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Do We Need To Reassess Diabetes Diagnostics?
A recent Article published in The Lancet suggests
that the criteria for diagnosing diabetes mellitus could need
reassessment. This conclusion comes from a study that looks at the
connection between diabetes mellitus and a frequent diabetic
complication called retinopathy.
Diabetes mellitus is a disorder due to an inability of pancreatic cells
to produce enough insulin in order to prevent inappropriately high
blood sugar (hyperglycemia). It is estimated to affect 380 million
people by 2025. Diagnosis of the disorder, by both the World Health
Organization (WHO) and the American Diabetes Association, is based on
an individual's "fasting plasma glucose" (FPG) concentration. The
guideline for diagnosis is a 7·0 mmol/L or higher FPG concentration.
Retinopathy is a common complication associated with diabetes that is
characterized by small blood vessel damage to the eye; it can also lead
to blindness. In the 1990s, three studies of retinopathy indicated that
the condition was unusual for patients with an FPG below 7·0 mmol/L,
but that the prevalence increased substantially above that threshold.
These three studies used either direct clinical ophthalmoscopic
examination or one retinal photograph, not multiple field retinal
photographs that are now considered the gold standard of clinical
trials. In addition, the Diabetes Prevention Program has reported that
many people have signs of retinopathy even when their FPG is below 7·0
mmol/L.
This most recent study - conducted by Professor Tien Wong, Center for
Eye Research Australia, University of Melbourne, VIC, Australia, and
colleagues - analyzed three more papers that used multiple field
retinal photographs in order to define retinopathy. The three studies
include:
The Blue Mountains Eye Study (BMES), Australia, 3162 people
The Australian Diabetes, Obesity, and Lifestyle Study
(AusDiab), Australia, 2182 people
The Multi-Ethnic Study of Atherosclerosis (MESA), USA, 6079
people.
Wong and colleagues report that 9.6% to 15.8% of the general population
had retinopathy, and there was no evidence of a clear and consistent
FPG threshold for the presence or incidence of retinopathy across the
populations. Further, the usual FPG cutoff of 7·0 mmol/L was too high
to capture all retinopathy cases. More than 60% of cases were missed
because the FPG levels were below the limit.
"We found no uniform FPG glycemic threshold for retinopathy across
different populations and poor performance of current FPG cutoffs in
separating individuals with and without retinopathy, largely due to the
much higher prevalence of retinopathy at low FPG concentrations than
previous studies reported," write the authors.
Wong and colleagues conclude: "These findings could help unify
the understanding of the risk of complications from diabetes,
suggesting that both macrovascular (large vessel) and microvascular
(small vessel) complications do not seem to respect a glycemic
threshold. These findings further question the validity of the current
WHO and American Diabetes Association approach of using retinopathy to
derive FPG thresholds for diagnosing diabetes, and point to the need to
revisit current diagnostic criteria for diabetes."
Drs. Quresh Mohamed and Alison Evans, Cheltenham General Hospital,
Cheltenham, UK, wrote in an accompanying editorial that although the
current diagnostic criteria may be limited, the FPG threshold is able
to distinguish a set of patients with a much greater risk of harm. They
suggest a need for larger prospective studies that analyze diabetes and
the complications that are associated with it.
"We perhaps should focus less on a single universal cut-off and instead
target resources on the basis of standardized evidence-based individual
risk scores in which measures of glycemia are combined with other risk
factors. But what would we tell our patients when they asked if they
had diabetes? We are probably best sticking with what we know until a
better alternative diagnostic tool becomes available," conclude Drs.
Mohamed and Evans.
Relation between fasting glucose and retinopathy for diagnosis
of diabetes: three population-based cross-sectional studies
Tien Y. Wongm, Gerald Liew, Robyn J. Tapp, Prof Maria
Inês Schmidt, Jie Jin Wang,
Paul Mitchell, Ronald Klein, Barbara
EK Klein, Paul Zimmet, and
Jonathan Shaw
The Lancet
(2008). 371:736-743
doi:10.1016/S0140-6736(08)60343-8
Click
Here to View Abstract
Written by: Peter M Crosta
Copyright: Start Sanatate
Not to be reproduced without permission of Start Sanatate
Nu avem nevoie de a reevalua diabet zaharat de diagnosticare? - Do We Need To Reassess Diabetes Diagnostics? - articole medicale engleza - startsanatate