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Am Fam Physician. 2000;61(1):48-50

to the editor: Drs. Florence and Yeager presented a current and complete outline for the diagnosis and treatment of type 2 diabetes (formerly non–insulin-dependent diabetes) in their recent review.1 However, their recommendations for screening asymptomatic populations were misleading.

The authors presented the recommendations of the Expert Committee of the Diagnosis and Classification of Diabetes Mellitus as standard criteria for the screening for type 2 diabetes in asymptomatic patients in certain high-risk groups.2 In this report, the Committee specifically states that screening for type 2 diabetes in these patients should be “considered” by physicians. The recommendations were not presented as requisite standards for screening. In allowing room for physician consideration, the Committee wisely acknowledged the controversial nature of screening for type 2 diabetes in asymptomatic persons and the important role physicians play in assessing the needs of individual patients.

Other groups differ in their recommendations for type 2 diabetes screening. The United States Preventative Services Task Force states that there is insufficient evidence to recommend for or against routine screening for type 2 diabetes in asymptomatic patients, giving a “C” recommendation.3 The Canadian Task Force on the Periodic Health Exam believes that fair evidence exists in recommending to exclude screening of asymptomatic patients—a “D” recommendation.4 In addition, the American College of Physicians5 and the American Academy of Family Physicians6 do not recommend routine screening. These two groups do agree, however, that screening patients for type 2 diabetes may be reasonable in certain high-risk patients based on other grounds.

The benefits of early diagnosis and treatment of type 2 diabetes before the development of symptoms are poorly defined and may have a negative impact on the quality of life in regard to insurance costs, lifestyle changes and increased physician follow-up visits. However, some high-risk patients may prefer and benefit from early diagnosis and treatment. Screening for type 2 diabetes in asymptomatic patients is certainly worthy of consideration and deserves discussion with patients, but it is not the well-established standard implied in the article.

to the editor: Because of its concise, clear and well-illustrated presentation, the article on type 2 diabetes by Florence and Yaeger1 may attract many readers, and they may not be aware of a couple of inaccurate or incomplete statements about repaglinide (Prandin).

Specifically, we disagree that repaglinide “should be titrated cautiously in elderly patients.”1 In fact, analysis of data from studies that included patients aged 65 years or older failed to document differences in the frequency of hypoglycemia in this population.2 Thus, repaglinide appears to be safer than the longer-acting sulphonylureas in this age group.

In addition, repaglinide was not included in Table 41 that contained information on the dose response of oral agents for the treatment of patients who have type 2 diabetes. A double-blind, placebo-controlled, three-month dose titration study2 demonstrated a mean improvement in two-hour postprandial glucose by 104.1 mg per dL and 47.6 mg per dL, compared with the concurrent placebo and baseline values, respectively.

Finally, in the patient information section, the statement, “You can adjust it [i.e., repaglinide] according to how much you eat,”1 is inaccurate. In fact, a dose adjustment is not required for meals of different sizes; the total daily dosage depends on the number of meals.

in reply: The recommendations on screening for type 2 diabetes in our review,1 which Dr. Konrad refers to, were taken from the report on the American Diabetic Association Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.2 The recommendations for screening for diabetes include patients who fall into a “high-risk” category, as well as patients who meet the age-specific guidelines (45 years of age or older).

The factors leading to the recommendations for screening are as follows: (1) the steep rise in the incidence of type 2 diabetes after the age of 45 years, (2) the negligible likelihood of patients developing any of the complications of diabetes within a three-year interval of a negative screening test and (3) knowledge of the well-documented risk factors for the disease.

Patients with undiagnosed diabetes are at significantly increased risk for coronary heart disease, stroke and peripheral vascular disease, and greater risk of dyslipidemia, hypertension and obesity. Along with the American Diabetes Association, we believe that screening for type 2 diabetes in asymptomatic, high-risk patients should be considered the standard of care.

editor's note: The letter from Dr. Kolaczynski was sent to the authors of “Treatment of Type 2 Diabetes Mellitus,” who declined to reply.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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