We all learned about type 1 diabetes in medical school. That is a disease where the bodies ability to produce insulin vanishes very quickly. Type 2 diabetes, which only affected 2% of Swedes when I went to medical school, is more a problem of insulin resistance. It used to be called a disease of old age, but it is now common in children with overweight. Lately, Alzheimer’s disease has been nicknamed type 3 diabetes. We are also screening our patients for Prediabetes in order to offer early intervention. With recent drug development and expanded indications for various medications, we suddenly have an entirely new class of people who take diabetes medicines because they have been proven to at least to some degree improve cardiovascular outcomes. Voilà, welcome to the bizarre phenomenon of Pseudodiabetes.
Let me explain:
A recently developed class of antidiabetic medications, the SGLT2 inhibitors (Jardiance and Farxiga) can lower blood sugar by inhibiting the body’s ability to reabsorb glucose that is about to be excreted in the urine. These medications can help improve or preserve kidney function in people with type 2 diabetes. They have also been shown to reduce cardiovascular event risk. I don’t know exactly how that works but I sure know how it has affected my daily work as a primary care doctor.
Primary care physicians are held to many treatment standards for our quality ratings and in many cases our insurance reimbursement. For example, if we have patients who refuse colon cancer screening, we get dinged for it. If we have diabetics with normal cholesterol, who don’t believe us when we say that cholesterol pills can reduce the heart attack risk even for people with normal cholesterol, we risk getting bad report cards and less money coming into our practices. In the case of this new class of anti-diabetic drugs, the SGLT2 inhibitors, even if somebody gets put on them purely for cardiovascular risk reduction, they are now in the eyes of the insurance companies, full-blown diabetics. We are obligated to check their urine for microalbumin and send them to the eye doctor for annual eye exams to look for diabetic eye disease.
This makes no medical sense and it is downright stupid. I would think a clever high school student or a simple AI program could find a way for the actuarial people to see whether this class of drug was started to reduce heart risk or control blood sugar, but so far that has not happened.
We can transplant hearts and do surgeries on fetuses, but we can’t eliminate the unnecessary Pseudodiabetes silliness.
Thank you, Dr Duvefelt! One more example of how the insurance companies pervert the practice of medicine in the U.S., as if we need any more. As a patient and a doctor's widow, I have to watch this all the time, and I'm glad you pointed this out, because my most recent cardiologist was trying to sell Jardiance to me, and I didn't want it, but couldn't yet give him coherent reasons why other than "side effects." So I am collecting info on Jardiance - because I am not a diabetic and prefer to control my blood sugar myself through diet and exercise. I can sympathize that maybe his RVU's require him to try to get me on Jardiance, so I can say "we talked about it, doctor, that shows you did a good job. But I still don't want to be on it!"