Multitherapy for diabetes
=========================

* Stewart B. Harris

The “Editor's Take” on the article by Julie Ménard and associates1 about intensive multitherapy for patients with diabetes was both discouraging and baffling. Russell Rothman and Tom Elasy, in their accompanying commentary,2 correctly state that “Ménard and colleagues … demonstrate again that an intensive disease management program can improve glycemic control and cardiovascular risk factors in patients with poorly controlled diabetes.” The fact that patients were unable to sustain these improvements when intensive therapy was stopped is hardly surprising. This small trial is best seen as a proof-of-concept study that adds to the literature showing that intensive multifactorial and interdisciplinary treatment improves patient outcomes.3–5 Rather than pointing to the need to establish health care teams and systems of care that are sustainable over the long term, the Editor advises that, “physicians should expect few of their patients to attain CDA goals and even fewer to maintain the goals over extended periods.”

The Editor also questions whether CDA guideline targets are realistic. It is important to note that the CDA metabolic and blood pressure targets are based on evidence and reflect thresholds for improved patient outcomes. These are clinical goals for best practice. Even if targets are not achieved, the evidence also points to the benefits of incremental improvements in blood glucose levels, blood pressure and lipids.

The defeatist attitude reflected in the Editor's comments does little to motivate physicians to advance diabetes care in this country. Physicians should continue to strive to achieve evidence-based targets, as the literature has clearly demonstrated that the serious complications of diabetes can be delayed or averted by this clinical approach. Our patients deserve nothing less.

## Footnotes

*   Editor's note: We acknowledge the concern expressed by Dr. Harris that a statement in the “Editor's Take” was interpretable as being unnecessarily pessimistic, whereas it was intended to provide a realistic caution regarding the limited application of the findings of this study.

## REFERENCES

1.  1. Ménard J, Payette H, Baillargeon JP, et al. Efficacy of intensive multitherapy for patients with type 2 diabetes mellitus: a randomized controlled trial. CMAJ 2005;173(12):1457-66.
    
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5.  5. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348:383-93.
    
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