Screening Asymptomatic Adults for Type 2 Diabetes May Not Improve Mortality

Updating the Recommendations

In 2008, the USPSTF recommended that physicians should screen for type 2 diabetes in asymptomatic adults with treated or untreated sustained blood pressure (BP) greater than 135/80 mm Hg. The 2008 recommendation was based on the ability of screening to identify persons with diabetes and evidence that more intensive BP treatment was associated with reduced risk for CV events, including CV mortality, in patients with diabetes and hypertension

The current body of evidence indicates that an intensive multifactorial intervention for screen-detected diabetes aimed at decreasing glucose and lipid levels and BP is not associated with a reduction in risk for all-cause or CV mortality or morbidity compared with standard treatment.

The USPSTF posted draft recommendations for public comment in October 2014 and is now finalizing its recommendations.

“The task force recognizes that clinical decisions involve more considerations than evidence alone, and clinicians should understand the evidence but individualize decision making to the specific patient or situation,” Pignone told Endocrinology Advisor.

“Task force recommendations address only services offered in the primary care setting or services referred by a primary care clinician. Several risk assessment models have been developed to assist clinicians in identifying persons at high risk for impaired glucose metabolism. Most risk models include factors such as age, race/ethnicity, family history of diabetes, blood pressure, and BMI or waist circumference.”

A Different Focus

Anne Peters, MD, who is the director of the University of Southern California (USC) Clinical Diabetes Program and professor at the Keck School of Medicine of University of Southern California in Los Angeles, said a major concern with this review is that it did not look at quality-of-life issues. 

It may be better to look at diabetes-related complications instead of mortality rates, she said, as quality of life is a very important issue in the treatment of diabetes and is something that should be considered in these types of evaluations.

“What might be misleading is the focus on mortality. Inherent in treating diabetes is reducing the risk of retinopathy, nephropathy and neuropathy that can lead to great morbidity in individuals with diabetes. Earlier diagnosis may lead to diabetes that is more responsive to treatment. With later disease, there is more beta cell failure,” Peters told Endocrinology Advisor.  

“There are all of the intangibles that come from the diagnosis of diabetes. People may become more committed to changing their life style with weight loss and increased physical activity which may help reduce issues such as sleep apnea, depression, joint and back problems. I think reviews tend to rely on hard endpoints such as mortality when in fact the quality of an individual’s life is harder to quantify.”

Sameer Bansilal, MD, who is an assistant professor of medicine and cardiology at the Icahn School of Medicine at Mount Sinai in New York, agreed with Peters and said screening should be conducted to motivate lifestyle change and reduce risk for microvascular complications. 

“I’m not surprised with their conclusions,” Dr. Bansilal told Endocrinology Advisor. “None of the pharmacological agents approved for glucose lowering have ever shown a mortality benefit. Diabetes is a disease of lifestyle, and hence not surprisingly, sustained lifestyle modification is the best weapon against its ill-effects. If labeling folks with diabetes spurs them towards such change, I’m all for it.”

Reference

  1. Selph S et al. Ann Intern Med. 2015; doi:10.7326/M14-2221.