pages. The first of its references is to a retrospective cohort study by Kamlesh Khunti et al, published in Diabetes Care in 2013. In their examination of the records of over 80,000 people with type 2 diabetes in the UK it is evident that there were significant delays in the intensification of therapy despite clear indications that such intensification was necessary. Median time to initiation of insulin therapy in people already treated with three oral hypoglycaemic agents was six years after the recording of an HbA1c result which clearly suggested that such initiation was needed. The effects of such delays in terms of the increased risk of complications and their personal and financial costs have still to be reported.

The main message from the Time2DoMore study is that, in the partnership which should exist between the person with diabetes and his or her physician, periodic therapeutic re-appraisals should be undertaken jointly so that treatment can be intensified in a timely manner – not a startling revelation perhaps but it’s a pity this point has to be made over and over again.

The “Diabetes Voices” contributions to this Issue include a number of examples of a failure to be given the information to understand the full implications of the diagnosis of diabetes at the time of that diagnosis. Should it have taken 16 years and impending quadruple by-pass surgery for John Morrison to begin his education about diabetes? I suspect that his experience is not that unusual.

Rhys Williams